Surgical video on the sternotomy-sparing medial approach thyroidectomy for a substernal multinodular goiter case report

Substernal goiters can significantly alter the native anatomy of patients and require a different approach than normal, benign goiters. Its enlarged bulk and substernal extension can present a major technical challenge for surgeons with increased risk of recurrent laryngeal nerve injury, parathyroid glands injury, and possible need for sternotomy or thoracostomy to fully excise the substernal component. A sternotomy or thoracotomy approach is associated with a significant surge in complications such as increased intraoperative blood loss, mediastinitis, hematoma, wound infection, osteomyelitis, chest bone fracture, and sternal dehiscence. On this video presentation, we visually demonstrate our medial approach thyroidectomy technique to facilitate transcervical resection of a large substernal goiter without the need for sternotomy. A 33-year-old female with dyspnea on exertion and orthopnea was found to have a massive 9-cm goiter compressing the trachea and extending below the aortic arch. She underwent a total thyroidectomy and en bloc delivery of the substernal component with successful preservation of bilateral recurrent laryngeal nerves and parathyroid glands. There was minimal deep neck and substernal dissection and no sternotomy was necessary. Postoperatively, her parathyroid hormone and calcium levels were normal and she was discharged on postoperative day (POD) 2. On follow-up, she had no hoarseness, dysphagia, or hypocalcemia. A medial approach thyroidectomy promotes early exposure of the recurrent laryngeal nerve and safe transection of Berry's ligament allowing mobilization of the thyroid and transcervical delivery of substernal components without injury of the native anatomic structures. Furthermore, this technique serves to minimize the morbidity and mortality associated with sternotomy, thus reducing hospital stay and improving patient satisfaction.