Introduction

With the transformation of thyroid and parathyroid surgery since the late 1990s, there are now a variety of methods for accessing the thyroid and central neck. A number of technological advances such as advanced energy devices for hemostasis,¹ high-resolution endoscopes for improved visualization,² and laryngeal nerve monitoring³ have increased the focus on cosmetic outcomes and the pursuit of smaller, well-camouflaged incisions.⁴ Also emerging are techniques for remote access thyroid and parathyroid surgery.^5,⁶ Conventional surgery remains necessary in many circumstances, such as for large substernal goiters or advanced malignancy, and will remain in the endocrine surgeon’s armamentarium.

Please see the Expert Consult website for more discussion of this topic.

This chapter presents historical discussions followed by a series of important guiding principles that serve as fundamental reference points during thyroid and parathyroid surgery incisional design. Specific procedural considerations are described, and then a concise enumeration of proposed “best practices” is offered.

Historical Perspectives

Please see the Expert Consult website for more discussion of this topic, including Figure 42-1.

Figure 42-1 The Lahey incision (A) affords wide access to the lateral neck, but it is associated with a trifurcation, which is subject to necrosis. The MacFee incision (B) respects the relaxed skin tension lines in the neck and is therefore cosmetically superior, but it can be awkward to work through. The hockey-stick incision (C) avoids trifurcations and provides plentiful exposure for a comprehensive neck dissection.

(A and B, Redrawn from Lore JM, Medina JE, editors: Atlas of head and neck surgery, Philadelphia, 2005, Elsevier-Saunders.)

Modern thyroid surgery found its origins in the late 19th century in the work of Billroth and Kocher.⁷ Although Billroth is credited with first systematically pursuing thyroidectomy in a deliberate fashion, it was Kocher who developed a safe and reproducible technique for accomplishing a therapeutic thyroidectomy. He was able to demonstrate efficacy and efficiency through a low cervical collar incision that bears his name. Kocher himself, however, recognized the logic behind utilizing as small an incision as possible and is quoted as saying thyroidectomy incisions should be “as small as possible, as big as necessary,” therefore perhaps qualifying him as the first minimally invasive surgeon.

Because much of the earlier thyroid surgery was done for malignancy, descriptions emerged regarding the appropriate way to accomplish a thyroidectomy combined with a neck dissection. Popular incisions included the Lahey incision (Figure 42-1, A), the MacFee incision (Figure 42-1, B), and eventually a hockey stick type of incision (Figure 42-1, C).⁸ This last approach developed with recognition of the dangers of a trifurcated incision in which the tips of the trifurcation were prone to ischemia and devitalization, sometimes putting the great vessels of the neck at risk. As the “radical” operations of the 1960s and 1970s gave way to the more “selective” operations of the 1980s and 1990s, neck incisions for thyroid and neck dissection evolved.

General Principles

A number of important principles are worth considering when planning a thyroidectomy or parathyroidectomy, and these transcend the specific procedure that is anticipated.

Individualizing Incisions

A concept that has gained traction in recent years is the customization of both the incision and the surgery to the patient and the disease characteristics, rather than a “one size fits all” approach.⁹ Historically, surgeons proposing to accomplish a thyroidectomy would make a standard length incision in a routine location and accomplish an identical operation for each patient. More recently, partly driven by public demand, ever smaller incisions have been utilized (when it can be done safely) in order to improve patient satisfaction, and the procedure is now tailored to the individual condition.

Please see the Expert Consult website for more discussion of this topic, including Figures 42-2, 42-3, 42-4, and 42-5.

For example, a gentleman with a 26-inch neck (Figure 42-2, A) and a large goiter (Figure 42-2, B) is not a good candidate for any type of minimally invasive approach. By contrast, a television commentator with an 11-inch neck (Figure 42-3, A) and a 2-cm follicular neoplasm (Figure 42-3, B) is an ideal candidate for an endoscopic thyroidectomy. It is no longer sufficient to remove a thyroid, preserve the laryngeal nerves, and preserve the parathyroid glands (Figure 42-4). Patients now expect a more measured approach to their care, which sometimes includes quite small incisions (Figure 42-5).