Thyroidectomy: Berry’s ligament, gland delivery and final inspection
THE CONTEXT
Final thyroid mobilisation requires careful management of Berry’s ligament because of its variable relationship to the recurrent laryngeal nerve.
Berry’s ligament and nerve protection
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Trace the recurrent laryngeal nerve towards the cricothyroid joint as it enters the larynx. The pretracheal fascia condenses into Berry’s ligament at this point.
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Small vessels within the ligament can retract if not controlled with bipolar cautery or ties. Resulting bleeding may disorientate the surgeon and endanger the nerve.
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Pre-emptive diathermy with careful layer-by-layer dissection permits final lobe mobilisation. Some surgeons instead isolate the ligament and apply a careful tie for haemostasis.
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The nerve may be distant from the ligament or run up to and through it. Keep the nerve directly visible and divide the ligament minimally, layer by layer, allowing the nerve to move back until it lies well lateral.
Bleeding control
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If bleeding occurs, use targeted pressure and, occasionally, fine-tip suction to locate the specific bleeding point, followed by careful bipolar cautery.
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Haemostasis must be meticulous because re-exploration of this area for bleeding places the recurrent laryngeal nerve at significant risk.
Gland delivery and inspection
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Open loose pretracheal fascia over the trachea using monopolar diathermy, extending to and beyond the midline to remove the isthmus and encompass any pyramidal lobe tissue.
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Oversew the residual isthmus or seal it with bipolar cautery. Repeat the procedure on the opposite side if total thyroidectomy is required.
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Inspect the operative field and irrigate with saline to identify small bleeding points.
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Confirm the anatomy and, ideally, neural integrity by stimulating the vagus nerve if it was previously located. Use bipolar cautery carefully to avoid nerve or parathyroid injury.