Ventilation-assisted functional visualization: a stepwise workflow for planned management of a preoperatively identified tracheal diverticulum during thyroidectomy

Tracheal diverticulum is frequently detected incidentally on cross-sectional imaging but may pose a significant intraoperative challenge when anticipated within or adjacent to the thyroid surgical field, particularly in close proximity to the recurrent laryngeal nerve (RLN) and during central compartment (level VI) dissection. Conventionally, surgeons use preoperative computed tomography (CT) to approximate diverticular anatomy and then rely on intraoperative experience and anatomic landmarks for dissection. Recognition is challenging because intraoperative localization relies on CT correlation and anatomic landmarks within the posterior capsular plane; limited exposure may obscure the diverticulum, and a non-aerated sac may collapse and become indistinguishable from surrounding soft tissue, increasing the risk of rupture and subsequent loss of tension with further obscured planes and potential operative-field contamination. However, a standardized intraoperative workflow to functionally localize the diverticulum (and confirm tracheal communication) before definitive posterior dissection, and to verify tracheal integrity after diverticulectomy and repair, is lacking. Here, we describe a stepwise surgical technique for planned thyroidectomy in which a cervical tracheal diverticulum has been identified preoperatively. The workflow integrates preoperative contrast-enhanced CT-based risk stratification with a ventilation-assisted functional visualization maneuver [standardized endotracheal tube (ETT) repositioning within recorded cuff-depth boundaries 'D_cuff, the ETT incisor depth at which the proximal cuff margin is visualized just distal to the vocal cords; D_cuff2, the deeper ETT incisor depth after advancement beyond the diverticular level to keep the cuff distal to the diverticular ostium'] to localize the diverticular sac at the CT-predicted region and confirm tracheal communication before definitive posterior dissection. After localization, posterior dissection proceeds with deliberate RLN identification and protection, followed by controlled diverticulectomy and submerged air-leak testing under gentle manual ventilation to verify tracheal wall integrity.