operative technique in general surgery

Editorial
I
n this modern age of minimally invasive surgery, it is easy
to forget or lose the sometimes subtle skills necessary to
perform major surgical procedures through larger, more con-
ventional incisions. We all realize that the larger the incision
the more the risk for wound complications, but the priority
in any surgical procedure is still the successful completion of
that procedure, even if it means extending the incision. In
addition, the “default” midline abdominal incision may not
be the best for the disease being addressed. Careful preoper-
ative assessment and planning can dictate a more limited
incision that provides for even better exposure at the exact
site of disease. Thus the general surgeon must have a full
armamentarium of incisions and exposures and be able to
choose and perform the correct one for the problem at hand.
These more rarely used incisions however, have subtleties
of management that if improperly performed, can result in
significant morbidity. This is especially true for surgical ex-
posures that cross conventional partitions of anatomy. Thus
the thoracoabominal and abdominoinguinal incisions have
specialized applications and details of performance that can
make all the difference in the success of the surgery and the
morbidity associated with it. Similarly, thoracic incisions and
retroperitoneal exposures are less commonly performed by
most general surgeons but, when needed, familiarity with the
anatomy and technique of reconstructive closure is critical.
Cervical exposures are needed for more than just thyroid
disease and clearly a meticulously performed incision in this
relatively cosmetic area of the body is important for patient

satisfaction as well as for minimizing complications.
The present collection of operative incisional techniques
provides the detail and description necessary for the general
surgeon who may be somewhat less practiced in these more
unusual exposures to perform them in a fashion that will
provide the greatest operative success with minimal subse-
quent morbidity.
Walter A. Koltun, MD
Professor of Surgery
Peter and Marshia Carlino
Professor of Inflammatory Bowel Disease
Chief, Section of Colon and Rectal Surgery
Penn State College of Medicine
Milton S. Hershey Medical Center
Editor-in-Chief
Volume 10, Number 2 June 2008
611524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2008.05.004
Introduction
A
dequate exposure is the key to successful surgery. Al-
though the abdominal incision has become the mainstay
of the general surgeon’s exposure, there are a number of other
incisions that are critical to the general surgeon’s armamen-
tarium. In this issue, we describe in detail the following ex-
posures: cervical, retroperitoneal, thoracic, thoraco-abdomi-
nal, and abdomino-inguinal.
Each of the authors has extensive clinical experience with
the techniques described, allowing them to share the critical
nuances that make the exposures successful. As a result, they

have been able to detail in a stepwise fashion the indications
for each incision, the positioning of the patient, the surgical
anatomy, the appropriate retraction systems, and the closure
of the surgical wound. The anatomical exposures are care-
fully illustrated with the aim of allowing an experienced sur-
geon who is unfamiliar with the incision to perform the tech-
nique.
One of the beauties of general surgery is the variability in
the clinical and operative challenges that it presents. By being
well versed in a variety of exposures, the surgeon is much
better equipped to successfully meet these challenges. It is
my sincere hope that this issue will increase the practicing
general surgeon’s versatility. It was a pleasure preparing this
issue and seeing it come together in its final form. I’m very
grateful to the authors for their hard work.
Kevin F. Staveley-O’Carroll, MD, PhD, FACS
Guest Editor
Volume 10, Number 2 June 2008
62 1524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2008.05.003
Incisions and Exposure of the Neck
for Thyroidectomy and Parathyroidectomy
Scott Pinchot, MD, Herbert Chen, MD, and Rebecca Sippel, MD
W
hile many articles in the medical literature focus on
the complications of thyroid and parathyroid surgery
such as nerve injury and hypoparathyroidism, very little at-
tention has been directed toward incision length and location
as they relate to conventional open thyroidectomy and para-
thyroidectomy.

1,2
Current techniques for open thyroidec-
tomy and parathyroidectomy are evolving to enable shorter
incisions; however, descriptions of the optimal location for a
cervical incision remain varied.
3
In this review, we aim to
briefly outline the historical background as it pertains to the
cervical incision for these procedures, and we hope to pro-
vide a thorough review of current methodological ap-
proaches to thyroidectomy and parathyroidectomy.
Historical Background
Some of the first descriptions of operations for “lumps in the
neck” may be found within the writings of The School of Sal-
erno, the 12th and 13th century cradle of thyroid surgery.
4
Published in 1170, the writings of Roger Frugardi describe
some of the earliest accounts of the cervical incision for treat-
ment of a single, large goiter; he writes, “two setons were in-
serted at right angles, with the help of a hot iron, and manipu-
lated toward the surface [of the skin] twice daily until they had
cut through the flesh.”
4
It is little wonder why (based on these
writings) the mid-19th century English surgeon Gross de-
nounced thyroid surgery as “horrid butchery . . . deserving
of rebuke and condemnation.”
5
Less barbaric means of per-
forming a cervical incision for thyroidectomy were detailed

in the writings of Pierre-Joseph Desault, a French surgeon
practicing in Paris during the years of the French Revolution
(1789-1799), during what would become the first well-doc-
umented partial thyroidectomy.
4
Desault notes the use of an
anterior median longitudinal skin incision to gain access to
the thyroid.
6
By the early 19th century, the technical principles govern-
ing cervical incisions for thyroidectomy usually included ei-
ther a longitudinal or oblique incision, although Y-shaped
and cruciate incisions were still documented in the litera-
ture.
4
However, thyroid surgery would truly come of age
during the 1850s, largely through the efforts of outstanding
surgeons like Theodor Billroth of Vienna and Theodor
Kocher of Berne. Before settling in Austria, Billroth held the
Chair of Surgery in Zürich, where he instituted surgery for
compressive symptoms of endemic goiter. While in Switzer-
land, Billroth used a lateral incision parallel to the inner bor-
der of the sternocleidomastoid muscle to gain access to the
thyroid.
6
Unfortunately, disheartened by a nearly 40% mor-
tality among his thyroidectomy patients, Billroth abandoned
thyroid surgery for some time, though not before passing the
baton to Theodor Kocher, a surgeon 12 years his junior.
4,5

Kocher, who would later be lauded as the “Father of Thyroid
Surgery,” initially performed his thyroidectomy through an
incision along the anterior border of the sternocleidomas-
toid.
5
His technique would later evolve to include a midline
and vertical component, adding his oblique extension to the
anterior border of the sternocleidomastoid (“Winkelschnitt”)
only when he needed better access.
4
By 1895, Kocher had
reduced the mortality from thyroidectomy to less than 1%
and then became more concerned with the cosmetic aspects
of his surgical incision. Employing an 8 to 10 cm collar inci-
sion that would later bear his name, Kocher popularized an
approach that would last well into the 20th century (Fig 1).
Central Incisions in
Modern Thyroid Surgery
The cervical collar incision is generally regarded in modern
texts of surgery as the appropriate neck incision for thyroid-
ectomy.
7-10
However, unlike the long transverse incision
popularized by Kocher, current techniques in thyroid inci-
sions have evolved, enabling surgeons to minimize the size of
their surgical incision.
3
Although this transition toward
smaller incisions has been readily put to practice, very little
has been published with regard to the optimal position and

length of the cervical collar incision.
Positioning of the collar incision during thyroidectomy is
of critical importance, as an inappropriately placed incision
may lead to needless scarring or unusual prominence. Inci-
sions placed less than 2 cm or one finger breadth from the
sternal notch frequently lead to hypertrophic scarring, espe-
cially when the scar overlies the manubrium.
10
Furthermore,
appropriate placement of the surgical incision may allow
Department of Surgery, University of Wisconsin Hospitals and Clinics,
Madison, WI.
Address reprint requests to Herbert Chen, MD, Associate Professor, Division
of General Surgery, University of Wisconsin Hospitals and Clinics, 600
Highland Avenue, Madison, WI 53792. E-mail:
631524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2008.03.001
scarring to be hidden by clothing.
12
Several techniques have
been described to aid in optimal incision placement. They
include (1) 1.5 to 2.0 cm superior to the sternoclavicular
joints,
9
(2) 1 cm caudal to the cricoid cartilage,
3,10,11
(3)3to
4 cm above the sternum extending laterally to the sternomas-
toid muscles,
13

(4) midway between the sternal notch and the
notch of the thyroid cartilage.
14
Of note, all techniques recommend incision placement in a
pre-existing neck crease whenever possible. In 2002, in a
detailed prospective study, Jancewicz and co-workers pro-
posed the optimal position for marking the midpoint of a
collar incision is one finger-breadth above the sternal notch
in the neutral upright neck position, or two finger-breadths
above the sternal notch in the supine, extended neck.
7
These
suggestions were reached after performing a thorough study
of incision migration in the supine and hyperextended neck
and after evaluating the influence of the degree of neck pa-
thology (factors such as goiter size, patient body mass index,
neck circumference, and type of surgery) on incision posi-
tion.
7
More recently, Sturgeon and colleagues disputed this
claim after an evaluation of several patients referred to their
practice for a “missed thyroid” during initial operation.
11
They noted one of the main reasons for failure at the initial
operation to locate the thyroid was that the incision was
made too low on the neck of patients with subjectively long
necks.
11
Based on their recommendations, the cricoid carti
-

lage should be palpated and the incision made approximately
1 cm inferior to this site because it centers the incision di-
rectly over the mid portion of the thyroid gland.
11
This ap
-
proach also gives the surgeon better exposure of the superior
Figure 1 Historical incisions. Before the transverse cervical collar incision was popularized, skin incisions were of
myriad variety, length, and direction. The incisions of many great pioneers of thyroid surgery are shown above.
64
S. Pinchot, H. Chen, and R. Sippel
pole vessels, allowing an overall smaller incision length. This
is our current procedure of choice.
Driven by patient demand for less pain and better cosmetic
results, the length of incision for thyroid surgery has been
decreasing in size.
3,15-19
Unlike the traditional 8 to 10 cm
collar incision popularized by Kocher and his contemporar-
ies, several studies now indicate that thyroidectomy may be
accomplished through a much smaller incision.
3
Much of the
decrease in incision length can be attributed to a higher
placement of the incision, which allows better and safer ex-
posure of the superior pole vessels through a much smaller
incision. Ferzli and colleagues described the use of a 2.5 cm
to 3 cm incision, termed a “mini-thyroidectomy.”
15
Similarly,

Takami
16
outlined the use ofa3cmskin incision, and Park
and co-workers described a minimally invasive open thyroid-
ectomy technique througha3to3.5cmincision.
17
Brunaud
and colleagues at the University of California, San Francisco
clarified the demarcation between conventional thyroidec-
tomy and its minimally invasive counterpart.
3
After deter
-
mining the minimum incision length in over 200 consecutive
operations, this group proposed the term “minimally inva-
sive” should be associated with an incision shorter than 3 cm
for thyroidectomy and 2.5 cm for parathyroidectomy.
3
Sev
-
eral studies identify the only limiting factor to mini-thyroid-
ectomy is the size of the gland; glands larger than 7 cm
frequently required extension of the incision beyond 4
cm.
15,16
Brunaud and colleagues suggest patient BMI, extent
of the planned exploration, and the resident clinical training
stage should also be taken into account before performing a
minimally invasive thyroidectomy or parathyroidectomy.
3

Lateral Focused Incision
for Minimal Access Thyroid
Surgery and Parathyroidectomy
While historically the traditional approach to the central
neck has been a central incision, recently there has been a
significant increase in the use of a lateral incision to approach
the central neck. It has been recently shown that neck sur-
gery, either parathyroidectomy or hemithyroidectomy,
may be feasibly performed througha2cmlateral incision
and is safe.
20
We find the lateral approach is especially useful
for focused parathyroidectomies and for reoperative neck
surgery. The lateral approach has also been applied to pri-
mary thyroidectomy for Minimal Access Thyroid Surgery
(MATS).
20-24
For parathyroidectomies, the lateral approach
gives excellent exposure for an upper gland, especially if
located deep in the tracheoesophageal groove. For reopera-
tive surgery, the lateral approach allows dissection through a
relatively unspoiled tissue plain.
23-24
Park and co-workers initially described the use of a lateral
incision for hemithyroidectomy in a cohort of 466 patients;
compared with historical controls, these patients had no dif-
ference in demographics, complications, or extent of surgery
including central compartment lymph node dissections but
exhibited smaller scar size, operative time, blood loss, and
analgesia requirements.

17
Stemming from the study of over
500 minimally invasive parathyroidectomies, Delbridge and
colleagues from the University of Sydney Endocrine Surgical
Unit have extensively described their ‘focused’ lateral approach
to thyroidectomy/(MATS).
20-23
Delbridge and co-workers have
shown MATS utilizinga2cmlateral incision may be a superior
approach and is especially suited to patients with a single follic-
ular thyroid nodule Ͻ2 c m in diameter.
20
Some contraindica
-
tions to the focused lateral approach to thyroidectomy include a
history of neck irradiation, history of prior neck surgery, multi-
nodular goiter, a diagnosis or family history of multiple endo-
crine neoplasia, proven autoimmune thyroiditis, significant co-
morbidity such as pregnancy, a nodule size Ͼ3 cm, fine needle
aspiration biopsy confirmation of carcinoma, and anatomic con-
siderations such as extreme obesity.
21,23
Indeed, a thorough understanding of the anatomy and
embryology of the thyroid and parathyroid glands is of par-
amount importance when performing a lateral approach. An-
atomic considerations will be detailed later in this paper.
Delbridge and co-workers have clearly shown that with suf-
ficient light and retraction, key anatomical structures in the
neck may be safely dissected through a small lateral inci-
sion.

21,23
Perioperative Care
Anesthesia
Most thyroid and parathyroid operations are performed un-
der general anesthesia; however, it is possible to perform the
procedure under local anesthesia. In fact, Spenknabel and
co-workers recently reported prospective data on 1,025 con-
secutive thyroidectomies performed under local anesthesia
and noted that this method appears safe and applicable to a
wide range of patients.
25
Confounding factors, including pa
-
tient anxiety and comfort, suggest this approach may be best
for high-risk patients in whom general anesthesia is ‘contra-
indicated’ or in remote areas where an anesthetist is unavail-
able. More commonly, general inhalation anesthetic agents
are utilized via endotracheal intubation; this airway is espe-
cially preferred for those in whom large goiters exert chronic
pressure against the trachea or in those with large substernal
goiters.
Incisions and exposure of the neck
65
Position and Operative Preparation
Figure 2 General topography of the thyroid gland (with left-sided tumor) in gentle neck extension. The technique
for thyroidectomy demands a thorough working knowledge of the anatomical details of normal and pathological
thyroid glands and their relationship to anatomic landmarks in the neck. A general understanding of the surface
anatomy will facilitate placement of cosmetically desirable incisions whereas minimizing complications relating to poor
wound healing, such as scar widening or keloid formation. Prominent landmarks of the neck’s surface anatomy include
the sternocleidomastoid muscle and the midline landmarks including the thyroid cartilage, body of the hyoid bone,

arch of the cricoid cartilage, and the sternal notch. Of the midline structures, the most prominent is the crest of the
thyroid cartilage, or “Adam’s apple.” Prominent in postpubertal men, this structure is usually located between the 3rd
and 5th cervical vertebrae. The body of the hyoid bone is palpated approximately 1.5 cm above the thyroid cartilage at
the level of the 3rd cervical vertebra. Likewise, the arch of the cricoid cartilage, the only complete cartilaginous ring
around the airway, is located on the same horizontal plane as the 6th cervical vertebra. As the consistency of cervical
skin changes with age, gentle extension of the neck facilitates identification of these structure.
27
The thyroid gland lies immediately caudal to the larynx, deep to the stenothyroid and sternohyoid muscles at
the level of the C5-T1 vertebral bodies. Though the gland may lie cephalad to C5 (lingual thyroid), it is rarely
found lower than T1.
27
Weighing approximately 30 g in the adult, the thyroid gland typically consists of two
lobes, a connecting isthmus, and an ascending pyramidal lobe. Each lobe is approximately 5 cm in length, 3 cm
at its greatest width, and 2 to 3 cm thick,
28
though one lobe may be smaller than the other or may be congenitally
absent. The thyroid isthmus unites the lobes over the trachea, usually at the 2nd through 3rd tracheal rings.
Interestingly, the isthmus may be absent in up to 10% of thyroid glands while the pyramidal lobe is absent in
about 50%.
66
S. Pinchot, H. Chen, and R. Sippel
Figure 3 Optimal placement of the cervical collar incision for thyroidectomy. After the induction of general
anesthesia, the patient is placed in a supine position and the neck is gently extended. Perfect alignment of the head and
body must be ensured to prevent erroneous placement of the cervical incision. Appropriate positioning ensures the
isthmus of the thyroid overlies the second and third tracheal rings just caudal to the cricoid cartilage.
11
The cricoid
cartilage is then palpated and its location noted. The skin incision is placed in a skin crease approximately 1 cm below
the cricoid cartilage. The orientation of the incision should be along the lines of Langer, since crossing the normal skin
lines may lead to more prominent scarring.

27
It is of paramount importance to place the incision in a neck crease
whenever possible, as neck creases have the least amount of tension. An incision made too low will result in pro-
nounced scar formation, difficulty in dissecting the superior pole, or perhaps missing the thyroid entirely. Incisions
made too high will make it difficult to remove lymph nodes in the superior mediastinum if indicated and can be
cosmetically unappealing.
11
In smaller masses, we traditionally begin with a 3 to 4 cm incision, though lateral extension of this incision may be
warranted based on the size of the gland. Factors that affect the size of the incision include gland size, patient body mass
index, extent of planned exploration, and resident training level.
3,15-16
The skin incision should be made with a deliberate sweep of the scalpel, dividing the skin and subcutaneous tissue
simultaneously. Hemostasis is achieved with bipolar electrocautery; alternatively, larger bleeding subcutaneous vessels
may require application of hemostats with subsequent ligation of the bleeding vessel. The latter method should be
limited to one or two ligatures, as many more may result in tissue strangulation with subsequent induration and
inflammation.
26
The incision is deepened to the areolar tissue plane just deep to the platysma muscle where an
avascular plane is reached.
Incisions and exposure of the neck
67
Figure 4 Development of the subplatysmal plane. Once the incision is made and deepened through the platysma, the
superior and inferior subplatysmal planes are developed. Using two Alice clamps or 3 to 5 straight Kelly clamps, the superior
edge of the platysma muscle or dermis is grasped and placed under tension. Ideally, dissection should proceed within the
relatively avascular plane between the platysma muscle fibers and the anterior jugular veins. Utilizing a combination of blunt
and sharp dissection within this plane—alternatively, bipolar electrocautery is acceptable to raise the skin flap in the hands
of an experienced surgeon—the upper skin flap is freed to the level of the thyroid notch. Th e inferior edge of the platysma is
then grasped and an inferior flap is created in similar fashion. Dissection should be carried down to the level of the suprasternal
notch.
The anterior jugular veins symmetrically flank the midline raphe of the neck. Special care must be taken to avoid injury to

these veins, as active bleeding and danger of air embolus have been reported with openings made into the anterior jugular vein.
26
68
S. Pinchot, H. Chen, and R. Sippel
Figure 5 Exposing the thyroid gland. The skin flaps are held apart with a self-retaining retractor. With a scalpel or
bipolar electrocautery device, the cervical fascia investing the paired sternohyoid muscles is then incised, separating the
strap muscles (sternohyoid and sternothyroid). As the length of this incision will ultimately determine access to the
thyroid gland, the incision should be placed exactly in the midline of the neck between the sternohyoid muscles,
extending from the thyroid notch to the level of the sternal notch. There are frequently crossing veins at both the
superior and inferior aspects of the midline and care must be taken to avoid bleeding.
The strap muscles are then elevated and gently dissected off the thyroid capsule bilaterally. This step may be
facilitated by the use of a peanut dissector or blunt forceps. The blunt handle of the forceps may be inserted beneath the
paired sternohyoid muscles to assist with dissection. This avascular plane between the strap muscles and the thyroid
gland can be bluntly dissected until the middle thyroid vein is identified. Alternatively, should the strap muscles and
thyroid capsule be densely adherent, the loose fascia investing the thyroid gland may be elevated with forceps and
incised with a scalpel to develop the appropriate cleavage plane.
26
Development of the proper cleavage plane will allow
lateral mobilization of the sternohyoid and sternothyroid muscles. Complete incision and reflection of the fascia of the
sternothyroid muscle clearly reveals the blood vessels within the capsule of the thyroid gland. Further exposure of the
thyroid gland may be facilitated by the use of small Richardson retractors, which are utilized for exposure of the gland
via lateral retraction of the strap muscles. Routine division of the strap muscles is unnecessary unless greater exposure
is required to gain safe access to an extremely large or vascular goiter.
13
Incisions and exposure of the neck
69
Figure 6 Central approach to thyroidectomy. Before lateral dissection, the isthmus should be identified and mobilized
both superiorly and inferiorly just anterior to the trachea. The isthmus is divided at this point if a lobectomy is
indicated; alternatively, if a total thyroidectomy is to be done, our preference is to remove the gland in one piece. During
this medial dissection, the pyramidal lobe, if present, is dissected free from the surrounding tissues with electrocautery.

The superior extent of this lobe is divided at the point in which the gland tapers to a fibrous band, usually near the level
of the thyroid cartilage. Small Richardson retractors are then utilized for lateral retraction of the strap muscles. The
dissection should proceed laterally until the middle thyroid vein is identified. The thyroid lobe is retracted anterome-
dially and the carotid is retracted laterally, placing the middle thyroid vein on tension. The vein is then divided to allow
better exposure of the superior pole and posterior thyroid.
The lateral tissues are then bluntly dissected up to the level of the superior pole. The superior pole is then dissected free
medially, between the cricothyroid muscle and the thyroid capsule. The space medial to the superior thyroid artery is
carefully opened to expose the external branch of the superior laryngeal nerve (ESLN). Using right angle clamps from medial
to lateral, the superior pole vessels are dissected and doubly clamped and tied with 2-0 silk ties. These vascular branches must
be tied close to the thyroid gland to prevent injury to the ESLN. With the superior pole mobilized, the upper parathyroid
gland is identified and separated from the thyroid gland, taking care to protect its vascular pedicle. Through careful
dissection of the tissues along the lateral aspect of the mid thyroid gland, the recurrent laryngeal nerve (RLN) is
visualized. Once identified, the inferior pole vessels can be safely divided using 2 to 0 silk ties. Care should be taken to
avoid injury to the inferior parathyroid gland, which lies anterior to the RLN on the posterior lateral surface of the
thyroid. The ligament of Berry is then sharply divided, taking care to perform dissection anterior to the RLN to avoid
injuring any medial branches. For a total thyroidectomy, the above procedure is repeated on the contralateral side.
70
S. Pinchot, H. Chen, and R. Sippel
Figure 7 Focused lateral approach to the neck. The lateral approach was developed for minimal-access parathyroid-
ectomy, but after much success has also been applied to minimal access thyroidectomy.
23
A thorough understanding
of the anatomical details of normal and pathological thyroid and parathyroid glands and their relationship to anatom-
ical landmarks in the neck is critical. As thyroid gland anatomy has been previously reviewed, emphasis will be placed on
important parathyroid considerations. The superior parathyroids develop from the fourth pharyngeal pouch and are rela-
tively constant in their location. An enlarged superior parathyroid gland frequently descends along the tracheoesophageal
grove and may be found in a relatively posterior plane in the lower part of the neck.
21
The inferior parathyroid glands develop
from the third pharyngeal pouch and are more inconsistent in their location. Descending with the developing thymus, the

inferior parathyroids are found in a relatively anterior plane.
Intraoperative identification of the tumor is the critical, though often daunting, task of any minimally invasive neck
surgeon. Important anatomic landmarks that aid in the localization of pathology include the tracheoesophageal groove,
prevertebral fascia, tubercle of Zuckerkandl, and recurrent laryngeal nerve (RLN).
21
Deformities from large thyroid nodules
or parathyroid adenomas may displace the RLN; therefore, the nerve must be visualized and preserved through gentle
dissection to avoid vocal cord dysfunction and/or paralysis.
With this said, similar to conventional thyroidectomy, the patient is positioned in a supine position with the arms
tucked at their side. The neck is placed in mild extension and the head supported with a donut pillow or foam head
support. The bed is placed in 15 to 30 degrees of the reverse Trendelenburg position to lessen venous congestion in the
neck veins. A fiber optic operating headlight is used for optimal viewing of the surgical field.
Incisions and exposure of the neck
71
Figure 8 Incision and exposure during lateral approach. The site of the incision depends on the location of the
thyroid or parathyroid pathology. Important anatomical landmarks including the midline, suprasternal notch, and
medial margins of the sternocleidomastoid (SCM) muscles are identified and may be marked. With a deliberate sweep
of a scalpel, a 2.5 cm lateral transverse incision is made directly over the pathology or over the middle of the thyroid
lobe, straddling the medial margin of the SCM. The incision should be performed sharply through the platysma.
Counter traction on the skin with a sterile sponge prevents back bleeding. Again, electrocautery should be limited on
the subcutaneous bleeding sites to prevent thermal injury.
The subplatysmal plane is developed using a combination of blunt finger dissection and electrocautery. Any vessels
encountered may be ligated or clipped with metal clips. For parathyroidectomy, minimal subplatysmal plane is needed.
However, for thyroidectomy adequate development of the subplatysmal plane will allow mobility of the skin incision
over the relevant area of dissection throughout the procedure. Skin and platysma flaps may be retracted with a
self-retaining retractor; alternatively, a hand-held retractor (i.e., vein or loop) may be utilized to allow for greater
mobility and repositioning of the incision to where the dissection is being done.
The SCM is then identified and its overlying investing layer of cervical fascia is incised. Lateral dissection along the
SCM will allow exposure of the lateral margin of the strap muscles. The SCM is retracted laterally; a silk stay stitch may
be placed to hold the muscle in position and allow adequate exposure.

72
S. Pinchot, H. Chen, and R. Sippel
Figure 9 With the SCM retracted laterally, the investing fascia of the strap muscles is incised. Exposure of the thyroid
gland is facilitated by careful dissection of the space posterior to the strap muscles. Adequate dissection of this space will
allow for visualization of the inferior pole of the thyroid and trachea. The thyroid gland and strap muscles are then
retracted medially together, exposing the middle thyroid vein. The middle thyroid vein is divided and ligated with 2-0
silk ties or metal clips. The space medial to the common carotid artery is then dissected down to the prevertebral fascial
plane. Gentle finger dissection facilitates the development of the space between the posterior aspect of the thyroid gland
and prevertebral fascia. This essentially frees up the entire parathyroid-bearing region of that side of the neck.
21,23
Incisions and exposure of the neck
73
Following induction of general anesthesia, the patient
should be placed in a supine, semierect position on a stan-
dard operating table. Neck extension is facilitated by placing
a folded sheet, pillow, or sandbag beneath the shoulders.
Jancewicz and co-workers suggest placing a 1 liter flask of
intravenous fluid transversely in line with the spines of the
scapulae beneath the patient, allowing gentle extension of the
neck.
7
Our preference is to place a deflated intravenous pres-
sure bag underneath the patient’s shoulders. The bag is then
inflated to produce the appropriate amount of neck exten-
sion. The head should be well supported using a gelatinous
head-ring, and special care must be taken, especially in the
elderly, to avoid over-extension of the neck. Hyperextension
of the neck may lead to increased postoperative pain and a
slight risk of spinal cord damage.
11

The operating table may
be tilted 15 to 30 degrees in the reverse Trendelenburg posi-
tion to reduce venous congestion in the neck. A headlight
facilitates lighting and exposure through the limited inci-
sions. Importantly, the anesthesiologist and surgeon must
ensure perfect alignment of the head and body before mark-
ing the line of incision; any small deviation to the side may
result in an inaccurately placed incision.
26
Hemithyroidectomy then proceeds in systematic fashion.
Cranial retraction of the skin incision reveals key structures
involved in dissection of the superior pole. The superior pole
of the thyroid lobe is retracted laterally, opening the avascu-
lar space and allowing for visualization of the external branch
of the superior laryngeal nerve (ESLN) and superior thyroid
artery. The artery is divided between silk ties or metal clips
immediately adjacent to the thyroid capsule, preventing in-
jury to the ESLN. Adjustment of skin retraction toward the
midline allows for exposure of the trachea and thyroid isth-
mus. We expose the tracheal surface above and below the
isthmus and subsequently divide the isthmus. This facilitates
mobility of the thyroid lobe and allows for increased expo-
sure during the lateral dissection. Caudal retraction allows
for mobilization and dissection of the inferior pole. Care
must be taken to avoid injury to the inferior parathyroid
gland. Finally, the skin incision is retracted laterally; delivery
of the thyroid nodule or lobe through the small incision
facilitates lateral gland exposure. Careful dissection will allow
for identification and protection of the recurrent laryngeal
nerve (RLN). The ligament of Berry is then divided and the

thyroid lobe is removed.
21,23
Wound Closure
Meticulous hemostasis must be the standard of practice as the
most serious and life-threatening complication of thryoidec-
tomy and parathyroidectomy is postoperative airway ob-
struction because of excessive bleeding and hematoma for-
mation. Although the placement of surgical suction drains
may allow for drainage of a small hematoma, the routine use
of surgical drains is not an alternative to hemostasis. In fact,
Hurtado-Lopez and co-workers recently showed that pa-
tients in whom surgical drains were used required prolonged
hospitalization compared with those without drains.
29
Addi-
tionally, active suction may damage the recurrent laryngeal
nerve or parathyroid glands if the drain is in close contact
with these structures.
30
After adequate hemostasis is ob-
tained, the strap muscles are reapproximated with absorb-
able suture in simple or figure-of-eight fashion. The wound is
closed with subcutaneous absorbable suture to the platysma
and a running subcuticular non-absorbable suture for dermal
approximation.
Special Postoperative Care
Postoperatively, the patient should immediately be placed in
a low Fowler position with the head of the bed elevated at
least 10 to 20 degrees. This position should be maintained for
12 hours to facilitate hemostasis and limit neck vein engorge-

ment.
Guidelines should be developed to address serum calcium
management after total, near total, or subtotal thyroidecto-
mies and total parathyroidectomies. On the postoperative
evening, we refrain from routine use of intravenous calcium
supplementation, reserving the use of 1 amp of calcium glu-
conate only if carpopedal spasm and/or tetany suggest severe
hypocalcemia. Serum calcium levels should be measured 4
hours postoperatively and again the following morning. Cal-
cium carbonate is given as needed for mild symptoms of
hypocalcemia; patients with severe hypocalcemia are started
on scheduled calcium carbonate three times per day. All pa-
tients are started and sent home on scheduled calcium car-
bonate twice daily beginning on postoperative day 1. We
recommend patients discontinue the use of calcium supple-
mentation at least 1 day before the follow-up clinic visit so as
to assess an accurate serum calcium and PTH level at that
time.
Important Complications
Several important complications may be encountered after
thyroidectomy or parathyroidectomy. Complications result-
ing from damage to vital structures, such as the laryngeal
nerves and parathyroid glands, may be avoided by maintain-
ing a near bloodless surgical field and performing meticulous
dissection. The most important complications of thyroidec-
tomy are:
● Recurrent laryngeal nerve injury
● External branch of superior laryngeal nerve injury
● Hypocalcemia resulting from hypoparathyroidism
● Neck hematoma

● Seroma formation
● Infection
● Wound complications
Unilateral recurrent laryngeal nerve injury manifests as tran-
sient or permanent hoarseness in the postoperative period. Bi-
lateral recurrent laryngeal nerve injury is much more serious,
because the vocal cords may assume a median or paramedian
position, often causing inspiratory stridor and the need for
emergent intubation. Fortunately, bilateral recurrent laryngeal
nerve palsy is an exceedingly rare complication of thyroidec-
tomy and is most likely to be encountered with difficult reop-
eration when one recurrent laryngeal nerve has already been
injured during a prior operation. Indeed, the identification of
the recurrent laryngeal nerve throughout its course is quite fun-
damental if damage from thyroidectomy is to be avoided.
Injury to the external branch of the superior laryngeal
nerve occurs when the nerve is inadequately visualized dur-
ing the dissection and ligation of the upper pole vessels.
74
S. Pinchot, H. Chen, and R. Sippel
Injury to the nerve can result in transient impairment of the
ipsilateral cricothyroid muscle, making projection of one’s
voice or singing a high note quite difficult. Although these
injuries tend to be transient and improve in the months after
surgery, permanent injuries do occur.
Hypocalcemia in the postoperative period is not un-
common and results from removal, injury or devascular-
ization of the parathyroid glands resulting in mild to se-
vere hypocalcemia. The nadir for serum calcium levels
after surgery often does not occur until 48 to 72 hours

postoperatively; however, symptoms consistent with mild
and severe hypocalcemia must be recognized. Symptoms
range from mild paresthesias to carpopedal spasm and
tetany. Mild hypocalcemia may be treated with oral cal-
cium supplementation and close observation; more pro-
found hypocalcemia requires intravenous calcium supple-
mentation initially, followed by oral supplementation with
calcium and/or calcitriol.
Perhaps the most serious and life-threatening complica-
tion of thyroidectomy and parathyroidectomy is airway ob-
struction resulting from postoperative bleeding and neck he-
matoma. Though extremely rare, the urgency of treating this
condition once recognized cannot be overemphasized, espe-
cially if respiratory compromise is present. In emergency sit-
uations, treatment requires removal of the surgical dressing
and reopening the wound, even if at the bedside, for evacu-
ation of the hematoma and relief of the pressure being ex-
erted on the upper airway. Aseptic technique should be
maintained whenever possible. Pressure should be applied
with a sterile sponge and the patient should immediately
return to the operating room for surgical exploration and
hemostasis.
Wound complications can be minimized by the use of
appropriate incision placement and the use of non-absorb-
able suture. This is especially true of keloid formation and
scar granuloma. Though seroma is common with extended
lymph node dissection, most resorb spontaneously and do
not require further intervention. Infection is quite rare, and
we do not routinely use prophylactic antibiotics preopera-
tively.

Conclusion
Surgical incisions and exposures in the neck, particularly
with regard to thyroidectomy and parathyroidectomy, have
evolved drastically since the days of Kocher and Billroth.
Techniques for optimally placing a neck incision have
evolved to accommodate the desire for minimally invasive
surgery and improved cosmesis. The transverse cervical col-
lar incision, initially described by Kocher and altered by
countless others, remains the preferred incision of choice for
most surgeons based on its relative ease, adequacy of expo-
sure, and suitable cosmetic result. In selected patients, a lat-
eral focused approach to the parathyroid gland and thyroid
lobe is feasible, safe, and effective. In the hands of a skilled
surgeon familiar with the anatomic details of each surgical
technique, either approach should be associated with ex-
tremely low morbidity and mortality.
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76
S. Pinchot, H. Chen, and R. Sippel
Thoracic Incisions
David B. Campbell, MD
A
ccess to chest contents and appreciation of the anatomy
of the chest wall and internal anatomy are practical req-
uisites for all general and trauma surgeons. The expediency of
a clinical situation and the scope of the patient’s problems
dictate the access options chosen. Although minimally inva-
sive options for elective operations within the chest are evolv-
ing, small chest incisions offer less flexible access than lapa-
roscopic surgery because of fixed intercostal positions,
postoperative pain from involvement of multiple intercostal
nerves, and immature instrumentation to address the variety
of pathologies encountered. The need for adequate ventila-
tion with endobronchial control is a unique concern for all
chest operations, but a generous open exposure is required
for rapid and uncompromised exposure of the heart, lung
hilum, or aorta. A collaborative effort with anesthesia pro-
vides lung isolation. A double lumen endotracheal tube, an
endobronchial blocker or mainstem bronchial intubation can

all be effective. Abdominal incisions through soft tissues have
inherent mobility, but most thoracic incisions provide lim-
ited flexibility because access is limited by the rigid chest wall
and overlapping muscles with different functions. A proper
thoracic incision provides adequate exposure while minimiz-
ing damage to ribs, cartilage, muscle, and intercostal nerves.
Options for extension should be anticipated. A limited inci-
sion provides limited exposure, and over-retraction may re-
sult in complex local rib fractures and muscle tears. The skin
incision may be minimized, but the internal intercostal inci-
sion should be relatively wide from front to back to allow the
ribs to separate by “hinging” like bucket handles. Optimal
pain management begins before thoracotomy, and a variety
of ancillary indwelling catheters can alleviate pain and expe-
dite recovery.
Chest Incision Closure
Hemostasis is achieved in the usual manner, but unipolar
electrocautery should be used with caution in the posterior
mediastinum near intervertebral foramina. After every thora-
cotomy, the chest should be flooded with warm saline and
the lung re-inflated to check for air leaks. Direct suture, sta-
pling, and applied topical adhesives and hemostatic agents
should be used aggressively to minimize postoperative air
leaks. Infection risks are thereby minimized, chest tube
removal expedited and lengths of stay minimized. Inter-
rupted paracostal sutures of #1 braided Dacron provide
secure rib approximation. Intrathoracic dead space should
be minimized and routinely two 32°F chest tubes are used:
a straight tube in an apical anterior position for air evacu-
ation and a basal curved tube in the posterior recess to

recover blood and fluid. Tubes should exit the skin ante-
rior to the mid axillary line to minimize discomfort when
the patient lays supine. Incised muscles are re-approxi-
mated with strong running suture taking bites of fascia in
front and back. Large spaces around separated muscles
should be drained with soft flexible catheters to prevent se-
roma formation.
The risk of chest wall hernia after thoracotomy is low, and
most incision closures are straightforward. However, pain
control deserves special emphasis, as adequate analgesia al-
lows patients to maintain adequate pulmonary toilet and to
progress toward functional recovery. Epidural, paravertebral,
and intercostal catheters all have proper places in postoperative
management. Intercostal nerve blocks (bupivacaine 0.5% with
epinephrine 1/200,000) offer excellent supplemental pain relief.
Brief discussions of chest incisions useful to the general surgeon,
particularly with respect to trauma, follow.
Table 1 presents a summary comparison of four useful
incisions.
Anterior Thoracotomy
Emergent access to the heart for manual cardiopulmonary
resuscitation or tamponade can be achieved by left antero-
lateral thoracotomy. Access to both ventricles, the left hi-
lum, and the descending aorta is possible. A submammary
incision is made and extended down to the superior sur-
face of the underlying fifth or sixth rib (Fig 1A). This is at
the inferior margin of the pectoralis major muscle, and
intercostal incision is made over the top of the underlying
rib. Extension laterally follows the split fibers of the ser-
ratus. Medial extension to the sternum will divide the

internal mammary artery, which lies 1 cm lateral to the
sternum. Limiting the medial extent avoids this trouble-
Department of Cardiothoracic Surgery, Penn State Milton S. Hershey Med-
ical Center, Hershey, PA.
Address reprint requests to David B. Campbell, MD, Professor of Cardiotho-
racic Surgery, Penn State Milton S. Hershey Medical Center, MC H-165,
500 University Drive, Hershey, PA 17033. E-mail:
771524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2008.06.001
Figure 1 Anterior thoracotomy. (A) Line of incision, left chest rotated up 30 degrees. (B) Deep exposure with pectoralis
major incised medially.
78
D.B. Campbell
Figure 1 (Continued) Anterior thoracotomy, continued. (C) Pericardium opened, heart exposed, sutures placed in stab
wound. (D) Chest closure with rib reapproximation and paracostal sutures.
Thoracic incisions
79
some bleeding. A retractor is inserted and opened as much
as needed, mindful that the anterior costal cartilages are
more fragile than bone. These cartilages can be divided
with rib shears to enhance the exposure (Fig 1B), although
wound closure is tedious and healing is not rapid. Stout
sutures are placed through the cartilages and interspace
musculature, and several paracostal sutures are placed
around the ribs of the interspace incision (Fig 1D). Two
chest tubes (apicoanterior and posterobasal) are brought
out below, and a subcutaneous drain may be prudent if
large muscle flaps were developed.
This incision provides access to the ipsilateral hilum that is
unrestricted (Fig 1C). In case of massive lung bleeding, a

large hilar clamp can be applied from above downwards
across the pulmonary artery, bronchus, and both veins.
Emergent clamping of the descending thoracic aorta is pos-
sible by pulling the lung forward. Relief of pericardial tam-
ponade or open cardiac message requires incision into the
pericardial space, and widest exposure is possible with a
longitudinal incision anterior and parallel to the phrenic
nerve. Pericardiotomy should avoid phrenic nerve divi-
sion. Finger pressure may be required to control bleeding
from a cardiac stab wound, and traction sutures maintain
exposure of the heart for suture placement. The pericar-
dium can be loosely re-approximated with interrupted su-
tures to provide cardiac support. Closure should be loose
enough to prevent tamponade from epicardial bleeding, but
sutures should be close enough to prevent cardiac herniation
through the defect.
Broken costal cartilages and ribs are frequent with this
emergency access. Transection of the anterior costal carti-
lages may be more prudent than applying increasing raw
retraction. Nevertheless, closure is routine with paracostal
sutures providing needed stabilization. This incision can be
extended across the sternum with a saw or rib shears, al-
though closure is less stable. Postoperative pain control ef-
forts (above) will be appreciated by the patient.
Posterolateral Thoracotomy
When uncompromised access to the lung and mediasti-
num is necessary, the patient should be placed in full
lateral position. If hemoptysis is a significant problem,
then the airway should be controlled with a double lumen
tube, or at least with an intrabronchial blocker. Turning

the patient into the lateral decubitus position places the
“good” lung down, making it more vulnerable to blood
and secretions in the airway. Posterolateral thoracotomy is
the classic incision for lung and mediastinal surgery and
on the left side this exposure is still preferred for descend-
ing aortic procedures. On the right side, it offers the best
access to the intrathoracic trachea and to the mid and
upper esophagus.
The skin incision for posterolateral thoracotomy is
generous, from behind the scapula around its inferior bor-
der to the submammary crease anteriorly (Fig 2A). The
blood and nerve supplies of the latissimus dorsi originate
above, so this muscle should be mobilized inferiorly and
transected at a low level to maximize its functional recov-
ery. Intercostal division is made widely from front to back,
and the serratus anterior can often be left intact and re-
Table 1 Comparison of the Four Most Useful Incisions
Incision Advantages Disadvantages
Median sternotomy Wide mediastinal exposure
Access to both hila
Full cardiac access
Option for cardiopulmonary bypass
Little postoperative pain
Augments liver and IVC exposure for difficult
abdominal cases
Good internal access to chest wall injuries
Requires a saw
Poor access to descending aorta
Poor access to left lower lobe
Suboptimal access to trachea and

bronchi
No esophageal access
Anterior thoracotomy Rapid access to heart and hila, especially on left side
Vertical and/or trans-sternal extensions possible
Limited access to lung
No esophageal or large airway access
Moderate postoperative pain
Posterolateral
thoracotomy
Adequate for all lung and esophageal problems
Best distal arch and descending aortic exposure
Conventional instruments used
Intercostal flap can be harvested
Extension for thoracoabdominal exposure possible
Frequent rib fractures
Requires muscle division and
reconstruction
Cosmetically undesirable
Moderate postoperative pain
Lateral muscle sparing
thoracotomy
Adequate for almost all lung and esophageal problems
Conventional instruments used
No muscle division, little to heal
Cosmetically acceptable
Extension to posterolateral thoracotomy possible
Intercostal flap can be harvested
Requires dissection and retraction
(not rapid)
Inadequate aortic exposure

Moderate postoperative pain
80
D.B. Campbell
Figure 2 Posterolateral thoracotomy. (A) In-
cision with patient in left lateral decubitus
position. (B) Wide exposure with latissimus
dorsi divided, 5th rib incised posteriorly. (C)
Rib approximator allows secure closure with
paracostal sutures.
Thoracic incisions
81
Figure 3 Muscle sparing lateral thoracotomy. (A) Incisions, patient in left lateral decubitus position. (B) Subcutaneous
flaps allow serratus anterior muscle retraction upward and chest wall access.
82
D.B. Campbell
tracted upward and forward. If wider exposure is required,
then a short length of rib can be transected posteriorly
with rib shears (Fig 2B) to prevent multiple complex frac-
tures. Closure is conducted in layers, with strong perma-
nent paracostal sutures (Fig 2C) and running absorbable
sutures for muscle re-approximation and subcutaneous
layers. When this incision is made, two interspaces lower,
extension across the costal margin for thoracoabdominal
exposure is straightforward.
Muscle Sparing
Lateral Thoracotomy
Large muscle division can be avoided for most routine
thoracic exposures, including those for acute chest wall
and lung trauma, and for late empyema drainage and de-
cortication. A lateral thoracotomy of 4 to 5 inches with

separation and retraction of latissimus and serratus mus-
cles allows manual palpation of intrathoracic structures
and use of conventional instruments for most elective op-
erations. Crossed Tuffier and Balfour retractors provide
ample access and exposure at the level of the hila over the
major fissure. Landmarks for the skin incision are a point
one inch above the scapular tip and the inframammary
crease (Fig 3A). The sixth rib underlies a line connecting
these points, but chest entry can be an interspace higher.
Skin and subcutaneous tissues are incised along this line
from just behind the midaxillary line (the anterior border
of the latissimus) forward about 5 inches. The anterior
border of the latissimus is mobilized above and below.
This muscle is retracted posteriorly and away from the
chest wall. With finger dissection, the underlying serratus
is separated, taking care not to injure the long thoracic
nerve on its surface. Traction is applied to the serratus in
an upward and anterior direction to allow identification of
its inferior border, and the fat below is cauterized and
divided to expose the chest wall (Fig 3B). When access to
the top of the thoracic cavity is desired (fourth intercostal
space) it is often advantageous to separate the lowest in-
sertion of the serratus from the chest wall. Maintaining
upward traction on the serratus, ipsilateral ventilation is
stopped and intercostal incision is made above a rib, from
back to front through the three layers of intercostal mus-
cle. Using a Kelly clamp for initial intercostal entry allows
the lung to fall away from the chest wall, minimizing the
chance of lung injury from cautery. The incision is en-
larged anteriorly and posteriorly with electrocautery.

Paraspinous muscles posteriorly and the upward sweep of
the ribs (short of the internal thoracic artery pedicle) an-
teriorly are practical limits for intercostal division. If an
intercostal flap is not required, a Tuffier retractor main-
tains intercostal distraction, and a Balfour is opened at
right angles to provide additional soft tissue retraction (Fig
3C). Rib division and fractures are avoided. This exposure
allows insertion of a hand for full palpation of the lung and
mediastinum, and conventional instruments and tech-
niques are used for necessary procedures.
Figure 3 (Continued) Muscle sparing lateral thoracotomy, continued. (C) After interior front-to-back muscle division,
crossed Balfour and Tuffier retractors provide exposure without rib fractures.
Thoracic incisions
83
Figure 4 Median sternotomy. (A) Sternum is divided in the midline with a saw. (B) Pericardium is opened and
suspended, allowing full cardiac and hilar access.
84
D.B. Campbell