Total thyroidectomy in bilateral nodular goiter

The surgical technique will be demonstrated in stage II multinodular goiter. The procedure is started on the right side.
Kocher collar incision about 2 fingers wide superior to the suprasternal notch.

Tip:

If the incision is placed too far inferior this may result in keloid formation.
In large goiters the incision should be placed somewhat more superior since it will descend once the goiter has been removed.

After transecting the subcutaneous tissues free a superior and inferior skin-platysma flap while preserving the straight cervical veins, if at all possible.

Incise along the white line (linea alba colli) and mobilize the strap muscles.

Tip:

It is important to identify the correct plane of connective tissue between the thyroid and the muscles because this will avoid venous bleeding. This maneuver may be rather difficult in a status post previous inflammation.

In large goiters it is recommended to transversely transect the infrahyoid muscles.

Identify the vagus nerve between the internal jugular vein and common carotid artery, perform continuous vagal neuromonitoring

Mobilize the superior pole of the thyroid and with the LigaSure® system transect the vessels there close to the gland.

Caution:
When pulling too hard on the thyroid, this will tear off the veins at their next branching, in other words craniad. In this case identification and ligation of the stumps may prove to be rather challenging!
Whenever the superior pole extends far craniad and the ligatures are not placed close to the gland, this runs the risk of injury to the external branch of the superior laryngeal nerve.

Tips on how to avoid secondary bleeding from the pole vessels is found here:Polgefäße [Pole vessels]