Retrosternal Thyroid Goiter: Recurrent Laryngeal Nerve Dissection According to the Charles Proye's Toboggan Technique

Abstract

Introduction: We present a case report supported by a video of a case of recurrent retrosternal thyroid goiter with superior identification of the recurrent laryngeal nerve (also called the Charles Proye's toboggan technique).1 Materials and Methods: In November 2012, we operated a 71-year-old patient for a recurrent unilateral retrosternal thyroid goiter. The patient underwent a subtotal thyroidectomy 20 years earlier; she showed symptoms of airway and esophageal compression. After a CT scan and a laryngoscopy, the patient underwent a right thyroid lobectomy. The surgery of retrosternal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion.2 Charles Proye described a surgical technique to avoid this lesion. To have a better exposition, a section of the prethyroid muscles can be considered, particularly if it is a voluminous and/or recurrent goiter.3–4 The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the middle thyroid vein is divided and the superior pole vessels are divided. The superior pole is then mobilized laterally, and the recurrent laryngeal nerve is searched for at its entry point into the larynx. The nerve function can be verified by the neuromonitoring, which also helps to find it in this vessel-rich area. The dissection continues between the nerve and the posterior part of the thyroid, progressively from top to bottom, descending as on a toboggan. After the recurrent nerve dissection, the goiter can usually be extracted without difficulty, dividing the last vessels holding the goiter inside.1–4 Results: With the toboggan technique, it is often possible to do the thyroidectomy for mediastinal goiter without sternotomy and recurrent nerve damage.1 Using this technique, the recurrent nerve is never put under tension. The patient operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Conclusions: Whenever possible, we prefer to operate intrathoracic goiters using this technique because it allows us to better recognize and preserve the recurrent nerve without putting it under tension. The Source of Work or Study: In 1981, Charles Proye described a new surgical technique to operate intrathoracic goiters without sternotomy and with preservation of recurrent nerve; the surgery of mediastinal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion. We utilize in our clinic this technique for intrathoracic goiters. This video describes the details of the Charles Proye's technique. The authors have not received any payment or support. The article is based on a videocommunication during the congress of the IAES in Helsinki, August 2013. Running time of video: 4 mins, 53 secs