World Journal of Surgery

, Volume 42, Issue 5, pp 1415–1423 | Cite as

Medial Approach for the Resection of Goiters with Suprahyoid, Retropharyngeal, or Substernal Extension

  • Harry H. Ching
  • Jacob B. Kahane
  • Megan J. Foggia
  • Annabel E. Barber
  • Robert C. Wang
Original Scientific Report with Video



Resection of massive goiters with suprahyoid, retropharyngeal, and substernal extension may not be amenable to standard approaches. This study evaluates a surgical approach allowing resection of massive goiters with minimal substernal and deep neck dissection.


Cases of thyroidectomy for goiters with substernal, retropharyngeal, or suprahyoid extension at a single institution from 2006 to 2017 were reviewed. The technique involves initial complete division of the medial thyroid tracheal attachments after identification of the RLN medial-inferiorly or superiorly. Deep components are then delivered into the superficial paratracheal region of the neck.


Sixty patients were included, 46 of which had substernal and 14 had only suprahyoid or retropharyngeal extension. Mean substernal extension was 3.7 cm (range 1.5–7.5 cm). The medial approach was successful in identifying the RLN in 70 (83%) of 84 goiter sides (71% medial-inferiorly and 29% superiorly). Standard inferior/lateral approaches were used in 12 (14%) nerves or not found until after goiter removal in 2 (2.5%). No patients required sternotomy or tracheotomy. Complications included postoperative seroma/hematoma (n = 9, 15%) with one re-exploration, transient RLN injury (n = 4, 4% of all lobectomies), transient hypocalcemia (n = 6, 16% of total thyroidectomies), permanent hypocalcemia (n = 2, 5% of total thyroidectomies), and permanent RLN paralysis (n = 1, 1% of all lobectomies).


Large suprahyoid, retropharyngeal, and substernal goiters were resected transcervically with low morbidity. Early complete division of Berry’s ligament after medial-inferior RLN identification was achieved in a high proportion of patients, facilitating goiter delivery with minimal mediastinal and deep neck dissection.



Illustrations in Figs. 1, 4, and 8 by Robert C. Wang.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

268_2018_4576_MOESM1_ESM.mp4 (111.4 mb)
Supplementary material 1 (MP4 114027 kb)


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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Harry H. Ching
    • 1
  • Jacob B. Kahane
    • 1
  • Megan J. Foggia
    • 1
    • 2
  • Annabel E. Barber
    • 1
    • 3
  • Robert C. Wang
    • 1
  1. 1.Department of Otolaryngology - Head and Neck SurgeryUniversity of Nevada Las Vegas School of MedicineLas VegasUSA
  2. 2.University of Nevada, Reno School of MedicineLas VegasUSA
  3. 3.Department of SurgeryUniversity of Nevada Las Vegas School of MedicineLas VegasUSA

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