Identifying and freeing the recurrent laryngeal nerve during thyroidectomy
THE CONTEXT
As thyroid mobilisation progresses, careful fascial dissection identifies the recurrent laryngeal nerve and permits further mobilisation towards Berry’s ligament.
Location and identification
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At this stage, the recurrent laryngeal nerve lies superior and lateral to the trachea and inferior to the plane developed superiorly.
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The amount of dissection already completed depends on fascial compliance and lobe size. A pledget may be used to brush fascia laterally.
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If the nerve is not visible, gently mobilise fascia while staying directly on the gland. Do not divide any structure that could be neural.
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The nerve is often behind the inferior thyroid artery, in approximately 70% of cases, but this relationship is not constant.
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Slow fascial dissection permits delivery of the lobe from above and below towards Berry’s ligament. The identified nerve can be confirmed with a nerve stimulator.
Dissection after identification
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A nerve lying largely lateral to the gland allows dissection to proceed until only Berry’s ligament remains.
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A medially situated nerve may lie on the thyroid surface and require gentle separation. Stay directly on the nerve, dissect it slowly from surrounding tissue and avoid injury from direct pressure.