Make a transverse collar incision within a skin crease approximately 1 cm below the cricoid cartilage.
Incise through the skin, subcutaneous tissue, and platysma muscle.
Raise subplatysmal flaps, extending superiorly to the thyroid cartilage and inferiorly to the sternal notch.
Divide the fascia between the strap muscles midline, typically right between the paired anterior jugular veins, paying careful attention to any branches that may cross the midline. Separate the sternohyoid muscle from the sternothyroid muscle bluntly.
Dissect the sternothyroid muscle off of the thyroid and retract the strap muscles laterally, exposing the anterior surface of the thyroid gland.
Medially rotate the thyroid gland, divide the middle thyroid veins near the thyroid capsule. Be careful not to disrupt the blood supply, and carefully sweep the parathyroid gland off the thyroid.
Expose & ligate the superior pole vessels close to the thyroid. Avoid damaging the external branch of superior laryngeal nerve, which typically crosses these vessels within about 1 cm above the apex of the thyroid gland.
Expose & protect the RLN at the cricoid at the ligament of Berry (tracheal attachment to the thyroid) near the tubercle of Zuckerkandl (posterior pyramidal thyroid extensions) and the tracheoesophageal groove. The inferior thyroid artery is also a good marker for the RLN, which passes beneath it.
The small branches of the inferior thyroid artery and the thick fibrous ligament of Berry fibers should be divided carefully with bipolar, clips, or ties in order to protect the nearby nerve from monopolar cautery or other vessel-ligating devices that can cause thermal injury.
The thyroid can be removed after dividing the ligament of Berry and all remaining attachments to the thyroid gland.
Educational aid only. Verify every dose, indication, and guideline against current institutional protocol. This is not a substitute for clinical judgment.
