Tension-free thyroidectomy (TFT)

In this video, we present a new method of tension-free thyroidectomy (TFT). The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of isthmus and successive complete dissection of Berry’s ligament. The operation was performed under general anesthesia with endotracheal intubation. Patients were placed in a supine position without neck extension. A 35-40 mm horizontal skin incision was made 1 cm above the sternal notch. Subcutaneous fat and platysma muscle were dissected. The linea alba was incised longitudinally for 4–5 cm. When the isthmus capsule was exposed, the last was divided in the middle. Full mobilization of the isthmus and thyroid lobe from the trachea by dissecting the Berry’s ligament was performed. Intermitted neuromonitoring (5 mA, Inomed C2) was used to guide the division of fibers of the Berry’s ligament. By using the pinnate the thyroid lobe was retracted into the lateral direction (only lateral traction of the thyroid lobe was used during the operation).  The mobilization of the thyroid lobe from the trachea was completed by the division of small branches of the inferior thyroid artery and vein. The main branch of the inferior thyroid artery and vein were preserved along with the vessels supplying the parathyroid glands. After complete separation of the thyroid lobe and inferior thyroid vessels from the trachea the recurrent laryngeal nerve was identified and dissected. Also from the medial side, the upper and lower parathyroid glands and their vessels were identified and fully separated from the thyroid capsule. The lower pole of the lobe was pulled out of the thyroid bed. Finally, after neuromonitoring of the superior laryngeal nerve, the upper pole vessels were dissected and divided. In case a total thyroidectomy the same procedure was performed on the contralateral side after vagus stimulation (V2).

Absence of medial traction of the thyroid lobe. Mobilisation of the thyroid starts from the trachea with full dissection of all the Berry's ligament branches. Thus the recurrent laryngeal nerve is fully mobilised from the trachea and the thyroid before any upward traction is applied to the thyroid lobe. Parathyroid glands are mobilised also from the medial surface of the thyroid before any traction of the lobe.
Any operation on the thyroid - lobectomy or total thyroidectomy.
Only when the thyroid volume is extremely large (but in our series we performed TFT even in patients with thyroid volume large than 100 ml).
1. Always use the lowest power on bipolar electrocautery which is possible. I use ERBE VIO 3 - it is more delicate than the previous version as I think. I use 2.8/2.8 on the bipolar. It is enough. The higher is the power - the more possible is the damage. Only bipolar should be used. 2. Use 5 mA on neuromonitoring to check Berry's ligament before you cut it. It is safe but creates an alarm before you are too close to the nerve. 3. Cut the thyrohyoid muscle along the course of cricohyoid muscle in 1 cm from it before you start to manipulate of the thyroid. It makes the lobe more mobile and makes it easier to work on the final part of Berry's ligament - the highest portion just above the nerve. This is an important hint. 4. Before you mobilise the Berry's ligament cut some vessels in Joll's triangle - just about 1 cm laterally from the trachea. Together with muscle cutting it makes the upper part of the lobe more retractable laterally 5. Mobilise the Berry's ligament step by step on its whole width. Don't create "holes" in it where you see the nerve but the other parts are not mobilised. The lobe should gradually move laterally. 6. Important: when you cut all the Berry's ligament fibers you see the small vessels going from behind to the thyroid lobe. This means that the Berry's ligament is cut by 99%. Stop medial mobilisation and come the lateral side. Mobilise thyrohyoid muscle from the lateral side of the lobe and open the space behind the muscle - the lateral/back side of the lobe, above the Kocher vein. It is really deep. Take a gauze ball about 1.5-2 cm and diameter and put it there. Then put the lobe back - on the ball. Now pressing on the lobe laterally and backward you will lift the medial portion of the lobe - this will increase the space between the nerve and the vessels making the nerve release easier. 7. As you some to the final portion of the ligament, the most firm and the most dangerous - the highest portion where the nerve come to the larynx - don't use bipolar to cut the vessels you are lifting by the fine Gemini clamp. Just put a 3-mm titanium clip on the medial part of the vessel, then cut it with scissors, push the bleeding lateral portion of the vessel laterally and only then coagulate it on the thyroid surface. This increases the space between the vessel and the nerve.
- thyroid ultrasound (performed by the operating surgeon) - fine-needle aspiration biopsy for thyroid nodules - laryngoscopy
- you can switch to the lateral approach to recurrent laryngeal nerve in case there is no possibility to cut the thyroid isthmus (thick isthmus in Grave's disease patient or malignant nodule in the isthmus)
Main advantages: - low risk of recurrent laryngeal nerve damage - low risk of postoperative hypoparathyroidism - low risk of superior laryngeal nerve damage - decreased bleeding from the thyroid tissue - direct approach the the main anatomical structures (recurrent laryngeal nerve, inferior thyroid artery) Disadvantages: - longer operation time - necessity to use neuromonitoring
The main risk is to damage the recurrent laryngeal nerve during its mobilisation. To prevent this don't coagulate too close to the nerve, use 3-mm titanium clips instead of coagulation.
1. Lodovico Rosato, Nicola Avenia, Paolo Bernante, Maurizio De Palma, Giuseppe Gulino, Pier Giorgio Nasi, Maria Rosa Pelizzo, Luciano Pezzullo. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg. 2004; 28: 271-276.· DOI: 10.1007/s00268-003-6903-1 2. Bai, B., Chen, W. Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis. Sci Rep 2018 May 17;8(1):7761. DOI: 10.1038/s41598-018-26219-5. 3. Yavuz E, Biricik A, Karagulle OO, Ercetin C, Arici S, Yigitbas H, Meric S, Solmaz A, Celik A, Gulcicek OB. A comparison of the quantitative evaluation of in situ parathyroid gland perfusion by indocyanine green fluorescence angiography and by visual examination in thyroid surgery. Arch Endocrinol Metab. 2020 Aug;64(4):427-435. DOI: 10.20945/2359-3997000000219. 4. Celestino Pio Lombardi, Marco Raffaelli, Americo Cicchetti, Marco Marchetti, Carmela De Crea, Rossella Di Bidino, Luigi Oragano, Rocco Bellantone The use of “harmonic scalpel” versus “knot tying” for conventional “open” thyroidectomy: results of a prospective randomized study. Langenbecks Arch Surg. 2008 Sep;393(5):627-31. doi: 10.1007/s00423-008-0380-9. 5. Charles Meltzer, Michaela Hull, Alvina Sundang, John L Adams. Association Between Annual Surgeon Total Thyroidectomy Volume and Transient and Permanent Complications. JAMA Otolaryngol Head Neck Surg. 2019 Sep 1;145(9):830-837. DOI: 10.1001/jamaoto.2019.1752

Review Tension-free thyroidectomy (TFT).

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