Lateral Approach to Attack Superior Thyroid Vascular Pedicle Eliminates the Need for Strap Muscles Cutting during Thyroidectomy

Background: Strap muscle division during thyroidectomy is a controversial issue. The role of strap muscles in voice and swallowing functions and the postoperative morbid sequelae after strap muscles cutting have been proved by some investigators. So we have been enthused to develop a surgical approach that enables us to avoid such an unnecessary invasiveness, an idea that seems to be in harmony with both surgical orthodoxy and modern surgical trends towards less invasiveness. Objective: To give a precise detailed stepwise description of such proposed procedural surgical approach and its anatomical basis with the assessment of its feasibility and safety. Patients and Methods: 100 cases 35-60 years, F:M (3:2) presenting for thyroidectomy from April 2010 through May 2013; were selected for lateral (carotid triangle) approach, where we approach the superior thyroid vascular pedicle and the middle thyroid vein through the carotid triangle. Eligibility criteria were: Huge goitres not more than 12cm in greatest dimension, strong taut strap muscles in males, retropharyngyal, retrooesophageal or large Zuckerkandl tuberculum and vascular goitres with marked adhesions. Patients with small goitres, recurrent goitres, retrostenal goiters reaching aortic arch, previous neck irradiation, and malignant goitres were excluded. Intraoperative and postoperative data were gathered for procedural assessmen. Results: The procedure was successful in all of the study cases with no conversion to strap muscles cutting. RLN was identified in 93% of pts and EBSLN in 30%. Parahtyroid glands were identified and preserved in all pts. The mean intraoperative blood loss was 70cc, the mean operative time was 90 minutes, postoperative pain was well tolerated, mean amount of postoperative drainage was 78cc with a mean duration of 2 days and a mean hospital stay of 3 days. There were 2% permanent unilateral RLN injury, one developed transient EBSLN injury and 2 developed transient hypoparathyroidism. None developed sympathetic nerve injury. Conclusion: Lateral (Carotid triangle) approach to control the superior thyroid vascular pedicle enables us to avoid aggressive surgical handling of strap muscles by cutting or even excessive exhausting muscle retraction with its possible morbid sequelae in terms of voice and swallowing function post-thyroidectomy.