We present the case of a 58-year-old man with no other medical history who presented with dysphagia and inspiratory difficulty due to the presence of a large normofunctioning, endothoracic goiter, mainly dependent on the asymmetric left thyroid lobe and clearly visible in a chest x-ray. The rest of the preoperative study ruled out indirect signs of malignancy. As can be seen in the cervico-thoracic CT, more than 50% of the total volume of the goiter is retrosternal, fulfilling Katlic’s criteria. Likewise, the thyroid growth generates an obvious anterior-posterior displacement of the mediastinal structures, even extending below the carina. The patient is scheduled to undergo a left hemithyroidectomy possibly associated with a median sternotomy.
An atypical T cervicotomy is then initiated. The subcutaneous plane is dissected, the platysma muscle is sectioned, and vascular selective control is applied to multiple anterior jugular branches, which in this case are very prominent due to the compression exerted by the goiter itself. In order to obtain better exposure and using the “harmonic” scalpel, we proceed to section the left sternal insertion of the sternocleidomastoid, dissecting down to its medial border and accessing the medial fascia colli via the omohyoid section. Then the middle line is opened by separating the prethyroid muscles and the left package is laterally sectioned and retracted.
As the dissection progresses, numerous venous vessels of considerable caliber continue to appear, leading to significant bleeding during access to the cricothyroid space that is controlled by classic dissection and selective ligation. Again, venous bleeding is seen in the upper left pole which is temporarily controlled by compression.
Given the difficulty of achieving adequate vascular control and the impossibility of mobilizing the left thyroid lobe through a conventional approach, it was decided to change the surgical strategy. Conversion to median sternotomy is performed by extending the vertical part of the cutaneous incision and the controlled section of the manubrium and upper third of the sternum using a motorized surgical saw. A Finochietto retractor is placed exposing the structures of the upper anterior mediastinum.
Then, the pyramidal lobe is approached, observing that the bleeding of the left superior pole has stopped spontaneously. After the lateral dissection of the pyramid, the thyroid section begins at the level of the isthmus. In this maneuver, identification of the anterior face of the laryngeal cartilages and the trachea is essential. The left recurrent laryngeal nerve is identified at the level of the cervico-thoracic junction. We proceed to reference it with a blue vessel-loop.
Once the left upper pole and the medial thyroid veins are released, it is possible to partially mobilize the thyroid lobe. Using again the “harmonic” scalpel , the extracapsular dissection is continued, which involves the ligation of the rest of the median thyroid veins. After re-checking the position of the left recurrent laryngeal nerve, the lower thyroid artery is identified and ligated. After detaching the inferior pole of some loose adhesions from thymic remnants, the surgical specimen is removed. During the examination, the presence of an adenomatous parathyroid gland in the subcapsular position is observed.
Finally, the sternotomy is closed first. For this purpose a continuous suture of number 1 polyglactinic acid and a triangular needle are used, completely crossing the thickness of the bone. A surgical steel spoon is used as a protector of the mediastinal structures. It is important to note that the continuous suture is left loose, leaving space between each point as the final tension and the suture tie are made after the approach of both sternal edges. Wound closure is completed after suturing the muscular and subcutaneous planes, and the placement of staples in the skin.
The patient had a favorable postoperative period, and was discharged on the second day.