Lateral Mobilization of the Recurrent Laryngeal Nerve to Facilitate Tracheal Surgery in Patients with Thyroid Cancer Invading the Trachea Near Berry’s Ligament

Abstract

Thyroid cancer often invades the trachea and the recurrent laryngeal nerve (RLN) at or near Berry's ligament, which fixes the thyroid gland to the trachea. In patients with thyroid cancer invading the trachea near the ligament, preservation of the RLN is very difficult. Regardless of whether the nerve is preserved or is resected and reconstructed, the presence of the nerve interferes with tracheal resection and repair. We proposed a new technique to solve this problem. Before tracheal surgery, the inferior pharyngeal constrictor muscle was divided along the lateral edge of the thyroid cartilage, and the RLN was mobilized and retracted laterally. We applied this technique in 11 patients with papillary thyroid carcinoma invading the trachea. Two patients demonstrated vocal cord paralysis preoperatively. The procedures used for tracheal surgery in this series were partial resection of the trachea with creation of a tracheocutaneostomy, that with direct suture, and shaving off the tumor in 7, 2, and 2 patients, respectively. The RLN could be preserved and mobilized laterally in eight patients. While three patients demonstrated transient vocal cord paralysis, the remaining five had functioning cords postoperatively. In three patients the RLN was resected, and the remaining distal stump was mobilized and anastomosed with the ansa cervicalis. These patients recovered their voices and maximum phonation time increased to the normal level. The tracheocutaneous stoma was closed with local skin flap about four months later in all patients. Lateral mobilization of the RLN facilitates the preservation of the nerve and the performance of tracheal surgery in patients with thyroid cancer invading the trachea at or near Berry's ligament.