The location for the cervical incision is determined preoperatively in the holding area with the patient sitting or standing upright. This is particularly important when a cosmetic outcome is desirable , and serves to ensure that the incision is made in an appropriate vertical location (not so low that it is on the anterior chest wall where the risk of hypertrophic scarring is increased, and not so superior that it will be easily visible postoperatively) and to ensure that there is horizontal symmetry. The line of marking is extended beyond the anticipated incision length, in case lengthening of the incision should be needed intraoperatively. Multiple incision length options can be denoted by vertical hash marks ( Fig. 1 ).

To ensure the proper positioning of the thyroidectomy incision, the optimal time to mark the patient is with him/her sitting upright (in the holding area). Symmetry is ensured by also marking the ends of the intended incision with vertical hash marks. Because it is occasionally necessary to extend the incision to retrieve a gland, it is helpful to mark multiple symmetric incision length options, as shown.

The use of laryngeal nerve monitoring is a natural complement to the necessarily reduced aperture represented by minimal access thyroid surgery. To simplify this undertaking, the GlideScope (Verathon, Inc., Bothell, WA) device is used to accomplish intubation, so that proper positioning of the electromyographic endotracheal tube can be confirmed. The GlideScope is also profoundly helpful with the difficult airway.

Because of the multitude of devices used to accomplish a modern thyroidectomy, rotation of the operating table 180° from the anesthesiologist allows comfortable positioning of surgeon, assistants, and technology ( Fig. 2 ).

The typical room arrangement is shown, with the operating table rotated by 180° to accommodate the devices necessary to perform an endoscopic thyroidectomy (nerve monitoring unit, ultrasonic device, and endoscopic tower). The use of a slave monitor (white arrow) increases the ergonomic comfort of the camera assistant, who can then face the image squarely.

Although no modifications have been made to the excellent visualization that can be obtained with the 30°, 5-mm laparoscope, we have introduced the use of a slave monitor ( Fig. 2 ) to facilitate participation by the camera assistant and also for improved education of the retractor assistant. Taking this a step further, these surgeries are even more easily accomplished in an endoscopic suite; and this has now become our preference.

For the nonendoscopic portions of the minimally invasive video-assisted thyroidectomy and for all other thyroid procedures, loupe magnification combined with a portable battery-powered headlight optimizes visualization as well as surgeon comfort.

Instrumentation has emerged that in some ways represents an improvement upon the original Miccoli video-assisted thyroidectomy set. The Medtronic (Jacksonville, FL) thyroidectomy instrument set incorporates a nonreflective finish on its retractors, which are angled more than 90° to minimize the interference with the anterior chest wall and the face. The atraumatic suction has a malleable shaft, variable suction strength, and a blunt tip; and therefore, suction trauma to both the parathyroid glands and the laryngeal nerves may be minimized. A specially designed peanut-holder allows use of this type of cottonoid in a small space.

When making the horizontal surgical incision, we have found it to be useful to reach deep and beyond the edge of the incision to horizontally divide the platysma to maximize the exposure achieved by a given incision and thereby facilitate delivery of the thyroid through the incision.

We have found the management of the superior pole to be easier when the avascular cleft between the inferior constrictor muscles and the superior pole of the thyroid gland is identified and developed ( Fig. 3 ). Furthermore, when combined with lateral dissection of the superior pole, the entire upper pedicle can be ligated using a Harmonic device (Ethicon Endo-Surgery, Cincinnati, OH) ( Fig. 4 ). This thereby minimizes trauma introduced by dissection of the vessels and makes the ligation of the superior pole vasculature easier and faster.

Management of the superior thyroid pole is facilitated by developing the mostly avascular cleft sometimes called Joll triangle (black arrow) between the upper pole of the thyroid and the inferior constrictor muscles. This allows the upper pedicle to be completely isolated without the need to individually dissect out the superior thyroid artery and vein.

After the superior pole of the thyroid has been thoroughly isolated laterally and medially, the upper pedicle may be ligated as a single bundle using an advanced energy device. This not only saves time, but is easier and probably safer (because one can stay further from the superior laryngeal nerve and because the terminal branches of the superior pole vessels are ligated rather than the main trunks).

We prefer a completely clipless and sutureless removal of the thyroid gland. For example, even in the region of the recurrent nerve, we have not needed to use sutures or clips to achieve hemostasis. Instead, we favor the use of ultrasonic energy, which we have found to be safe and advantageous.

In selected patients, a lateral endoscopic approach can be undertaken ( Fig. 5 ). Although this obviates the possibility of performing a bilateral thyroidectomy through the same incision, occasional patient preference may dictate this access. Although a somewhat unfamiliar approach to most surgeons, it is similar to the lateral approach to a superior parathyroidectomy, in which the gland is approached posterior to the strap muscles.

Although the usual approach is through a midline cervical incision, for selected cases, a lateral approach may be used (A), in which the thyroid is approached posterior to the strap muscles (as is sometimes done for reoperative parathyroid surgery, particularly for a superior parathyroid adenoma) (B). The cosmetic result is acceptable (C).

For all thyroid surgeries, including endoscopic minimally invasive techniques, a deep extubation of the patient (which implies removal of the endotracheal tube while the patient is asleep but breathing spontaneously) is very helpful for minimizing coughing and bucking, which may lead to bothersome oozing.

We prefer that all patients undergo preoperative laryngoscopy to identify unanticipated preexisting nerve dysfunction . Postoperatively, all patients also undergo laryngeal examination in the postanesthesia care unit to confirm absence of laryngeal dysfunction before discharge. Occasionally, very transient nerve paresis can be appreciated at this examination, which is resolved by the time of the first postoperative visit. Therefore, useful information may be derived.

An important departure from the practice of the Miccoli thyroidectomy in Italy is that nearly all of our patients undergoing endoscopic thyroidectomy are managed on an outpatient basis, including those undergoing total thyroidectomy. To introduce a measure of safety with this approach, patients in whom all 4 parathyroid glands are at risk during the surgery are treated prophylactically with oral calcium and vitamin D supplementation .