Step-by-Step Thyroidectomy-Incision, Nerve Identification, Parathyroid Preservation, and Gland Removal.

Thyroidectomy is a surgical procedure to remove part or all of the thyroid gland. Although the general tenets of surgery have remained the same, improvements in techniques, diagnostics, understanding of anatomy, and technology have allowed thyroid surgery to become a standard, effective, and safe surgery. For surgeons undertaking this procedure, it is imperative to have an in-depth knowledge of critical anatomy and a comprehensive understanding of surgical techniques to perform safe and effective surgery. This article aims to provide an overview of surgical techniques that may be applied in both benign and malignant disease settings.

Common Carotid-to-Internal Jugular Arteriovenous Loop for Single-Stage Microsurgical Reconstruction in the Radiated Vessel-Depleted Neck.

ABSTRACT: Management of head and neck defects in a radiated field can be quite challenging owing to the dearth of vasculature and significant degree of post-radiation fibrosis. In this setting, arteriovenous (AV) loop vascular grafts can bypass nonviable local vessels to provide viable and reliable inflow and outflow vessels for free tissue transfer in an otherwise hostile environment. Prior reports of the Corlett loop utilizing a cephalic vein transposition has been described however a common carotid-to-internal jugular AV loop has not been recently reported. Three patients underwent carotid artery to internal jugular vein AV loop creation to facilitate free-flap reconstruction secondary to radiation-induced vessel depletion. The specific technique described utilizes the saphenous vein as a donor and spares the cephalic vein for the possibility of flap complication. All three cases resulted in successful reconstruction, maintaining healthy tissue, vascular flow, and flap viability at all follow-up intervals. In our experience, vascular augmentation via AV loop formation provides reliable vascular inflow and outflow in the vessel-depleted neck to facilitate microvascular reconstruction. Sparing the cephalic vein yields an additional salvage mechanism in the event of venous congestion.

Flap Failure and Salvage in Head and Neck Reconstruction.

With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.

Prophylactic Use of the Pectoralis Major Flap to Prevent Anastomotic Leak in the Reconstruction of a Total Laryngopharyngoesophagectomy Defect Combined With Gastric Pull-Up After Chemoradiotherapy.

Total laryngopharyngoesophagectomy defects after surgical ablation for laryngopharyngeal carcinoma with involvement of the cervical esophagus represents a challenge to the reconstructive surgeon. Complicating an already challenging operation is when surgical ablation occurs after failure of primary chemoradiation requiring the surgeon to operate and reconstruct in an irradiated field limiting potential reconstructive options. Due to the advanced stage at diagnosis, some studies have shown that while traditional management with radiotherapy may be considered as an initial treatment modality, often times this has failed to provide sustainable improvement in survival with reported high local recurrence rates. With relatively high local recurrence rates following radiotherapy, movement towards aggressive surgical resection is favored in some institutions. Despite this movement, primary treatment with chemoradiation is still commonly used as a primary modality opening up the opportunity for residual or recurrent disease leading the surgeon to perform salvage surgery to eradicate disease after primary treatment failure. With advanced ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional outcomes which has shown to be particularly challenging when operating in a post-radiated field with a higher risk for pharyngocutaneous fistulas. The authors present a case where reconstruction of such a defect after local failure with primary chemoradiation was successful using a single stage reconstruction with the gastric pull up technique in combination with a pectoralis major myocutaneous flap. As the risk of anastomotic leak is significantly higher in patients following radiation, this method showed utilizing a prophylactic muscle flap at the time of reconstruction may further bolster the repair and prevent anastomotic leak.