Retrosternal goitre surgery requires adequate cervical access, careful mobilisation and conversion to sternotomy when cervical delivery is unsafe or impossible.
Access and mobilisation
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A longer incision is required. Mobilising the sternomastoid muscle from the strap muscles may improve access.
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The ligamentous tissue between the sternal heads of the clavicles may be gently divided to enlarge the opening for gland delivery.
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Blunt dissection on the gland capsule permits mobilisation, followed by gentle traction to deliver the gland into the neck.
Structures at risk
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A goitre arising from a posteriorly positioned nodule may displace the RLN anteriorly. Apparent fascial bands overlying the gland must therefore be divided with great care.
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The gland receives its blood supply from the neck, reducing the risk of catastrophic bleeding from the great vessels. Care remains necessary around major vessels in the neck and chest.
When sternotomy is required
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A fixed, immobile gland or one too large for cervical delivery requires a midline sternotomy.
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Sternotomy allows dissection from below to achieve a safe total thyroidectomy.