The Medial Approach to the Recurrent Laryngeal Nerve in Thyroidectomy

Abstract

Abstract

Introduction:

Three general approaches to identifying the recurrent laryngeal nerve during thyroid surgery are recognized: lateral, inferior, and superior. ¹ In the presented video we introduce a different technique for the recurrent laryngeal nerve identification. We call this technique the medial approach to the recurrent laryngeal nerve.

Materials and Methods:

A 57-year-old female presented with Bethesda IV right thyroid nodule. Open thyroidectomy using the medial approach to the recurrent laryngeal nerve identification was performed. Anatomy, surgical technique, along with advantages and drawbacks of the medial approach as compared with the other approaches are illustrated and discussed in the video presentation.

Results:

The medial approach to the recurrent laryngeal nerve consists of four steps that are performed sequentially. First, the thyroid isthmus is divided and the edge on the resection side is grasped with Babcock tissue forceps, placing the isthmus on lateral traction. Second, the medial portion of the thyroid gland is separated from the cricothyroid muscle and trachea. In this step, the Berry's suspensory ligament adjacent to the first tracheal ring is left intact. Third, the avascular space between the superior pole and the cricothyroid muscle is opened. In the fourth and the most critical step, the Berry's ligament lateral to the first tracheal ring is placed on differential traction using two retractors, and the recurrent laryngeal nerve is identified and dissected as it courses deep to the superior edge of the ligament.

Conclusion:

The anatomy and the surgical technique for the medial approach to identify the recurrent laryngeal nerve in thyroid surgery are presented. The advantages of this technique are consistent anatomical location of the recurrent laryngeal nerve, efficiency of dissection, and complete removal of thyroid tissue at the cricothyroid joint. Although we use this approach routinely, ² the medial approach is especially useful for large goiters and cases wherein identification of the recurrent laryngeal nerve is otherwise problematic.

No competing financial interests exist.

Runtime of video: 11 mins 48 secs