Surgical Resection of Retrosternal Goitre: The Four-Finger Technique

Area of Science:

• Endocrinology
• Surgical Oncology
• Thoracic Surgery

Background:

• Retrosternal goitre (RSG) is defined as a thyroid gland with over 50% of its mass below the thoracic inlet.
• Pre-operative Computed Tomography (CT) is crucial for visualizing the anatomical relationships and extension level of RSG.
• While most RSG can be managed via a cervical approach, thoracic approaches carry higher complication risks.

Purpose of the Study:

• To describe a minimally invasive "four finger technique" for total thyroidectomy in patients with RSG.
• To demonstrate the feasibility of resecting RSG exclusively through a cervical incision, avoiding sternotomy.
• To highlight the importance of early identification of critical structures like the recurrent laryngeal nerve (RLN) and parathyroid glands.

Main Methods:

• A "four finger technique" was employed for total thyroidectomy in five patients with RSG.
• The procedure was performed through a standard neck incision, without requiring sternotomy.
• Key steps included early identification of the RLN in Baehr's triangle, ligation of feeding vessels, mobilization from tracheal attachments, and blunt dissection to deliver the retrosternal portion into the neck.

Main Results:

• Successful total thyroidectomy was achieved in all five cases using the described cervical approach.
• The technique allowed for the delivery of the retrosternal portion of the thyroid into the neck via blunt dissection.
• Early identification of the RLN and parathyroids was performed, aiming to prevent complications.

Conclusions:

• The "four finger technique" offers a safe and effective method for the cervical resection of retrosternal goiters.
• This approach obviates the need for sternotomy, thereby reducing surgical morbidity.
• Prioritizing early identification of the RLN and parathyroids is essential for minimizing surgical complications such as hoarseness and hypocalcemia.