- Email: [email protected]
Sternal manubriotomy for mediastinal goiter
Journal of Visceral Surgery (2017) 154, 361—365
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Sternal manubriotomy for mediastinal goiter H. Najah a, J. Gaudric b, F. Kasereka-Kisenge a, A. Taieb a, M. Goutard a, F. Menegaux a, C. Trésallet a,∗ a
Service de chirurgie générale, viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, Pierre-et-Marie-Curie-Sorbonne universités, AP—HP, 47—83, boulevard de l’Hôpital, 75013 Paris, France b Service de chirurgie vasculaire, hôpital de la Pitié-Salpêtrière, Pierre-et-Marie-Curie-Sorbonne universités, AP—HP, 47—83, boulevard de l’Hôpital, 75013 Paris, France Available online 18 October 2017
Introduction Substernal goiter refers to diffuse orthotopic thyroid gland hypertrophy or mediastinal extension. At the present time, there is no clear consensus as to how to best define the entity. Some authors consider that plunging goiters are those for which a part of the thyroid is not palpable and/or not visible on sonography with the patient’s head in a neutral position, while others reserve this denomination only for goiters that extend downward to the carina. The most commonly admitted definition is a goiter that has descended below the plane of the thoracic inlet or when more than 50% of its mass lies below the thoracic inlet. Because of the multiplicity of definitions, the exact incidence is difficult to determine and varies greatly in the literature, between 2 and 19% (White et al., 2008) [1]. Traditionally, any intrathoracic extension of thyroid goiter represents an indication for operation because of the risk of compression, the difficulty of clinical and sonographic surveillance and the potential risk of malignant degeneration. Since the origin of vascular supply of plunging goiters is predominantly cervical, exteriorization of goiters via a classical cervicotomy is possible in the vast majority of cases without any particular difficulty in dissection. However, ‘‘blind’’ intrathoracic maneuvers warrant a word of caution because of the risk of vascular injury, and in particular, of tearing the inferior thyroid vein as it enters one of the brachiocephalic veins. An associated thoracic approach may sometimes be necessary when classical cervicotomy does not allow safe extraction of the goiter. When extraction of the plunging part of the thyroid is impossible by cervicotomy only, or when difficulties in doing so are expected, a sternal manubriotomy may be needed and should suffice in almost every case without the need to resort to a larger sternotomy. Manubriotomy allows widening of the thoracic inlet and facilitates dissection and extraction of the goiter. Sternal manubriotomy is associated with fewer respiratory functional sequelae than the other thoracic approaches,
∗
Corresponding author. E-mail address: [email protected] (C. Trésallet).
http://dx.doi.org/10.1016/j.jviscsurg.2017.08.009 1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.
362
H. Najah et al.
preserves the rigidity of the thoracic wall, and therefore allows early mobilization and rapid resumption of physical activity after surgery (Triponez, 2015) [2]. The criteria that predict the need for sternal manubriotomy are inconsistently appreciated in the literature, ranging from the larger diameter of the intrathoracic conic portion of the goiter associated with a narrow thoracic inlet (Riffat et al., 2013) [3] to goiters extending below the aortic arch (Casella et al., 2010) [4] or even the malignant character of the goiter (de Perrot et al., 2007) [5]. However, the decision is often taken intra-operatively when the surgeon is faced with difficulties of exteriorization of the goiter through a cervical incision. We describe herein our surgical technique of sternal manubriotomy.
1
Plunging goiter
2
Patient position
Plunging goiters can be sub-divided into prevascular and retrovascular goiters according to their mediastinal extension. Prevascular goiters, as represented here, are by far the most prevalent, representing approximately 85% of plunging goiters. Their intrathoracic extension descends into the anterior mediastinum, anterior to the carotid, sub-clavian arteries and the aortic arch. Retrovascular goiters descend posterior to this vascular axis, either pretracheal in the middle mediastinum, or retrotracheal, in the posterior mediastinum. This extension can be ipsi-lateral or contra-lateral. Whereas prevascular plunging goiters can usually be extracted cervically, a sternal manubriotomy is often necessary for retrovascular plunging goiters. Cervicothoracic CT-scan is the investigation of choice to appreciate the relationship between the goiter and the vessels.
The patient is positioned supine, both arms alongside, the neck in hyperextension, thanks to a cushion placed between the two scapulae. A flexible hoop is placed over the patient’s head. The operator stands opposite the plunging lobe, the first assistant across from the operator and the instrument nurse to the left of the first assistant. The operative field should be widely draped, leaving both the anterior cervical and thoracic regions accessible. The operative field extends from the chin above, to the xiphoid below. On the thorax, the drapes are attached lateral to the nipples and on the neck, at the level of the posterior edge of the sterno-cleido-mastoid muscles.
Sternal manubriotomy for mediastinal goiter
3
Skin incision and approach to the thyroid space
4
Preparation for the manubriotomy
The skin incision takes the form of a ‘‘wine glass’’, combining a cervical incision at the base of the neck with an upper midline thoracic incision; this provides generous access to the anterior cervical and high mediastinal regions. The cervical incision is horizontal and arciform, two fingerbreadths above the sternal manubrium, ideally in a skin crease. The midline thoracic incision is vertical, 5—7 cm long, starting from the middle of the cervical incision and down to the level of the angle of Louis, corresponding to the junction between the manubrium and the body of the sternum, which presents as a small palpable bump between the second ribs. The thyroid compartment is entered as for an ordinary thyroidectomy. After dividing the platysmus muscle, the skin flaps are detached from the superficial cervical fascia up to the larynx cephalad, and the sternal manubrium caudad. The superior flap is then retracted cephalad. The laryngeal infra-hyoid muscle fascia is opened in the midline down to the sternal manubrium, allowing entry into the thyroid space. If needed to have a larger view of the cervical region, the strap muscles can be divided.
The preperiosteal subcutaneous planes are divided with electrocautery, taking care to remain on the midline between the sternal attachments of the pectoralis major. The upper edge of the sternal manubrium is then exposed. A transverse vein uniting the two anterior jugular veins is usually present and should be divided between ligatures. The interclavicular ligament is then divided at the posterosuperior edge of the sternal manubrium (A). This allows exposure of the posterior aspect of the sternal manubrium. The surgeon can then slide the index finger behind the manubrium to push the left brachocephalic vein posteriorly and prepare for the manubriotomy (B).
363
364
5 Sternal manubriotomy
H. Najah et al.
The sternum is divided with a power saw whose terminal end is protected by a rounded ribbon retractor inserted along the internal table of the sternal body. The division is made from top to bottom, in one step, down to the angle of Louis, following a line traced previously with electrocautery. The flat edge of the Lebsche sternal chisel is slid under the superior border of the manubrium while the operator applies traction on the top to keep contact with the sternum (A). Once the manubrium is divided, bleeding from intra-osseous vessels between the internal and external table periostium can occur. Hemostasis requires electrocautery completed by application of Horsley bone wax. A Finochietto type retractor is inserted to widen the exposure (B). The manubriotomy allows widening of the thoracic inlet for exposure and extraction of the goiter. The details of the thyroidectomy technique are classical and will not be given here. As in all such cases, caution must be paid to avoid damage to the recurrent nerves and the parathyroid glands.
Sternal manubriotomy for mediastinal goiter
6
365
Drainage and closure
Before closing the manubriotomy, a closed suction (Redon type) drainage system is placed behind the sternum and in the thyroid space, exiting through the cervical skin. The divided sternum is sutured together with trans-osseous steel wires. The steel wire is inserted by its needle extremity with a strong needle holder while the distal end is held by a Kocher grasper. Two to three transversal sutures are usually enough. After traversing the two parts of bone, the needle is cut off, and the bone parts are approximated by traction. Caution must be exercised to make sure that the suction drain is not caught in the wires. Once the knots are tied, the cut ends of the wire are impacted into the sternum. A slowly absorbable suture approximates the pectoral muscles, passing through the periosteum. Last, the subcutaneous plane and skin are closed as usual. The cervicotomy is closed as usual in three layers: strap muscles, platysmus and skin.
Disclosure of interest The authors declare that they have no competing interest.
References [1] White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg http://dx.doi.org/10.1007/s00268-0082008;32:1285—300, 9466-3. [2] Triponez F. Prise en charge des goitres plongeants et thoraciques. In: Trésallet C, Menegaux F, editors. Traité de chirurgie endocrinienne. Paris: Doin Editions; 2015. p. 135—41.
[3] Riffat F, Del Pero MM, Fish B, Jani P. Radiologically predicting when a sternotomy may be required in the management of retrosternal goiters. Ann Otol Rhinol Laryngol 2013;122: 15—9. [4] Casella C, Pata G, Cappelli C, Salerni B. Pre-operative predictors of sternotomy need in mediastinal goiter management. Head Neck 2010;32:1131—5, http://dx.doi.org/10.1002/hed.21303. [5] de Perrot M, Fadel E, Mercier O, Farhamand P, Fabre D, Mussot S, et al. Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 2007;55:39—43, http://dx.doi.org/10.1055/s-2006-924440.
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Sternal manubriotomy for mediastinal goiter H. Najah a, J. Gaudric b, F. Kasereka-Kisenge a, A. Taieb a, M. Goutard a, F. Menegaux a, C. Trésallet a,∗ a
Service de chirurgie générale, viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, Pierre-et-Marie-Curie-Sorbonne universités, AP—HP, 47—83, boulevard de l’Hôpital, 75013 Paris, France b Service de chirurgie vasculaire, hôpital de la Pitié-Salpêtrière, Pierre-et-Marie-Curie-Sorbonne universités, AP—HP, 47—83, boulevard de l’Hôpital, 75013 Paris, France Available online 18 October 2017
Introduction Substernal goiter refers to diffuse orthotopic thyroid gland hypertrophy or mediastinal extension. At the present time, there is no clear consensus as to how to best define the entity. Some authors consider that plunging goiters are those for which a part of the thyroid is not palpable and/or not visible on sonography with the patient’s head in a neutral position, while others reserve this denomination only for goiters that extend downward to the carina. The most commonly admitted definition is a goiter that has descended below the plane of the thoracic inlet or when more than 50% of its mass lies below the thoracic inlet. Because of the multiplicity of definitions, the exact incidence is difficult to determine and varies greatly in the literature, between 2 and 19% (White et al., 2008) [1]. Traditionally, any intrathoracic extension of thyroid goiter represents an indication for operation because of the risk of compression, the difficulty of clinical and sonographic surveillance and the potential risk of malignant degeneration. Since the origin of vascular supply of plunging goiters is predominantly cervical, exteriorization of goiters via a classical cervicotomy is possible in the vast majority of cases without any particular difficulty in dissection. However, ‘‘blind’’ intrathoracic maneuvers warrant a word of caution because of the risk of vascular injury, and in particular, of tearing the inferior thyroid vein as it enters one of the brachiocephalic veins. An associated thoracic approach may sometimes be necessary when classical cervicotomy does not allow safe extraction of the goiter. When extraction of the plunging part of the thyroid is impossible by cervicotomy only, or when difficulties in doing so are expected, a sternal manubriotomy may be needed and should suffice in almost every case without the need to resort to a larger sternotomy. Manubriotomy allows widening of the thoracic inlet and facilitates dissection and extraction of the goiter. Sternal manubriotomy is associated with fewer respiratory functional sequelae than the other thoracic approaches,
∗
Corresponding author. E-mail address: [email protected] (C. Trésallet).
http://dx.doi.org/10.1016/j.jviscsurg.2017.08.009 1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.
362
H. Najah et al.
preserves the rigidity of the thoracic wall, and therefore allows early mobilization and rapid resumption of physical activity after surgery (Triponez, 2015) [2]. The criteria that predict the need for sternal manubriotomy are inconsistently appreciated in the literature, ranging from the larger diameter of the intrathoracic conic portion of the goiter associated with a narrow thoracic inlet (Riffat et al., 2013) [3] to goiters extending below the aortic arch (Casella et al., 2010) [4] or even the malignant character of the goiter (de Perrot et al., 2007) [5]. However, the decision is often taken intra-operatively when the surgeon is faced with difficulties of exteriorization of the goiter through a cervical incision. We describe herein our surgical technique of sternal manubriotomy.
1
Plunging goiter
2
Patient position
Plunging goiters can be sub-divided into prevascular and retrovascular goiters according to their mediastinal extension. Prevascular goiters, as represented here, are by far the most prevalent, representing approximately 85% of plunging goiters. Their intrathoracic extension descends into the anterior mediastinum, anterior to the carotid, sub-clavian arteries and the aortic arch. Retrovascular goiters descend posterior to this vascular axis, either pretracheal in the middle mediastinum, or retrotracheal, in the posterior mediastinum. This extension can be ipsi-lateral or contra-lateral. Whereas prevascular plunging goiters can usually be extracted cervically, a sternal manubriotomy is often necessary for retrovascular plunging goiters. Cervicothoracic CT-scan is the investigation of choice to appreciate the relationship between the goiter and the vessels.
The patient is positioned supine, both arms alongside, the neck in hyperextension, thanks to a cushion placed between the two scapulae. A flexible hoop is placed over the patient’s head. The operator stands opposite the plunging lobe, the first assistant across from the operator and the instrument nurse to the left of the first assistant. The operative field should be widely draped, leaving both the anterior cervical and thoracic regions accessible. The operative field extends from the chin above, to the xiphoid below. On the thorax, the drapes are attached lateral to the nipples and on the neck, at the level of the posterior edge of the sterno-cleido-mastoid muscles.
Sternal manubriotomy for mediastinal goiter
3
Skin incision and approach to the thyroid space
4
Preparation for the manubriotomy
The skin incision takes the form of a ‘‘wine glass’’, combining a cervical incision at the base of the neck with an upper midline thoracic incision; this provides generous access to the anterior cervical and high mediastinal regions. The cervical incision is horizontal and arciform, two fingerbreadths above the sternal manubrium, ideally in a skin crease. The midline thoracic incision is vertical, 5—7 cm long, starting from the middle of the cervical incision and down to the level of the angle of Louis, corresponding to the junction between the manubrium and the body of the sternum, which presents as a small palpable bump between the second ribs. The thyroid compartment is entered as for an ordinary thyroidectomy. After dividing the platysmus muscle, the skin flaps are detached from the superficial cervical fascia up to the larynx cephalad, and the sternal manubrium caudad. The superior flap is then retracted cephalad. The laryngeal infra-hyoid muscle fascia is opened in the midline down to the sternal manubrium, allowing entry into the thyroid space. If needed to have a larger view of the cervical region, the strap muscles can be divided.
The preperiosteal subcutaneous planes are divided with electrocautery, taking care to remain on the midline between the sternal attachments of the pectoralis major. The upper edge of the sternal manubrium is then exposed. A transverse vein uniting the two anterior jugular veins is usually present and should be divided between ligatures. The interclavicular ligament is then divided at the posterosuperior edge of the sternal manubrium (A). This allows exposure of the posterior aspect of the sternal manubrium. The surgeon can then slide the index finger behind the manubrium to push the left brachocephalic vein posteriorly and prepare for the manubriotomy (B).
363
364
5 Sternal manubriotomy
H. Najah et al.
The sternum is divided with a power saw whose terminal end is protected by a rounded ribbon retractor inserted along the internal table of the sternal body. The division is made from top to bottom, in one step, down to the angle of Louis, following a line traced previously with electrocautery. The flat edge of the Lebsche sternal chisel is slid under the superior border of the manubrium while the operator applies traction on the top to keep contact with the sternum (A). Once the manubrium is divided, bleeding from intra-osseous vessels between the internal and external table periostium can occur. Hemostasis requires electrocautery completed by application of Horsley bone wax. A Finochietto type retractor is inserted to widen the exposure (B). The manubriotomy allows widening of the thoracic inlet for exposure and extraction of the goiter. The details of the thyroidectomy technique are classical and will not be given here. As in all such cases, caution must be paid to avoid damage to the recurrent nerves and the parathyroid glands.
Sternal manubriotomy for mediastinal goiter
6
365
Drainage and closure
Before closing the manubriotomy, a closed suction (Redon type) drainage system is placed behind the sternum and in the thyroid space, exiting through the cervical skin. The divided sternum is sutured together with trans-osseous steel wires. The steel wire is inserted by its needle extremity with a strong needle holder while the distal end is held by a Kocher grasper. Two to three transversal sutures are usually enough. After traversing the two parts of bone, the needle is cut off, and the bone parts are approximated by traction. Caution must be exercised to make sure that the suction drain is not caught in the wires. Once the knots are tied, the cut ends of the wire are impacted into the sternum. A slowly absorbable suture approximates the pectoral muscles, passing through the periosteum. Last, the subcutaneous plane and skin are closed as usual. The cervicotomy is closed as usual in three layers: strap muscles, platysmus and skin.
Disclosure of interest The authors declare that they have no competing interest.
References [1] White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg http://dx.doi.org/10.1007/s00268-0082008;32:1285—300, 9466-3. [2] Triponez F. Prise en charge des goitres plongeants et thoraciques. In: Trésallet C, Menegaux F, editors. Traité de chirurgie endocrinienne. Paris: Doin Editions; 2015. p. 135—41.
[3] Riffat F, Del Pero MM, Fish B, Jani P. Radiologically predicting when a sternotomy may be required in the management of retrosternal goiters. Ann Otol Rhinol Laryngol 2013;122: 15—9. [4] Casella C, Pata G, Cappelli C, Salerni B. Pre-operative predictors of sternotomy need in mediastinal goiter management. Head Neck 2010;32:1131—5, http://dx.doi.org/10.1002/hed.21303. [5] de Perrot M, Fadel E, Mercier O, Farhamand P, Fabre D, Mussot S, et al. Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 2007;55:39—43, http://dx.doi.org/10.1055/s-2006-924440.