Foreword. Foreword. in a blood-free field, which decreases the risk of complications.

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1 Foreword V Foreword During my first visit to Basel, Switzerland, in 1980, I had the pleasure of meeting Prof. Ernst Gemsenjäger. I was immediately impressed by the knowledge of this experienced and skillful surgeon. Other leaders, such as Professors Philipp Heitz and Hugo Studer, had most positive comments about Professor Gemsenjäger, who has special expertise in thyroid surgery. Safe thyroid surgery was established in Switzerland by Kocher ( ), and Professor Gemsenjäger follows in his tradition. Kocher, as many already know, received the Nobel Prize in 1909 for his contributions to experimental physiology, pathology, and surgery. He not only helped make thyroid operations a safe procedure, but also by honestly reporting his complications, such as postoperative myxedema (cachexia strumipriva), documented that the thyroid gland was essential for life. Kocher was also a great surgical educator and certainly influenced William S. Halsted, MD ( ), from Johns Hopkins Medical Center, and many other surgeons about the importance of meticulous surgical technique in a blood-free field, which decreases the risk of complications. Professor Gemsenjäger s book is clearly written and provides useful information for physicians who care for patients with surgical disorders of the thyroid. The author uses his vast experience to illustrate proper clinical management. His description of surgical anatomy, the appropriate position of the surgical incision, and the technique of capsular dissection to avoid injuring the recurrent laryngeal nerves or devascularizing the parathyroid glands during thyroid operations is informative. He also outlines the mechanisms involved in the pathogenesis of nodular goiter and thyroid neoplasms. General, endocrine, and ENT surgeons will benefit from reading this superb book, as will endocrinologists, pathologists, residents, and medical students. Orlo H. Clark, MD Professor, Department of Surgery UCSF, Mt. Zion Medical Center San Francisco, USA Foreword For several decades, clinical thyroidologists throughout this country sent patients with unusually difficult surgical problems to the author of this Atlas of Thyroid Surgery for advice or intervention. Any reader leafing through this magnificent book will immediately understand why so much credit was lent to its author. All available techniques for surgically removing diseased thyroid tissue be it nodular or diffuse, benign or malignant are critically reviewed. A beautifully illustrated example is given for nearly every possible situation. Any thyroid surgeon faced with an uncommon or particularly difficult thyroid problem is most likely to find a detailed and well-founded description of the best procedure to be chosen in just the case they are confronted with. However, every surgeon who turns for advice to this book is expected to master the demanding technique of capsular dissection. This technique first described by Theodore Kocher 100 years ago is, in the author s mind, underused or even ignored in some centers. It is, however, safer and far superior to any other technique (e. g., the often ill-defined subtotal thyroidectomy ) for removing all pathologically growing thyrocytes a prerequisite to avoid recurrence of benign or malignant nodules. The credentials of the author are exceptional. On the one hand, he has not only performed some 2500 thyroidectomies himself, but he has also personally followed all patients operated for thyroid malignancies over years and even decades, carefully monitoring every event related to the surgical intervention. This enormous clinical experience has been published in a number of widely cited papers. On the other hand, the author did participate in several fields of thyroid research not related to surgery. A particular hallmark of this book is Professor Gemsenjäger s constant effort to explain the modern concepts of biological and molecular events that underlie the pathogenesis of thyroid lesions that may eventually appear in the hands of the surgeon. Particular consideration is given to the very early states of benign and malignant nodular growth, i. e., to those clusters of hydrolytes that are endowed with an intrinsic or acquired growth advantage. Radical surgical elimination of all such clusters is the ultimate goal of an optimal therapeutic approach. The author is highly qualified to critically review the techniques that allow this goal to be achieved. Professor Emeritus H. Studer Muri/Bern, Switzerland

2 VI Foreword Foreword As an internist, I had the privilege to work with Professor Ernst Gemsenjäger at the Zollikerberg District hospital, Zurich, Switzerland, from 1988 to During those 15 years, there were many opportunities for me to learn from his broad and precise knowledge of the field of thyroidology, which included modern cell biology, such as Professor Hugo Studer s concept of follicle cell growth and function. It was typical of Professor Gemsenjäger that he not only focused on the local surgical problem but also always included endocrine pathophysiology in diagnostic and therapeutic considerations. As a result, every patient who came to his attention was a stimulating didactic lesson for the surgical and intern medical house staff as well as a source of knowledge for himself. His enthusiasm for clinical research combined with a deeply self-critical mind and his personal example as an excellent surgeon with huge experience in the field allowed several of his disciples to bring thyroid surgery to a high level of quality in other hospitals. Professor Gemsenjäger s surgical procedures in endocrine surgery as well as in the whole spectrum of gastrointestinal surgery, which I was able to watch repeatedly in the operating theater, were meticulously nonbloody and complications were extraordinarily rare. Accordingly, even our many frail and polymorbid patients who needed thyroid or other surgical treatment were in very safe hands. Professor Max Stäubli, MD Zollikerberg, Zurich, Switzerland

3 4 Part 1 Surgical Anatomy and Surgical Technique 3 Incisions; Thyroid Exposure 3.1 Skin and Platysma Fig. 3.1 The Kocher incision (1 in Fig. 3.1) is centered over the isthmus of the thyroid, which lies just caudad to the cricoid cartilage. This placement is preferred to a more caudal one. 215 If the neck is hyperextended the incision will lie more caudally once the patient is in the erect position. The level of the suprasternal notch should be avoided because of the risk of unfavorable scar formation since the platysma is lacking in the midline at that level. Symmetry of length and height of the slightly curved incision, placed in a normal neck line or skin fold, is important. The length depends on neck configuration, goiter size, and planned surgical procedure. The planned incision line is marked preoperatively with the patient in the erect position, and on the operating table with the neck hyperextended. The laryngotracheal axis, the anterior border of the sternocleidomastoid muscles (SCM), and the sternal notch are also outlined with a marking pen. In selected patients an additional vertical midline (T-)incision of the skin (and of the SF and MF) extending down to the manubrium (2 in Fig. 3.1) may be essential for mobilization of large mediastinal and thoracic inlet goiters. There is a risk of scar enlargement or contraction, which may later necessitate a Z-plastic correction. The Kocher incision may be extended laterally to the posterior margin of the SCM (McFee incision) or to the trapezius muscle (3 in Fig. 3.1) if excisions of large goiters or lateral nodal dissection are planned. For these indications a longitudinal incision along the anterior border of the SCM may also be used (4 in Fig. 3.1), with or without a simultaneous Kocher incision. Hemostasis of these incisions is effected for the most part by pressure on a gauze for a short time. 3.2 Transverse Division of the Superficial Fascia and Middle Fascia Fig. 3.2 Superficial fascia (SF). No mobilization of skin platysma flaps is carried out. After transection of the platysma a very shallow scalpel incision will denude the superficial veins, which may turn out to be rather large. They are not dissected free, but simply cut between perpendicularly placed clamps and ligated or secured with suture ligatures (a later sudden flooding bleeding may originate from a reopened superficial vein). The SF encompasses the SCM and may be incised on its medial border, freeing the muscle for lateral retraction (Fig. 3.2 a, b). Middle fascia (MF, strap muscles). The underlying sternohyoid muscles, incorporated in a thin fascia, are cut transversely with a scalpel or with blunt scissors from the midline laterally; the fine fascia encompassing the a 2 b Fig. 3.1 a,b Incisions of skin and platysma. 1, Kocher incision; 2, midline incision extending to the manubrium; 3, Kocher incision extended laterally to the posterior margin of the SCM; 4, longitudinal incision along the anterior border of the SCM.

4 Incisions; Thyroid Exposure 5 SCM SF a b Platysma Skin Subcutaneous tissue SF, veins c d Sternothyroid muscle (MF) Sternohyoid muscle (MF) MF e Capsula propia f SF SF, SCM Internal jugular vein Fig. 3.2 a g Transverse division of the superficial fascia (SF) and middle fascia (MF). a, b Superficial fascia divided, MF exposed. The sheath of the sternocleidomastoid muscle (SCM) is opened on the left side. c Sternohyoid muscle divided. The thin fascia of the more laterally situated sternothyroid muscles is exposed. d Strap muscles (MF) divided. e, f MF transected. Exposure of the capsula propria with enlarged vessels beneath. g Incision of the MF at the lateral edge. g MF

5 14 Part 1 Surgical Anatomy and Surgical Technique a b Fig. 4.6 a, b Capsular dissection (multinodular colloid goiter). The fascia of the visceral compartment (VF) is put under tension and exposed by traction and countertraction ( Cases 1, 2). Its separation from the thyroid capsule is achieved by dissection and division of the numerous branches of the inferior thyroid artery on the capsula propria (arrows). In both patients total lobectomy is indispensable for complete excision of all nodules. The capsular dissection is yet incomplete posteriorly for a total extracapsular removal of the lobe.

6 Capsular Dissection 15 a1 a2 b1 b2 Fig. 4.7 a, b Capsular dissection (left side), pursued posteriorly toward the trachea. a The thin fascia of the visceral compartment ( Grenzlamelle ) remains intact and will be dissected away from the nodules (arrows). X: a more lateral dissection through the fascia is avoided. The visceral compartment is not entered. % = Upper parathyroid lying on the visceral fascia. %% = Recurrent nerve visualized par transparence running in the visceral compartment. b Two of the rare illustrations of the visceral fascia in the literature: b1 Represents a part ( just the cranial part ) of the cervical visceral fascia as shown in the Textbook of Operative Surgery by Theodor Kocher. 141b He was the first surgeon to describe the technique of capsular dissection. 141 b2 According to the German surgeon E. Enderlen ( ), 57 the thin visceral fascial layer becomes visible when the goiter is retracted medially. The inferior thyroid artery pierces the fascia; note, however, that the recurrent nerve is incorrectly depicted as running on top of the fascia instead of dorsally underneath the fascia. The resemblance to fascial structure shown in Fig. 4.6 a, b is obvious. (Published with permission. Figure b2 was published in Der Chirurg, Vol. 4, Enderlen E., Zur Technik der Operation des Kropfes, pp Copyright Springer [1932].)

7 20 Part 1 Surgical Anatomy and Surgical Technique a Fig a j Total completion lobectomy for a retrovisceral and upper mediastinal recurrent goiter; lateral approach and capsular dissection (see also Fig. 4.9 c, d). a Cervicomediastinal goiter with deviation of trachea and venous stasis. Kocher incision along with an extensive longitudinal incision. b Incision of the transverse anterior scar and of the SF (arrows) along the SCM (sheath of the SCM). c, d Transection of the strap muscles down to the goiter capsule; longitudinal lateral transection of the MF (Z). e j Meticulous capsular dissection of numerous colloid nodules. They are successively freed and mobilized anteriorly as they emerge from their retrovisceral and upper mediastinal location. No postoperative adhesions or scar formation are encountered in this area. Following total lobectomy the layers (MF, SF, platysma) are closed longitudinally and transversely. The skin is reapproximated with intracutaneous stitches and SteriStrips. b c d e

8 Capsular Dissection 21 f g h i j ular tissue behind. 76,217 On the basis of its inherent, persistent growth advantage 45,254 it may grow to a clinical recurrent goiter. U The rational procedure consists of a complete extracapsular excision of the goitrous thyroid remnant. This can usually be done safely by capsular dissection, with the same low morbidity as in primary surgery, because scar formation is encountered in the anterior but not in the delicate posterior area. The difficulty of the operation is determined rather by the extent of the goiter. Recurrent goiters selected for surgery are larger, grow more rapidly and lead to retrovisceral extension and compressive and functional (autonomy) symptoms. With posterior thorax inlet goiters the recurrent laryngeal nerve may be displaced anteriorly (see section 5.2). Meticulous dissection close to the capsula propria will protect the nerve (running be-

9 26 Part 1 Surgical Anatomy and Surgical Technique Thyroid hilus Thyroid hilus, suspensory ligament Inferior PT Recurrent laryngeal nerve Superior PT a Superior PT Tubercle b Tubercle Recurrent laryngeal nerve Visceral fascia c d Tubercle Traction suture on tubercle Superior PT Suspensory ligament Recurrent laryngeal nerve Suspensory ligament e f Recurrent laryngeal nerve Visceral fascia Fig. 5.2 a f Capsular dissection at the level of the posterior tubercle of Zuckerkandl (lateral view in a, c, d, e; transection in b, f). a, b The branches of the inferior thyroid artery for the tuberculum. Ultraligation of the upper PT and individual ligation and division of the lateral, inferior, medial c f branches of the inferior artery are performed on the capsula propria of the tubercle. The tubercle lies anterior to the visceral fascia that covers the inferior laryngeal nerve. Capsular dissection of the tubercle in progress.

10 Thyroid Hilus: Suspensory Ligament of Berry; Inferior (Recurrent) Laryngeal Nerve; Parathyroids; Posterior Thyroid Process (Tubercle of Zuckerkandl) 27 The suspensory ligament of Berry (named also the ligament of Gruber) contains terminal branches of the inferior thyroid artery (see Fig. 4.3), which are divided during total lobectomy ( Cases 2, 3). With the thyroid retracted anteriorly, these short peritracheal vessels are successively clamped with curved mosquito clamps on the tracheal surface from posterior to anterior and sharply divided (Fig. 5.2 e, f). The minute arterial branches must be ligated or suture-ligated; they may be the source of a severe, rapidly developing bleeding with compression (see postoperative hemorrhage, p. 50). When a short bleeding stump retracts beneath the recurrent nerve, bleeding must be controlled with fine stick tieligatures, with the nerve being carefully protected. For the posterior capsular dissection, the use of magnifying glasses or of a surgical loupe is recommended (see Fig. 22.2). For minute bleeders, bipolar electrocoagulation is briefly applied. Note: Modern technologies and devices that produce heat should not be used for dissection of the tubercle and suspensory ligament or for sealing the vessels encountered. The suspensory ligament may contain minute amounts of residual thyroid tissue surrounding the vessel stumps and fixed on the tracheal wall (see Figs. 6.4 c, 6.5 c). Though appearing on scans with postthyroidectomy nuclear imaging in some patients, this kind of remnant clearly differs from that of near total excision (see section ; Fig. 5.15). Excision of the tuberculum of Zuckerkandl and transection of the suspensory ligament of Berry represent steps of capsular dissection ( Cases 2, 3). 79 Berry visited Kocher in Berne 142 ; Kocher called James Berry an intelligent learner ( ein so intelligenter Schüler ) who adopted Kocher s technique [see ref. 142: p. 1644]. In his description of total lobectomy from 1919, Dunhill mentions the attachment of the thyroid gland to the trachea not as the ligament of Berry but as the three penny patch of Professor Watson. 53a He notes that the dissection may be extraordinarily difficult when dealing with the very short, fragile, newly-formed vessels in exophthalmic goiter (see also 6.1). veins ought to be divided, keeping close to the capsula propria. U The nerve may split in two (or several) branches at some distance from the larynx (Figs. 4.2 b, 5.3). 33,133,149a A ventral branch with motor function for the vocalis muscle or a posterior branch innervating the posticus muscle may both lead to vocal cord paresis when inadvertently injured. U In a few patients with a posterior tubercle, the nerve (or a branch of it) courses on the lateral aspect of the tubercle instead of its medial side, 33,69 though still behind the visceral fascia (Figs. 5.3, 5.4). Such a deviating nerve is at high risk when the tubercle is involved in goitrous enlargement and when a goiter of the tubercle is lifted from the thoracic inlet and posterior mediastinum (see also Fig. 5.19). U A nonrecurrent inferior laryngeal nerve runs either together with the peduncle of the superior thyroid vessels, or transversely at any level through the visceral compartment. 264 The nerve runs always behind the visceral fascia and is thus anatomically protected on strict capsular dissection. a Capsular dissection Visceral fascia 5.2 The Nerve at Risk The surgeon must be aware of the inferior laryngeal nerve being at high risk of injury in the following situations and anatomical variations: U During reoperative surgery when the visceral compartment and its fascia have been severed (in most patients with recurrent benign goiter this is not the case) (see Fig. 4.11). 217 U The nerve may be drawn or may run anteriorly in relation to the tracheoesophageal groove at the level of the inferior thyroid pole, where the inferior thyroid Inferior thyroid artery b Recurrent inferior laryngeal nerves Fig. 5.3 a,b Extralaryngeal division of the recurrent inferior laryngeal nerve into two branches (lateral view; cross-section at the level of the thyroid hilus). In this case the branches course under and over the tubercle, respectively. Arrows indicate capsular dissection.

11 42 Part 1 Surgical Anatomy and Surgical Technique 6 Further Case Records with Demonstrations of the Technique of Capsular Dissection Figs In Fig. 6.1, a left-sided lobectomy in the course of a total thyroidectomy for PTC is demonstrated. The 64-year-old woman patient noticed a solitary, rather firm nodule in the upper pole of her left thyroid. TSH and calcitonin were normal. FNAB cytology revealed a PTC. a b c Fig. 6.1 a j Total thyroidectomy for PTC; capsular dissection, left side. Macroscopic appearance of PTC (nonencapsulated mass; intrathyroidal PTC upper pole). The patient was a 64-year-old woman. View from cephalad; firm nodule in the upper pole (x). Traction sutures avoiding the nodule. d a, b Mobilization, capsular dissection of the lateroposterior aspect of the left lobe; dissection with the visceral fascia placed under tension and countertension.

12 Further Case Records with Demonstrations of the Technique of Capsular Dissection 43 No suspicious lymph nodes were found on clinical, preoperative sonographic, and intraoperative macroscopic examinations (stage clinical (c) N0). Comment U PTC can often be diagnosed with confidence by FNAB. Clinically, a MTC must also be considered when a suspicious nodule is located in the upper pole (see Fig. 21.3). U The surgeon can recognize a characteristic macroscopic appearance of a PTC on section of the specimen; the tumor appears hypercellular, has no capsule and infiltrates the thyroid parenchyma ( Case 3) (for various patterns of macroscopic appearance of PTC, see section ). U Staging and risk-group assignment (see section 19.5): this is a pt2 cn0, TNM low-risk stage II tumor 269 (former stage pt2a, unifocal). 268 U Prophylactic central node dissection is judged facultative, and use of prophylactic RAI (remnant ablation) is not recommended in this patient 83,110,111a,111b (see section ). Thyroid hormone substitution should induce subsuppression of TSH (sections , 19.10). U The prognosis after total thyroidectomy is excellent. There is a small risk (~3%) of subsequent (metachronous) lymph node involvement during the early post- e f g h c e Dissection continued posteriorly; a Zuckerkandl tubercle (arrow) becomes apparent and is mobilized, with preservation of the adjoining superior PT (e) (arrowhead). f h Division of the suspensory ligament (arrow) anterior to the recurrent nerve at the tip of the Overholt (g). Fig. 6.1 i,j

13 174 Index Index Page numbers in italics refer to illustrations A abscess 80, 137 adenoma 61 parathyroid 18, 18 19, 62, 84 differential diagnosis 84, 84, 85, 85 thyroid 63 follicular 62, 63, 64 macrofollicular 67, 68, 69 microfollicular 90, 126, 126 toxic 57 adrenalectomy 146, 147 anaplastic thyroid carcinoma (ATC) 121, differential diagnosis 136 genetic basis 136 prognosis 136 treatment gene therapy surgical , 137, 139 anatomy, surgical 3 see also capsular dissection; fascia, visceral; incision antibody anti-tsh receptor 56 antithyroglobulin 115 antithyroid drugs 46 50, 89 overtreatment 50 atypia, cellular 62 autoimmune thyroid disease see Graves disease; Hashimoto thyroiditis autonomy 55 functional 53, 55, 56, autoradiography 55 disseminated 96 in Graves disease (Marine Lenhart Syndrome) 96 in multinodular goiter 44, 45, in solitary thyroid nodule 70 molecular causes nuclear scans 55 surgical treatment 56 thyrotoxic crisis 89 see also Plummer disease of growth 53 proliferative 55 see also hyperthyroidism autoradiography 55 B Berry, J. 25 see also suspensory ligament of Berry biopsy see fine-needle aspiration biopsy (FNAB); open wedge biopsy C C-cells 141 calcitonin levels and hyperplasia 143 calcitonin (CT) 142 C-cell pathology and medullary thyroid carcinoma and , 146, 148, 152 capsular dissection 3, 9 24, 13 14, 35 38, 36 37, 44, 45, 77 79, 79, 154, anatomy of 9 12, 9, 10, 11 historical remarks minimal-access surgery modern technologies and 23 parathyroid glands 11, 11 preservation of 10, 31 reoperation and 7 tubercle of Zuckerkandl 26, 33, 34 35, 34, 157, 158 upper thyroid pole 12 17, 13 15, 16 versus subtotal thyroidectomy see also hemithyroidectomy; lobectomy; thyroidectomy carcinoma classifications extrathyroidal tumor growth 72 familial, nonmedullary in graves disease 97, 97, 98, 98 in Hashimoto thyroiditis 100 in multinodular goiter 39, 39, 76 parathyroid 28 29, 29, 62 small carcinoma 72, 127 surgeon as prognostic factor 39, see also anaplastic thyroid carcinoma (ATC); follicular thyroid carcinoma (FTC); medullary thyroid carcinoma (MTC); papillary thyroid carcinoma (PTC) cellular atypia 62 cellularity 60, 61, 92 93, 146 see also fine-needle aspiration biopsy (FNAB); follicular neoplasia clinical examination 154, 155 clonality 52, 53 54, 105 determination of 58 see also fine-needle aspiration biopsy (FNAB); goiter Cowden syndrome 58 cricothyroid space 12 Cushing, Harvey 22 Cushing syndrome cyst colloid 119, 120 lymph node metastases , 128, 129 papillary thyroid carcinoma , 128, 129 parathyroid 28, 29, 29 cytology see fine-needle aspiration biopsy (FNAB) D Dunhill, T. P. 23, 32, 46 dysphonia, postoperative 30 E ectopic thyroid 39 40, differential diagnosis embryology goiter in 40 intrathymic 84 lateral anlage 39, 40, 40, 41, 83 posterior mediastinum 83 median anlage 40, 83 anterior mediastinum 40, 83 thyroglossal route 83 thyrothymic area 83 thyroglobulin secretion 40 embryology 31, 31, endemic goiter see goiter evidence-based medicine 159 external thyroid capsule 9 resection through 65 see also capsular dissection; fascia, visceral extrathyroidal tumor growth 72, , 119, 120 minimal 39, 118 retrovisceral extension 76, 76, 119 F familial nonmedullary thyroid carcinoma (FNMTC) fascia, visceral 3, 9 see also capsular dissection fine-needle aspiration biopsy (FNAB) cellular atypia 62

14 Index 175 cellularity 60, 92 cystic neck lesion see cyst follicular neoplasia 28, 29, 62 functional autonomy and 56 Hashimoto thyroiditis 99, 100, lymphoma 100, 136 multinodular goiter 22, 62, 67 papillary thyroid carcinoma 42, 43, 92, 110, 111 selective FNAB 22, 62, 67, 68 solitary nodules 29, 70, 92 follicular neoplasia 60 62, 63, 70 clinical features diagnostic hemithyroidectomy 34, 35, 63 differential diagnosis 60, 62 follicular adenoma 62 follicular thyroid carcinoma 62 medullary thyroid carcinoma 62, , 149 papillary thyroid carcinoma 62 parathyroid adenoma 62 parathyroid carcinoma 62 fine-needle aspiration biopsy 28, 29, 62 frozen sections 60 see also follicular thyroid carcinoma (FTC) follicular thyroid carcinoma (FTC) 63, 91, 91, 92 classification 70 72, 72 minimally invasive 61, 69 70, 69, 72 75, 72 75, 91, 91, 92 risk-group assignment 70 72, 72 widely invasive 62, 64, 64, 70, 72, 72, 73, 75 77, 76, 80, 81 82, 82 diagnosis 62 extrathyroidal extension 72 lymph node metastases of 72 microcarcinoma 72 molecular profiling 58 retrovisceral extension 76, 76 small tumors 72 treatment 34 35, 35, 72 73, 72 results 73, 73 selective, risk-dependent see also follicular neoplasia functional autonomy see autonomy G gene profiling gene therapy 121, Goetsch disease 55, 90 goiter acute symptoms 105 dyshormonogenetic 133 ectopic 83, 84, 85 emergency case in 79, 80 endemic, Switzerland 44, 76 goitrogenesis 53 hemorrhage 79 80, 80 intrathoracic 84, 85 mediastinal 20 21, 40, 41, 77, 78, 79, 83 anterior mediastinum 82, 83, 84 mobilisation 28, 28 pemperton sign 82 posterior mediastinum 36, 37, 80 81, 81, 83 respiratory distress and 77, 79, 80 secondary 83 surgical technique in 28, 28, 77 79, 79 necrosis 79 80, 80 nodular 18, 40, 41, 56 fine needle aspiration biopsy 22, 62, 67, 92 hyperplastic 64, 67, 67, 73, 74, 92 multinodular 35, 36, 39, 39, 62, 67 68, 67, 75 carcinoma in 39, 39, 76, 88 colloidal 13, 14, 62, 63, 67, 67 intrathoracic 84, 85 long-standing (large) 75, 81 82, 82, 87, 87, 88 toxic 38, 38, 54, 62, 74, 76, 81, 88 89, 89 with functional autonomy 44, 45, solitary nodule 53, 60, 92, 93 see also thyroid nodules radioactive iodine (RAI) treatment 81 recurrent prophylaxis 35 pyramidal lobe 85 86, 86 surgical treatment 18 22, 44, 45 back door approach 18 22, retrovisceral 20 21, 36, 37, 38 simple 44, 45, 67 68, 67, 92, 93 pyramidal lobe 85 86, 86 surgical treatment 65, 65, capsular dissection 13 14, 16 17, 35 38, 36 37, 65, 65 completion lobectomy 44, 45 total lobectomy 20 21, 32, 33, 65 total thyroidectomy 36, 37, 44, 45, 65 morbidity 89 resection through external capsule 65 subtotal resection 64 65, 64, 65, 65 tubercle of Zuckerkandl 38, 38 see also Hashimoto thyroiditis; thyroid nodule Graves disease 70, 76 nodules in differential diagnosis 89, 96 Marine Lenhart Syndrome 96 papillary thyroid carcinoma 97, 98 ultrasound 96 recurrent thyrotoxicosis 40, 44 46, 47 surgical treatment 32 completion thyroidectomy 44 46, 47 follow-up 50 ophthalmopathy 46, 49 total thyroidectomy 39, 40, 46 50, 48, 49, 96 97, 96 versus subtotal 46 Grenzlamelle 3 see also fascia, visceral growth advantage 53, 57 H Halsted, W.S. 22 Hashimoto thyroiditis , 105 carcinoma in 100 compressive symptoms 101 diagnosis 99 hyperthyroidism in 99 lymphoma in 99, 100, , nodules in pseudonodules 99, 101, recurrent painful 101 surgical treatment , variants 99, 101 hemithyroidectomy anaplastic thyroid carcinoma 137 diagnostic 34, 35, 63, 147, 148 follicular thyroid carcinoma 34 35, 35 medullary thyroid carcinoma 144, 147, 148, 149 multinodular goiter 67, 67 papillary thyroid carcinoma , , 119, 120, 135 postoperative function see also lobectomy; thyroidectomy hemorrhage large goiter 79 80, 80 postoperative 50 Hürthle (oxyphilic) cells focal 62 neoplastic 62 Hashimoto thyroiditis 102 in papillary thyroid carcinoma 132 hypercalcemia 29, 50 hypercalcitoninemia 143 hyperparathyroidism, primary 18, 18 19, 29, 31 hyperplasia 54, 57, 60, 62 C-cell 143 hyperthyroidism apathetic, in elderly 75, 80

15 176 Index functional autonomy and 70, multinodular goiter 75, preoperative preparation 89 solitary toxic nodule 70 surgical treatment of 89 see also Plummer disease hereditary nonautoimmune 56, 96 recurrence 40, 41, 44 46, 47 subclinical 55, 77, 87 see also autonomy; Graves disease; Hashimoto thyroiditis hypocalcemia 50 hypothyroidism 105 antithyroid overtreatment and 50 in Hashimoto thyroiditis 101, 104, 105 subclinical 101 transient, following hyperthyroidism 90 I incidentaloma 68 69, 68, 95 incision 4 8 back-door 6, 8, 8, 17 22, Kocher 4, 4 longitudinal 6 7, 6 McFee 4 minimal access surgery modifications 7 8, 7, 8 skin and platysma 4, 4 transverse 4 6, 5 infarction, goiter 80 infection, wound 80, 137 inferior laryngeal nerve 25 functional investigation 30 neuromonitoring of 30 paralysis 80 surgical anatomy extralaryngeal division 27, 27 nonrecurrent nerve 27 risk of injury suspensory ligament relationship 27 tubercle of Zuckerkandl relationship 27, 28 internal laryngeal nerve see superior laryngeal nerve iodine deficiency 53 treatment with 50 K Kocher incision 4, 4 Kocher, Th. 22, 22, 23 L laryngeal nerve see inferior laryngeal nerve; superior laryngeal nerve laryngoscopy 30 lateral (back-door) approach 6, 8, 8, 17 22, lobectomy 16 completion 44, 45, 47, 63 near total 65 subtotal 63 total 3, 12, 20 21, 32 35, 32, 35 see also hemithyroidectomy; thyroidectomy Lugol s solution (iodine) 50 lymph nodes anatomy , 116, 117 metastasis to , 119, 120, 122, 123, 148 low intensity metastasis metachronous 116, , 131 microcarcinoma , 125, 127, 128, 128, 130 occult carcinoma and , 124, 125 penetration of lymph node capsule 116 risk factors for 116 skip lesion 117, 118, 128, , staging 115 prophylactic dissection 135 sentinel node biopsy 117 lymphadenectomy 117 berry picking 117 central 117 lateral 117 medullary thyroid carcinoma and 146, 148 prophylactic 43, 115, 117, 146 selective 117 stage migration 116 systematic 117 therapeutic , 117 see also neck dissection lymphangiogenesis 114, 131 lymphoma 95, 100, , 136 differential diagnosis 136 Hashimoto thyroiditis and 99, 100, , malignant , MALT lymphoma 100 M McFee incision 4 Madelung, O. W. 32 magnifying glasses 27, 154, 155 MALT lymphoma 100 Marine Lenhart Syndrome 96 medullary thyroid carcinoma (MTC) C-cells 141 hyperplasia/neoplasia 143 classification 141, 141 Cushing syndrome and diagnosis follicular neoplasia 62, , 149 serum calcitonin (CT) , 146, 148, 152 screening hereditary 141, 144, index patient 144, 146, multiple endocrine neoplasia (MEN) 144, 146, , 150 pheochromocytoma 144, 149, 150 incidental 148 metastases distant 145 lymph nodes 144, 148 skip lesion recurrence , 151 occult paraneoplastic syndrome 151 prevalence 142 rapidly progressing residual, recurrent disease somatostatin receptors in sporadic 141, 143, , 145, , 147 treatment 141 hemithyroidectomy 144, 149 lymphadenectomy 146, 148 selective 148 microcarcinoma 94 95, 112, 127 lymph node metastases 127, 130 treatment 127 see also papillary thyroid carcinoma (PTC); TNM classification middle fascia 3 longitudinal median division 6 7, 6 transverse division 4 6, 5 minimal-access surgery molecular biology functional autonomy RET protooncogene 141, 144 thyroid nodules 53 molecular classification 58 multiple endocrine neoplasia (MEN) 58, 144, 146, , 150 N Nebenschilddrüse see ectopic thyroid neck dissection 117 functional, modified radical 117 selective 117, 118, 132 see also lymph nodes; lymphadenectomy neoplasia 53 54, 57, 70 C-cell 143 see also follicular neoplasia neuromonitoring, inferior laryngeal nerve 30

16 Index 177 NIS (sodium iodide symporter) 54, 55 nodule see thyroid nodules nuclear scan 55 functional autonomy and 55, 89 Graves disease differential diagnosis 89, 96 nodular thyroid disease evaluation 55 toxic nodular goiter 89 O open wedge biopsy 105 ophthalmopathy, Graves disease 46, 49 P palpation 154, 155 papillary thyroid carcinoma (PTC) 63, classification systems 97, 108, morphological subclassification prognostic classification 97, 108, TNM classification 39, 113, 114, 119 clinical features 108 cystic , 128, 129 diagnosis 62, 70, fine-needle aspiration biopsy 42, 43, 92, 110, 111 frozen section macroscopic appearance 42, 43, 92, 110, 110, 113 nuclear features ultrasound 95, 95, 110 encapsulated 131, 132 extrathyroidal tumor extension 97, , 119, 120 minimal 39, 118 retrovisceral extension 119 familial , 132, 134 early diagnosis , 134 follicular variant (FVPTC) 62, follow up thyroglobulin, serum measurement genetic basis 108 in Graves disease 96, 97 98, 98 incidental 39, 39 intrathyroidal 39 lymph node metastasis , 119, 120, 122, 123, 129, 130 cystic , 128, 129 extension through lymph node capsule 116 low intensity metachronous 116, , 131 occult carcinoma and , 124, 125 prophylactic lymphadenectomy 115 recurrence 116 skip metastasis 117, 118, 128, solitary 128, 128 see also lymph nodes macrofollicular 132 microcarcinoma 94, 97 98, 98, 108, 112, 112, 127 capsular penetration 124 familial 127 incidental 126, 126 metastases , 125, 127, 128, 128, 130 minimal 127 multicentric/multifocal 108, 111, 122, 125, 126, 128 occult , 124, 125, 127 oxyphilic 132 pulmonary metastases , 123 pyramidal lobe 86 recurrence 108, 122, 159 contralateral, after hemithyroidectomy lymph node metastasis risk factors 108 solitary nodule , 111 staging 43, 115 treatment of , 135 hemithyroidectomy , , 119, 120, 135 lymph node dissection 135 overtreatment results 121, 121, 122 selective, risk-dependent 109, 135 subtotal thyroidectomy 111 total lobectomy 34, 35 total thyroidectomy 39, 39, 42 44, 42 44, , 109, 132, 135 parathyroid 31 adenoma 18, 18 19, 84 differential diagnosis 62, 85, 85 sites of 31, 31 autotransplantation of 31 capsular dissection 11, 11 carcinoma 28 29, 29, 62 cyst 28, 29, 29 preservation of 31, 84, 84, 85, 85 ultraligation 10, 11, 33, 47 patient positioning 2 Pemperton sign 82 Pendred syndrome 54, 55 pendrin 55 pheochromocytoma 144, 149, 150 platysma incisions 4, 4 Plummer disease 53, 55, 55, 73, 74, 77 79, 80 81, 88 89, 90 multinodular goiter and 75, 76, preoperative treatment 89 surgical treatment 89 preclinical hyperthyroidism 55, 77, 87 propranolol 50, 89 proteomic analysis 58 pulmonary metastases , 123 R radioactive iodine (RAI) therapy 72 large goiters 81 thyroid carcinoma 72, 121, 135 metastases see also follicular thyroid carcinoma (FTC); papillary thyroid carcinoma (PTC) radionuclid scan see nuclear scan radiotherapy anaplastic thyroid carcinoma 136, 137 see also radioactive iodine (RAI) therapy receptor somatostatin, in MTC see also TSH receptor (TSHR) recurrent inferior laryngeal nerve see inferior laryngeal nerve respiratory distress 77, 79, 80 RET protooncogene 58, 141, 144 Riedel thyroiditis 105 S sentinel lymph node biopsy 117 skin incisions 4, 4 sodium iodide symporter (NIS) 54, 55 solitary nodule see goiter; thyroid nodules somatostatin receptors in MTC subclinical hyperthyroidism 55, 77, 87 superficial fascia 3 longitudinal median division 6 7, 6 transverse division 4, 5 superior caval syndrome 80 superior laryngeal nerve 16 external branch 16 internal branch 16 suspensory ligament of Berry transection 27, 46, 48, 157, 158 T tachycardia 50 thymus ectopic 84, 84, 85, 85 intrathymic thyroid 84 thyroglobulin, serum 142 antibodies 115

17 178 Index metastasis detection postoperative measurement thyroglobulin gene-specific transcripts (TgmRNA) 126 TSH-stimulated thyroglobulin 125 thyroid 52 adenoma see adenoma capsule, external see external thyroid capsule carcinoma see carcinoma clonality of 52 ectopic see ectopic thyroid embryological development of 31, 31, hilus 25 27, 25 intrathymic 84 lateral aberrant 124 nodules see thyroid nodules posterior tubercle of Zuckerkandl see Zuckerkandl, tubercle of suspensory ligament thyroid hormone treatment goiter 53, 112 prophylaxis 53, 66 replacement therapy 65 thyroid carcinoma , 135 thyroid nodules 29, 53 54, adenomatous 67 68, 67 cold 56, 74, 88 89, colloid 61, 63, 67 68, 67, 68 69, 68 diagnoses 63 evaluation of excision strategy frozen section 92, 93 hyperplastic 67 68, 67 macrofollicular 68 molecular genetic causes 53 small nodules solitary nodule 60, 68 70, 68, 69, 75, 93, 94, , 118 autonomously functioning (AFN) 70 diagnosis 70, 71 encapsulated 68 69, 68, , 111 fine-needle aspiration biopsy 70 long-standing medullary thyroid carcinoma , 145, 151 papillary thyroid carcinoma , 111 toxic 90, 90 treatment 70, 71 see also follicular thyroid carcinoma (FTC); goiter; Graves disease; Hashimoto thyroiditis; medullary thyroid carcinoma (MTC); papillary thyroid carcinoma (PTC) thyroid stimulating hormone (TSH) 53, 112 antithyroid overtreatment and 50 postoperative levels receptor (TSHR) antibodies 56 mutations 54, recombinat (rhtsh) 113 suppression of 55, 113 endogenous 53, 55, 68, 70, 94 see also autonomy; hyperthyroidism exogenous 53, 73, , 135 see also thyroid hormone treatment subsuppression 112, 113 thyroid function and 90 thyroglobulin stimulation, postoperative measurement 125 thyroidectomy completion 44 46, 47, 146 complications 66, 80 hemorrhage 50 wound infection 80, 137 en bloc 36, 37, 38 goiter surgical treatment 32, 33, 36, 36, 37, 44, 45 near total 63, 111 postoperative function subtotal 18, 32, 33, 34, 44 46, 63 65, 111 total 3, 33, 35 40, 36 39, 72 anaplastic thyroid carcinoma 136, , 139 goiter 36 39, 44, 45, 87 89, 87 89, 101, 102 Graves disease 40, 46 50, 48, 49, 96 97, 96 Hashimoto thyroiditis 101, 102 papillary thyroid carcinoma 35, 42 44, 42 44, , 109, 111, 132, 135 see also capsular dissection; hemithyroidectomy; lobectomy thyroiditis, Hashimoto see Hashimoto thyroiditis thyrotoxic crisis 89, 105 TNM classification 39, 113, 114, 119, 141, 141 treatment results and 121, 121, 122 toxic goiter 38, 38, 54, 62, 74, 76, 81 TSH see thyroid stimulating hormone (TSH) tubercle of Zuckerkandl see Zuckerkandl, tubercle of tumor lysis syndrome 136, 137 U ultraligation 10, 11, 11, 33, 47 ultrasonography 95 Graves disease 96 Hashimoto thyroiditis 99 lymph node lymphoma 95, 100 thyroid 95 follicular thyroid carcinoma 74, 75 multinodular disease 95, 95 papillary thyroid carcinoma 95, 95, 110, , 134 follow-up 126 upper pole, capsular dissection of 12 17, 13 15, 16 V visceral fascia 3, 9 see also capsular dissection vocal cord paralysis 30 voice impairment, postoperative 30 W Will Rogers phenomenon 116 wound closure 7 wound infection 80, 137 Z Zuckerkandl, E. 32 Zuckerkandl, tubercle of 31 41, 31, 83 capsular dissection 26, 33 41, 34 35, 157, 158 goiter of 38, 38, 83 surgical importance 32, 32 41, 34 41