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Netter’s
Surgical
Anatomy and
Approaches
Conor P. Delaney,

MD, MCh,

PhD, FRCSI, FACS, FASCRS
Chief, Division of Colorectal Surgery
Vice-Chair, Department of Surgery
Surgical Director, Digestive Health Institute
University Hospitals Case Medical Center
Jeffrey L. Ponsky MD Professor of Surgical Education
Case Western Reserve University School of Medicine
Cleveland, Ohio

Illustrations by
Frank H. Netter, MD

Contributing Illustrators
Carlos A. G. Machado, MD
Kristen Wienandt Marzejon, MS, MFA
James A. Perkins, MS, MFA
John A. Craig, MD

1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-2899

NETTER’S SURGICAL ANATOMY AND APROACHES
Copyright © 2014 by Saunders, an imprint of Elsevier Inc.

ISBN: 978-1-4377-0833-2

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Permission for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing
Department in Philadelphia, PA: phone 1-800-523-1649, ext. 3276, or (215) 239-3276; or email
H.Licensing@elsevier.com

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such info; rmation or methods they should be mindful of their own safety and the
safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the method
and duration of administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.
ISBN: 978-1-4377-0833-2

Senior Content Strategist: Elyse O’Grady
Senior Content Development Manager: Marybeth Thiel
Publishing Services Manager: Patricia Tannian
Senior Project Manager: John Casey
Senior Design Manager: Steven Stave

Printed in China
Last digit is the print number: 9

8 7

6

5 4

3 2

1

In memory of my father,
Peter Vincent Delaney,
whose love of surgery and its ability to help others led me to this field

About the Artists
Frank H. Netter, MD
Frank H. Netter was born in 1906, in New York City. He studied art at the Art Students’ League
and the National Academy of Design before entering medical school at New York University,
where he received his MD degree in 1931. During his student years, Dr. Netter’s notebook
sketches attracted the attention of the medical faculty and other physicians, allowing him to
augment his income by illustrating articles and textbooks. He continued illustrating as a sideline
after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in
favor of a full-time commitment to art. After service in the United States Army during World
War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now
Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraordinary collection of medical art so familiar to medical professionals worldwide.
In 2005, Elsevier, Inc. purchased the Netter Collection and all publications from Icon Learning Systems. Over 50 publications featuring the art of Dr. Netter available through Elsevier, Inc.
(in the US: www.us.elsevierhealth.com/Netter and outside the US: www.elsevierhealth.com)
Dr. Netter’s works are among the finest examples of the use of illustration in the teaching
of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the
greater part of the more than 20,000 paintings created by Dr. Netter, became and remains one
of the most famous medical works ever published. The Netter Atlas of Human Anatomy, first
published in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions
students the world over.
The Netter illustrations are appreciated not only for their aesthetic qualities, but, more
important, for their intellectual content. As Dr. Netter wrote in 1949, “… clarification of a
subject is the aim and goal of illustration. No matter how beautifully painted, how delicately
and subtly rendered a subject may be, it is of little value as a medical illustration if it does not
serve to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and
approach are what inform his paintings and make them so intellectually valuable.
Frank H. Netter, MD, physician and artist, died in 1991.
Learn more about the physician-artist whose work has inspired the Netter Reference collection: http://www.netterimages.com/artist/netter.htm
Carlos Machado, MD
Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the
main artist contributing to the Netter collection of medical illustrations.
Self-taught in medical illustration, cardiologist Carlos Machado has meticulous updated
some of Dr. Netter’s original plates and has created many original paintings of his own in the
style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise
and keen insight into the physician-patient relationship informs his vivid and unforgettable
visual style. His dedication to researching each topic and subject he paints places him among
the premier medical illustrators at work today.
Learn more about his background and see more of his art at: http://www.netterimages.com/
artist/machado.htm

vi

Preface

The Atlas of Human Anatomy by Frank H. Netter, MD, has been the pinnacle of demonstrating
the anatomy of the human body for generations of students. To those who would wish to
perform or understand surgical procedures, however, there has been no direct link between
the beautiful images created by Dr. Netter and the surgical procedures being performed. In
Netter’s Surgical Anatomy and Approaches, we try to address a request by many Netter users to tie
these anatomical diagrams to the procedures they perform.
This book presents the curriculum of basic and common general surgical procedures in
chapters that portray the relevant anatomy for each procedure. In his very first edition, Dr.
Netter stated that “anatomy of course does not change, but our understanding of anatomy and
its clinical significance does.” Consequently, in some cases we have been able to pair the
anatomy demonstrated in his illustrations with a modern intraoperative photograph or radiographic image. For some chapters, a new Netter-style illustration has been created to demonstrate a key anatomical point for an operative procedure or to show a key sur­gical perspective
or orientation that is not captured in the original Netter images. The result is a volume that
covers the most important and commonest areas in surgery, addressing common procedures
in the head and neck, endocrine surgery, upper and lower gastrointestinal surgery, hepatobiliary surgery, surgery for hernias, vascular surgery, access and emergency procedures, breast and
oncology surgery, and urology and gynecology.
A book like this would not be possible without the help of many people. Being fortunate
to work at institutions such as University Hospitals Case Medical Center and Case Western
Reserve University, I elected to enlist the support of my faculty colleagues in many different
surgical specialties. It is only with the guidance and assistance of the editorial team of Jerry
Goldstone, Jeffrey Hardacre, Julian Kim, Pierre Lavertu, Mark Malangoni, Jeffrey Marks,
Christopher McHenry, Lee Ponsky, Michael Rosen, Christopher Siegel, and Sharon Stein, and
the direction and guidance of the ever-patient Marybeth Thiel at Elsevier that this project has
been completed.
On behalf of my co-editors and I, we hope you enjoy Netter’s Surgical Anatomy and Approaches.
Conor P. Delaney, MD, MCh, PhD

vii

Video Contents

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Neck Dissection (Chapter 1)
Tracheotomy (Chapter 2)
Thyroidectomy and Parathyroidectomy (Chapter 3)
Gastric Bypass (Chapter 11)
Laparoscopic Cholecystectomy (Chapter 12)
Appendectomy (Chapter 19)
Right Colectomy (Chapter 21)
Left Colectomy (Chapter 22)
Low Anterior Resection with Total Mesorectal Excision and Anastomosis (Chapter 24)
Carotid Endarterectomy (Chapter 32)
Abdominal Aortic Aneurysm (Chapter 33)
Oblique Femoral Artery Exposure for EVAR (Chapter 36)
Posterior Popliteal Artery Exposure (Chapter 38)
Retroperitoneal Sarcoma (Chapter 50)
Radical Prostatectomy (Chapter 54)

ix

Contributors

EDITOR

Mark A. Malangoni, MD, FACS

Conor P. Delaney, MD, MCh, PhD, FRCSI, FACS,
FASCRS

Associate Executive Director
American Board of Surgery
Adjunct Professor of Surgery
University of Pennsylvania
Philadelphia, Pennsylvania

Chief, Division of Colorectal Surgery
Vice-Chair, Department of Surgery
University Hospitals Case Medical Center
Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

SECTION EDITORS
Jerry Goldstone, MD, FACS, FRCSEd
Division Chief Emeritus
Division of Vascular Surgery and Endovascular Therapy
University Hospitals Case Medical Center
Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

Jeffrey M. Hardacre, MD, FACS
Section Head, Pancreatic Surgery
University Hospitals Case Medical Center
Associate Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

Julian A. Kim, MD
Chief, Division of Surgical Oncology
University Hospitals Case Medical Center
Program Director, Case Surgery
Charles Hubay Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

Pierre Lavertu, MD
Director of Head and Neck Surgery
Department of Otolaryngology—Head and Neck Surgery
University Hospitals Case Medical Center
Professor
Case Western Reserve University School of Medicine
Cleveland, Ohio

Jeffrey M. Marks, MD, FACS
Director of Surgical Endoscopy
University Hospitals Case Medical Center
Associate Professor, Department of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

Christopher R. McHenry, MD
Vice Chairman, Department of Surgery
MetroHealth Medical Center
Cleveland, Ohio

Lee E. Ponsky, MD, FACS
Leo and Charlotte Goldberg Chair in Advanced Surgical
Therapies
Director, Urologic Oncology and Minimally Invasive
Therapies Center
Urology Institute
University Hospitals Case Medical Center
Associate Professor, Urology
Case Western Reserve University School of Medicine
Cleveland, Ohio

Michael J. Rosen, MD, FACS
Professor of Surgery
Chief, Division of GI and General Surgery
Director, Case Comprehensive Hernia Center
University Hospitals Case Medical Center
Associate Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland Ohio

xi

xii

C o n t r i b u t ors

Christopher T. Siegel, MD, PhD

Bradley J. Champagne, MD

Associate Professor of Surgery
Division of Transplant and Hepatobiliary Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Associate Professor
Case Western Reserve University School of Medicine
Cleveland, Ohio

Sharon L. Stein, MD, FACS
Associate Program Director, General Surgery
Surgical Director, Inflammatory Bowel Disease Center,
Digestive Health Institute
University Hospitals Case Medical Center
Assistant Professor of Surgery
Division of Colorectal Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

CONTRIBUTORS
Mujjahid Abbas, MD
Staff Surgeon
Louis Stokes Cleveland Veterans Administration Medical
Center
Cleveland, Ohio

Robert Abouassaly, MD, MSc
Assistant Professor
Urology Institute
University Hospitals Case Medical Center
Cleveland, Ohio

Matthew T. Allemang, MD
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Henry R. Baele, MD
Assistant Professor of Surgery
Department of Surgery, Division of Vascular Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Jeffrey A. Blatnik, MD
General Surgery Resident
Allen Research Scholar
University Hospitals Case Medical Center
Cleveland, Ohio

Joshua I. S. Bleier, MD
Assistant Professor of Surgery
Division of Colon and Rectal Surgery
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Walter S. Cha, MD, FACS
Cleveland Clinic General Surgery
Digestive Disease Institute
Cleveland, Ohio

Edward Cherullo, MD
Vice Chairman, Clinical Operations
Program Director, Urology Institute
University Hospitals Case Medical Center
Associate Professor of Urology
Case Western Reserve University School of Medicine
Cleveland, Ohio

Jeffrey A. Claridge, MD, MS
Associate Professor of Surgery
Division of Trauma, Critical Care, and Burns
MetroHealth Medical Center
Cleveland, Ohio

John J. Como, MD, MPH
Associate Professor of Surgery
Division of Trauma, Critical Care, and Burns
MetroHealth Medical Center
Cleveland, Ohio

Robert L. DeBernardo, MD
Assistant Professor
Division of Gynecologic Oncology
Seidman Cancer Center
Case Western Reserve University School of Medicine
Cleveland, Ohio

Samuel J. DeJoy, DMD, MD
Assistant Professor of Anesthesiology
Case Western Reserve University School of Medicine
MetroHealth Medical Center
Cleveland, Ohio

Thomas J. Edwards, BSc, MBBS, MSc, FRCS
Consultant, Colorectal Surgeon
Taunton Hospitals NHS Trust
Somerset, England

Heidi L. Elliott, MD
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Bruce L. Gewertz, MD
Surgeon-in-Chief, H. & S. Nichols Endowed Chair in
Surgery
Chairman, Department of Surgery
Vice President for Interventional Services
Cedars-Sinai Medical Center
Los Angeles, California

Contributors

Jason F. Hall, MD, MPH

Jeremy M. Lipman, MD

Surgeon, Department of Colon and Rectal Surgery
Lahey Clinic
Burlington, Massachusetts;
Assistant Professor of Surgery
Tufts University School of Medicine
Boston, Massachusetts

Assistant Professor of Surgery
Case Western Reserve University School of Medicine
MetroHealth Medical Center
Department of Surgery
Cleveland, Ohio

Michael D. Holzman, MD, MPH

Yi-Chun Carol Liu, MD

Associate Professor, Department of Surgery
Vanderbilt University Medical Center
Nashville, Tennessee

Resident Physician
Ear, Nose, and Throat Institute
University Hospitals Case Medical Center
Cleveland, Ohio

Harry A. Hoyen, MD

Mark L. Manwaring, MD

Associate Professor
Department of Orthopaedic Surgery
Case Western Reserve University
Cleveland, Ohio

Colorectal Surgery
Department of Surgery
East Carolina University
Greenville, North Carolina

Natalie E. Joseph, MD, FACS

Eric L. Marderstein, MD, MPH

Assistant Professor of Surgery
Case Western Reserve University School of Medicine
Division of Surgical Oncology
MetroHealth Medical Center
Cleveland, Ohio

Director of Colorectal Surgery Services
Louis Stokes Cleveland VA Medical Center
Assistant Professor of Surgery
Division of Colorectal Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Arielle Kanters, MD
Division of Pediatric Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Vikram S. Kashyap, MD, FACS
Chief, Division of Vascular Surgery and Endovascular
Therapy
Co-Director, Harrington Heart and Vascular Institute
University Hospitals Case Medical Center
Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

Jonathan E. Kiechle, MD
Resident Physician
Urology Institute
University Hospitals Case Medical Center
Cleveland, Ohio

Evan R. McBeath, MD
Resident Physician
Ear, Nose, and Throat Institute
University Hospitals Case Medical Center
MetroHealth Medical Center
Louis Stokes Cleveland VA Medical Center
Cleveland, Ohio

Amy McDonald, MD, FACS
Assistant Professor of Surgery
Case Western Reserve University School of Medicine
Director, Trauma Intensive Care Unit
MetroHealth Medical Center
Cleveland, Ohio

Husein Moloo, MD, FRCS

Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Assistant Professor and Interim Chair
Division of General Surgery
University of Ottawa
Interim Chief, Division of General Surgery
Director, Minimally Invasive Surgery Program
The Ottawa Hospital
Ottawa, Ontario, Canada

Matthew J. Kruse, MD

Yuri W. Novitsky, MD

David M. Krpata, MD

Department of Surgery
Cedars-Sinai Medical Center
Los Angeles, California

Co-Director, Case Comprehensive Hernia Center
Director, Surgical Research
Department of Surgery
University Hospitals Case Medical Center
Associate Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

xiii

xiv

C o n t r i b u t ors

Raymond Onders, MD

Juan Sanabria, MD, MSc, FRCSC, FACS

Professor of Surgery
Director of Minimally Invasive Surgery
Margaret and Walter Remen Chair of Surgical
Innovation
University Hospitals Case Medical Center
Cleveland, Ohio

Director, Pancreas Transplant Program
University Hospitals Case Medical Center
Assistant Professor of Surgery and Nutrition
Case Western Reserve University School of Medicine
Cleveland, Ohio

Melissa S. Phillips, MD
Assistant Professor
Department of Surgery
University of Tennessee Graduate School of Medicine
Knoxville, Tennessee

Gilles Pinault, MD, FACS
Department of Vascular Surgery
Case Western Reserve University School of Medicine
Louis Stokes Cleveland VA Medical Center
Cleveland, Ohio

Todd Ponsky, MD
Associate Professor of Surgery and Pediatrics
Division of Pediatric Surgery
Akron Children’s Hospital
Akron, Ohio

Benjamin K. Poulose, MD, MPH
Assistant Professor, Department of Surgery
Vanderbilt University Medical Center
Nashville, Tennessee

Kimberly Resnick, MD
Assistant Professor, Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
University Hospitals Case Medical Center
Cleveland, Ohio

Harry L. Reynolds, Jr., MD, FACS, FASCRS
Director, Section of Colon and Rectal Cancer Surgery
Division of Colon and Rectal Surgery
University Hospitals Case Medical Center
Associate Professor of Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

Rod Rezaee, MD, FACS
Assistant Professor
Director, Microvascular Head and Neck Reconstructive
Surgery
Department of Otolaryngology—Head and Neck Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Alan A. Saber, MD, MS, FACS, FASMBS
Chief of Minimally Invasive Surgery
Medical Director of Bariatric and Metabolic Surgery
The Brooklyn Hospital Center
The Weill Medical College of Cornell University
The New York Presbyterian Healthcare System
New York, New York

Edmund Q. Sanchez, MD
Surgical Director, Liver and Pancreas Transplant
Programs
Division of Transplant and Hepatobiliary Surgery
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Victor M. Sandoval, MD
Resident Physician
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

James Schulak, MD
Director, Transplant Institute
Chief, Division of Transplant and Hepatobiliary Surgery
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Charles E. Smith, MD, FRCPC
Professor, Case Western Reserve University School of
Medicine
Director, Cardiothoracic and Trauma Anesthesia
MetroHealth Medical Center
Cleveland, Ohio

Christopher J. Smith, MD
Assistant Professor of Surgery
Division of Vascular Surgery
Case Western Reserve University School of Medicine
MetroHealth Medical Center
Cleveland, Ohio

Lee L Swanstrom, MD, FACS
Division Chief, GI and Minimally Invasive Surgery
The Oregon Clinic
Clinical Professor of Surgery
Oregon Health and Sciences University
Portland, Oregon

William Tabayoyong, MD, PhD
Urology Institute
University Hospitals Case Medical Center
Cleveland, Ohio

Anthony Visioni, MD
General Surgery Resident
University Hospitals Case Medical Center
Cleveland, Ohio

Contributors

xv

John C. Wang, MD

Kenneth J. Woodside, MD

Assistant Professor of Surgery
Case Western Reserve University School of Medicine
Division of Vascular Surgery and Endovascular Therapy
University Hospitals Case Medical Center
Cleveland, Ohio

Director, Living Kidney Donor Program
Division of Transplant and Hepatobiliary Surgery
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Scott M. Wilhelm, MD, FACS

Jessica Mae Yih, MD

Associate Professor of Surgery
Department of Surgery
University Hospitals Case Medical Center
Cleveland, Ohio

Resident Physician
Urology Institute
University Hospitals Case Medical Center
Cleveland, Ohio

Virginia Wong, MD, FACS

Chad A. Zender, MD, FACS

Assistant Professor of Surgery
Department of Surgery, Division of Vascular Surgery and
Endovascular Therapy
University Hospitals Case Medical Center
Cleveland, Ohio

Assistant Professor
Department of Otolaryngology—Head and Neck Surgery
Case Western Reserve University School of Medicine
Cleveland, Ohio

C H A P T E R

1
Selective (Supraomohyoid) Neck
Dissection, Levels I-III
Chad A. Zender, Evan McBeath, and Pierre Lavertu

INTRODUCTION

Neck dissection has been a standard method of removing at-risk or involved cancerous lymph
nodes in the head and neck for more than 100 years. Crile first described the radical neck
dissection in the early 1900s, but modifications by Bocca and others helped reduce the morbidity associated with lymph node removal, allowing for nerve and structure preservation
when oncologically sound. This chapter discusses one of these modifications in detail, the
selective or supraomohyoid neck dissection. A selective neck dissection, including levels I
through III, is typically used for malignancies of the oral cavity in patients with N0 disease.
When a larger nodal burden is present, an extended (levels I-IV) selective neck dissection
or a modified radical neck dissection (levels I-V) is indicated. Lesions in the oral cavity that
approach or cross the midline require treatment of both sides of the neck.

3

4

SECTION

1

THE NECK

NECK ANATOMY FOR SURGICAL PLANNING
Understanding the regional lymphatic drainage pathways is critical when planning which type
of neck dissection will be employed (Fig. 1-1). A supraomohyoid neck dissection is performed
when treating patients who are at risk for micrometastasis in levels I, II, and III. The boundaries of levels I (submental and submandibular), II (upper jugular nodal chain), and III (midjugular nodal chain) are defined as follows:
Level Ia: Bounded laterally by the medial aspects of the anterior belly of the digastric muscles,
and ending medially at a line drawn from the mandible to the hyoid bone at the anatomic
midline.
Level Ib: Bounded by the lateral aspect of the anterior belly of the digastric muscle, the medial
aspect of the posterior belly of the digastric and stylohyoid muscles, and the inferior border
of the mandibular body superiorly.
Level IIa: Bounded anteriorly and superiorly by the posterior belly of the digastric and stylohyoid muscles, posteriorly by the vertical plane defined by the spinal accessory nerve and
sternocleidomastoid muscle (SCM), and inferiorly by the horizontal plane defined by the
inferior border of the hyoid bone.
Level IIb: Bounded anteriorly by the jugular vein and inferiorly by the vertical plane defined
by the spinal accessory nerve, posteriorly by the posterior border of the SCM, and superiorly
by the skull base.
Level III: Bounded superiorly by the horizontal plane defined by the inferior border of the
hyoid bone, inferiorly by the horizontal plane defined by the inferior border of the cricoid
cartilage and/or the omohyoid muscle as it crosses the internal jugular vein, anteriorly
by the lateral border of the sternohyoid muscle, and posteriorly by the posterior border of
the SCM.

CHAPTER

1

5

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Mandibular
nodes

Superior lateral
superficial cervical
(external jugular)
node

Submandibular
nodes

Accessory nerve (XI)

The patient is positioned
on the table with his neck
extended, typically on a
shoulder roll, and head
turned away from the
operative side.

Jugulodigastric node

Submental
nodes
Suprahyoid node
Superior deep lateral cervical
(internal jugular) nodes
Superior thyroid nodes
Jugulo-omohyoid node
Anterior deep cervical
(pretracheal and thyroid) nodes
(deep to infrahyoid muscles)
Anterior superficial cervical
nodes (anterior jugular nodes)

Posterior lateral
superficial cervical
(spinal accessory)
nodes
Intercalated node
Inferior deep
lateral cervical
(scalene) node
Thoracic duct
Transverse
cervical
chain of
nodes

Jugular trunk
Supraclavicular nodes*
Subclavian trunk
and node

*The supraclavicular group of nodes (also known as the lower deep cervical group),
especially on the left, are also sometimes referred to as the signal or sentinel lymph
nodes of Virchow or Troisier, especially when sufficiently enlarged and palpable.
These nodes (or a single node) are so termed because they may be the first
recognized presumptive evidence of malignant disease in the viscera.
Parotid
gland
Superior flap dissected up along deep surface of anterior facial
vein and facial (external maxillary) artery, thus elevating ramus
marginalis mandibulae of facial nerve out of operating field.
Vessels ligated and distal end of vascular stump sutured to
undersurface of flap.

Platysma
muscle

Posterior
facial vein
Common
facial vein

Facial (external
maxillary)
artery and
anterior
facial vein
Ramus
marginalis
mandibularis
of facial nerve
Mandible
Hyoid bone
Fascia over
strap muscles
Anterior
jugular vein
Platysma
muscle
Transverse
cervical nerves
Sternocleidomastoid
muscle
Supraclavicular
nerves
Operative field exposed

FIGURE 1–1 Patient positioning and anatomy in neck dissection.

Great auricular
nerve
External jugular
vein
Accessory
nerve
Trapezius
muscle
Platysma
muscle

6

SECTION

1

THE NECK

INCISION PLANNING AND PATIENT POSITIONING
FOR NECK DISSECTION
Positioning for a neck dissection includes extending the neck and turning the patient’s head
away from the surgeon. This usually entails placing a shoulder roll under the patient to facilitate
adequate extension.
Various types of incisions may be employed. The authors typically use a “hockey stick” incision that extends from the mastoid tip down the middle of the SCM and then across the neck
in a crease, which is usually over the lowest level that will be surgically treated. The incision
can be brought across the midline to the contralateral neck in the same manner, creating an
“apron” incision, which will allow access to both sides of the neck when indicated to treat
bilateral neck disease.
Raising the Subplatysmal Flap
Skin and subcutaneous incisions are continued down through the subcutaneous fat and platysma muscle, but not through the superficial layer of the deep cervical fascia. A superior
subplatysmal flap is then elevated up to the inferior border of the mandible. Care is taken to
keep the plane of elevation immediately subplatysmal, to aid in identification and preservation
of the marginal mandibular branch of the facial nerve. Laterally, the platysma muscle is not
developed, and elevation must proceed over the external jugular vein and great auricular
nerve. This allows for complete elevation of the flap (Fig. 1-2).
Inferior elevation is performed in a subplatysmal manner down below where the omohyoid
crosses the jugular vein. This allows for complete exposure of level III and for incorporation
of level IV if needed. The flap elevation can be extended down to within 5 to 10 mm of the
clavicle to aid visualization.

CHAPTER

1

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Height of subplatysmal elevation

Platysma muscle elevated

FIGURE 1–2 Flap elevation in neck dissection.

7

8

SECTION

1

THE NECK

LEVEL IA-IB NECK DISSECTION
After flap elevation, expose the anterior belly of the digastric muscle by making a midline
incision from below the mentum to the hyoid bone. It is important to include all the fibrofatty
contents from the contralateral medial edge of the digastric muscle. The elevation continues
to the medial aspect of the submandibular gland to complete the level Ia dissection (Fig. 1-3).
The marginal mandibular branch of the facial nerve can be located approximately 1 cm
inferior to angle of the mandible. Incisions brought across the neck are always two fingerbreadths below the angle to prevent inadvertent injury to this nerve. The marginal mandibular
branch of the facial nerve lies between the superficial layer of the deep cervical fascia and the
adventitia investing the anterior facial vein. The superficial layer of the deep cervical fascia is
incised at the inferior border of the submandibular gland. It must be elevated and may be
tacked to the platysma muscle to aid in elevation.
Care must be taken to preserve the marginal mandibular branch of the facial nerve and
reflect it superiorly, along with the superficial layer of the deep cervical fascia, and to remove
any submandibular retrovascular (perifacial) lymph nodes in the area. This is accomplished by
developing a plane between the vein and superficial layer of the deep cervical fascia, keeping
the fat pad that contains the facial nodes down in the specimen, along with the submandibular
gland, and elevating and protecting the nerve.
At this point the anterior belly of the digastric muscle is isolated, and the gland and fibrofatty
contents of level Ia are brought posteriorly across the mylohyoid muscle.
Retract the mylohyoid muscle; identify and preserve the lingual and hypoglossal nerves;
then identify, ligate, and divide the submandibular duct, submandibular ganglion, and corresponding vasculature. Level I is released and left pedicled by the inferior fibrofatty attachments
to levels II and III (Fig. 1-3).

CHAPTER

1

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Marginal mandibular
branch of facial nerve
Facial artery and vein

Parotid gland
Level Ia
Greater
auricular nerve
External
jugular vein
Digastric muscle
(anterior belly)
Mylohyoid muscle

Level Ib

Mylohyoid muscle
(retracted)
Lingual nerve
Submandibular
ganglion
Hypoglossal nerve

Submandibular gland

FIGURE 1–3 Dissection of level I (submental and submandibular regions).

9

10

SECTION

1

THE NECK

LEVEL II-III NECK DISSECTION
Identify the posterior belly of the digastric muscle, creating the digastric tunnel back to the
mastoid tip under the SCM (Fig. 1-4).
Incise the investing fascial layer along the anterior border of the SCM, ligating and dividing
the external jugular vein in the process. An attempt should be made to preserve the greater
auricular nerve, if not involved with disease.
Unwrap the SCM from its investing fascia. This is accomplished along a broad, superior-toinferior plane, from the digastric muscle superiorly to the omohyoid muscle inferiorly.
Identify the spinal accessory nerve at its entrance into the SCM, and trace it under the
posterior belly of the digastric muscle. The spinal accessory nerve typically passes lateral to
the internal jugular vein just before diving under the posterior belly of the digastric muscle.
The nerve will occasionally bisect or run deep to the jugular vein.
The spinal accessory nerve is released from the surrounding soft tissue, and then level IIb
is released from the skull base, the back of the jugular vein, the SCM, and the deep cervical
fascia. Level IIb is left attached to IIa and brought under the spinal accessory nerve.
Once the investing fascial layer is elevated off the SCM down to the level of the deep cervical rootlets, the dissection is taken medially across the rootlets from the omohyoid muscle to
the spinal accessory nerve superiorly. Care must be taken to avoid injuring the spinal accessory
nerve in this area as it exits the SCM posteriorly (Fig. 1-5).
Dissect levels II and III medially in a plane lateral to the cervical rootlets and the carotid
sheath, which invests the carotid artery, internal jugular vein, and vagus nerve.
Once the elevation reaches the jugular vein, the fascia from the internal jugular vein is
unwrapped. Branches of the vein may be ligated and divided as the specimen is brought medially. The ansa cervicalis will be transected during the inferior dissection as the specimen is
brought across the jugular vein to the lateral aspect of the strap muscles. Superiorly, the hypoglossal nerve, which runs lateral to the carotid artery and medial to the jugular vein, must be
protected under the digastric muscle. The ansa hypoglossi will likely need to be transected as
the specimen is brought medially to the hyoid bone and strap musculature.
The specimen is then dissected away from the hypoglossal nerve and posterior belly of the
digastric muscle until it can be easily removed. The anterior dissection will meet with the
posterior dissection as the specimen is brought across the strap muscles, carotid artery, and
jugular vein (Fig. 1-5).

CHAPTER

1

11

Selective (Supraomohyoid) Neck Dissection, Levels I-III

Stylohyoid muscle
Digastric muscle
(posterior belly)
Sternocleidomastoid
muscle (retracted)

Level IIa
Level IIb

Greater
auricular
nerve
External
jugular vein

Hyoid bone
Sternohyoid muscle
Omohyoid muscle
Sternocleidomastoid muscle

Level III

FIGURE 1–4 Dissection of levels II (upper jugular nodal chain) and III (midjugular nodal chain).

12

SECTION

1

THE NECK

Internal jugular vein

Sternocleidomastoid muscle

Spinal accessory nerve

Cervical rootlets

Level I
Level II

Level III

Level I

Level II

Level III

FIGURE 1–5 Lymphadenectomy (levels I-III).

SUGGESTED READINGS
Janfaza P, editor. Cummings otolaryngology: head and neck surgery, 5th ed. Philadelphia:
Saunders; 2010.
Myers EN, editor. Operative otolaryngology: head and neck surgery, 2nd ed. Philadelphia:
Saunders; 2008.

C H A P T E R

2
Tracheotomy and Cricothyrotomy
Rod Rezaee, Yi-Chun Carol Liu, and Pierre Lavertu

INTRODUCTION

Tracheotomy (tracheostomy) is one of the oldest surgical procedures known, with the first
reference 3000 to 4000 years ago. Chevalier Jackson is credited with standardizing the tracheotomy procedure in 1932, outlining the individual steps for establishing a direct airway
through the anterior neck tissues and into the trachea. Jackson had the foresight to consider
potential surgical complications when he warned against placement of a high tracheotomy
or cricothyrotomy (cricothyroidotomy). Although the procedure has evolved and now
includes a percutaneous technique, this chapter focuses on open tracheotomy.
INDICATIONS AND PRINCIPLES OF TRACHEOTOMY
Indications for tracheotomy are multiple and include the need to bypass an airway obstruction
caused by congenital anomaly, vocal cord paralysis, inflammatory disease, benign or malignant
laryngeal pathology, laryngotracheal trauma, facial trauma, or severe sleep apnea refractory
to other interventions. Additional indications for tracheotomy include the need to provide an
airway for patients receiving mechanical ventilation for respiratory failure and for those with
chronic aspiration secondary to inadequate cough. Tracheotomy may also allow for a more
secure and comfortable airway for home ventilation in patients with neuromuscular or other
chronic diseases.

13

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SECTION

1

THE NECK

Preoperative Considerations
Once a tracheotomy is planned, certain factors influence whether patients should have an open
tracheotomy or a percutaneous dilatational tracheotomy, as first described by Ciaglia in 1985.
Regardless of the tracheotomy method chosen, a patient’s overall medical condition must be
optimized, body habitus assessed, and coagulation profile addressed. Other preoperative factors
to consider include the urgency of the procedure (emergency vs. elective); need for general or
local anesthesia, adult or pediatric patient, current status of the airway (intubated vs. nonintubated patient), availability of proper equipment, patient portability, surgeon’s experience
(open vs. percutaneous technique), and capability of the institution to perform bedside procedures. This will determine which team performs the procedure and whether it will be done in
the operating room or at the bedside in the intensive care unit.
SURGICAL ANATOMY AND TRACHEOTOMY PROCEDURE
External Anatomy
The patient is placed in the supine position. The surgeon might consider placing the neck into
slight extension, but this should not be too far past the neutral position, so that the skin incision remains in line with the tracheal incision. A shoulder roll may be used in some patients
to assist with positioning (Fig. 2-1).
The thyroid notch superiorly, cricoid cartilage, and suprasternal notch inferiorly can usually
be palpated and should be marked (Fig. 2-1). If an awake tracheotomy is being performed, the
skin is injected with 1% lidocaine with 1 : 100,000 epinephrine solution for hemostasis and
anesthesia. According to surgeon preference, this injection may also be done for general anesthesia patients. A vertical or horizontal incision is made in the midline of the neck, about 2 cm
above the sternal notch, and is carried down until the strap muscles are visible.
Strap Muscles and Midline Raphe
The anterior jugular veins are typically located on the strap musculature and may require ligation if encountered in the midline (Fig. 2-2). Small cricothyroid arteries traverse the superior
aspect of the cricothyroid space, forming an anastomosis near the midline. This may cause
problematic bleeding in the setting of emergent airway access or if dissection is carried out
above the cricoid cartilage. In the lower neck, the surgeon must be aware that the innominate
artery crosses over anterior to the trachea at the level of the thoracic inlet and is higher on
the right side. Before dissection of the strap muscles, the surgeon should palpate for innominate
pulsations in the suprasternal notch and should be cognizant of the pathway of the surgical
dissection in the setting of a high-riding vessel.
Midline dissection is essential for hemostasis and avoidance of paratracheal structures,
including the great vessels of the neck. The midline raphe between the paired sternohyoid and
sternothyroid muscles can be easily identified. Lateral retraction of the strap muscles along the
midline raphe will expose the underlying thyroid gland. Palpation of the trachea can help
maintain a midline course of dissection in those individuals with thick subcutaneous tissues.

CHAPTER

2

Tracheotomy and Cricothyrotomy

15

4. Strap muscles retracted
to expose trachea

Isthmus of thyroid gland
Strap muscles
Pretracheal venous plexus
1. Position of patient for tracheotomy;
shoulders elevated by sandbag

Thyroid cartilage
Cricothyroid membrane
Cricothyroid muscle
Common carotid artery
Cricoid cartilage

5. Pretracheal venous plexus
divided. Trachea stabilized
by hooks. Cruciate incision
in trachea.

Edge of
sternocleidomastoid
muscle
Thyroid gland
Skin incision
Dome of pleura
Tracheal incision
Trachea
Suprasternal notch
2. Anatomy and surface topography
relative to line of incision

Strap muscles
in cervical fascia
Anterior jugular vein

3. Skin and fat retracted

FIGURE 2–1 Tracheotomy procedure, steps 1-6.

6. Tracheotomy tube
tied securely in place
over gauze square

16

SECTION

1

THE NECK

Thyroid Isthmus
The strap muscles are separated using blunt dissection and retracted to either side until the
thyroid isthmus is visible. The isthmus of the thyroid gland generally lies across the first to
fourth tracheal rings. It must be divided when overlying the tracheotomy site, because this
will make reinsertion safer and easier in the setting of accidental dislodgement. The isthmus
can be addressed in one of several ways. First, the fascial attachments of the thyroid to the
anterior trachea may be dissected free, thus allowing the gland to be retracted above or below
the planned entry site into the trachea. If the thyroid is enlarged and cannot be retracted out
of the way, it will need to be divided by further dissecting it from the anterior tracheal wall in
the immediate pretracheal plane to establish a bloodless plane of dissection. By identifying the
bright-white layer of the tracheal cartilage, the surgeon will minimize bleeding from trauma
to the posterior aspect of the gland.
Once the thyroid isthmus is elevated from the trachea, the surgeon may use two clamps on
either side, then cutting in the midline with a Bovie cautery device. Once divided, the two
ends of isthmus are then suture-ligated using a running or figure-of-eight 2-0 silk stitch. If
available, other methods of dividing the gland include using the Harmonic scalpel or other
device, based on surgeon preference. Use of cautery alone to divide the thyroid is discouraged,
to minimize risk of postoperative hemorrhage.
Anatomy with Trachea Visualized
A cricoid hook may be used to help stabilize the position of the trachea before entering the
airway. A hook may also be used to elevate the trachea out of the chest in the patient with
kyphosis or a low-lying laryngotracheal complex. Once the anterior wall of the trachea is
visualized, the space between the second and third tracheal rings is identified by palpation
using a hemostat. A horizontal incision is made between the rings with a scalpel and can be
extended laterally in each direction using scissors. Care is taken not to rupture the cuff of the
endotracheal tube (ETT) by either deflating it before entering the airway or advancing it distally.
It is preferable to maintain the ETT inflated during the procedure. It allows ventilation and
minimizes the spray of blood and secretions into the surgical field.
Surgeon preference and age of the patient may influence the type of tracheal incision used.
In children, a vertical incision may be used, but in adults the most common technique is to
create an anterior tracheal window by removing a section of a single ring. Another technique
creates an inferiorly based “trapdoor” flap (Björk flap) composed of an anterior portion of a
single tracheal ring and interspace tissue below. After an intercartilaginous incision is made,
scissors are used to cut downward on either side to create an inferiorly based flap of tracheal
tissue. The superior edge of this flap is then stitched to the skin edge to exteriorize and secure
the trachea. Although some consider this to be the safest method because the airway is secured
to the skin, this may lead to future complications.

CHAPTER

Hyoid bone

2

Tracheotomy and Cricothyrotomy

17

Digastric muscle (anterior belly)
Mylohyoid muscle

Thyrohyoid membrane

Hyoglossus muscle
External carotid artery

Stylohyoid muscle

Internal jugular vein

Digastric muscle (posterior belly)

Thyrohyoid muscle

Fibrous loop for intermediate
digastric tendon

Thyroid cartilage
Omohyoid muscle
(superior belly)

Sternohyoid and omohyoid
muscles (cut)

Sternohyoid muscle

Thyrohyoid muscle

Median cricothyroid
ligament

Oblique line of thyroid cartilage

Cricoid cartilage

Cricothyroid muscle
Sternothyroid muscle

Scalene
muscles

Omohyoid muscle
(superior belly) (cut)

Trapezius
muscle

Thyroid gland

Omohyoid muscle
(inferior belly)

Sternohyoid muscle (cut)
Trachea

Clavicle

Styloid process

Mastoid process
Stylohyoid muscle

Mylohyoid muscle

Digastric muscle (posterior belly)
Digastric muscle (anterior belly)

Thyrohyoid muscle

Geniohyoid muscle
Oblique line of thyroid cartilage

Sternohyoid muscle

Omohyoid muscle (inferior belly)
Omohyoid muscle (superior belly)
Sternothyroid muscle

Infrahyoid and
suprahyoid muscles and
their action: schema

Sternum

Scapula

FIGURE 2–2 Infrahyoid and suprahyoid musculature for tracheotomy.

18

SECTION

1

THE NECK

Anatomy with Tracheotomy Tube in Place
Once the airway is entered, the ETT is pulled out slowly by the anesthesiologist until it is just
above the newly created tracheotomy. The tracheotomy tube or ETT is then placed through
the opening into the trachea. After the airway is secured, as confirmed by CO2 monitor or
ventilator, the oral ETT is then removed. The tracheostomy tube is then sutured to the skin
using 2-0 silk to minimize the risk of accidental dislodgement. In addition, a circumferential
tie is placed and secured around the neck, allowing at least one finger to slide underneath to
minimize constriction.
A flexible extension tube is used to connect the tube to the ventilator circuit to minimize
unnecessary movement of the tube in the immediate postoperative period.
SUMMARY
Tracheotomy is used to establish a surgical airway in patients requiring prolonged mechanical
ventilation. Surgeon mastery of anatomy and proper technique will maximize successful
patient outcomes and minimize potential complications.
SUGGESTED READINGS
Bailey BJ. Head and neck surgery: otolaryngology. 4th ed. Philadelphia: Lippincott-Raven;
2006, pp 785-800.
Beatrous WP. Tracheostomy: its expanded indications and its present status. Laryngoscope
1968;78(3):3-55.
Pahor AL. Ear, nose and throat in ancient Egypt. J Laryngol Otol 1992;106(9):773-9.
Shapiro BA, Harrison RA, Trout CA. The artificial airway: clinical application of respiratory
care, 2nd ed. Chicago: Year Book; 1979, pp 177-186.

C H A P T E R

3
Thyroidectomy and Parathyroidectomy
Christopher R. McHenry

THYROIDECTOMY

Thyroidectomy is the most common endocrine surgical procedure performed. It is indicated
for nodular thyroid disease when fine-needle aspiration biopsy is malignant or suspicious
for malignancy, consistent with a Hürthle or follicular cell neoplasm, persistent atypia/
follicular lesion of undetermined significance, or is persistently nondiagnostic. Thyroidectomy is indicated for benign thyroid nodules that progressively increase in size, extend
substernally, cause compressive symptoms, or impinge on the trachea, esophagus, recurrent
laryngeal nerve, or major vessels. Thyroidectomy is also an option for treatment of thyrotoxicosis caused by a solitary hyperfunctioning nodule, multinodular goiter, or Graves’
disease. The goal of thyroid surgery is to remove all diseased thyroid tissue safely, relieve
symptoms, minimize recurrent disease, and prolong survival.

21

22

SECTION

2

ENDOCRINE

Surgical Anatomy for Thyroidectomy
The thyroid gland consists of two lobes and an isthmus (Fig. 3-1). Between 30% and 60% of
patients also have a pyramidal lobe that forms as a result of the persistence of the embryologic
thyroglossal duct. The principal blood supply to the thyroid gland comes from the inferior
thyroid artery, a branch of the thyrocervical trunk and the superior thyroid artery, which is
the first branch of the external carotid artery. The venous drainage of the thyroid gland is from
the superior and middle thyroid veins, which empty into the internal jugular vein, and the
inferior thyroid veins, which empty into the brachiocephalic veins.

CHAPTER

3

Thyroidectomy and Parathyroidectomy

External carotid artery

Hyoid bone

Internal carotid artery

Superior laryngeal nerve
Internal branch
External branch

Infrahyoid artery
Superior thyroid artery and vein

Thyroid cartilage (lamina)

Superior laryngeal artery

Median cricothyroid
ligament

Thyrohyoid membrane
Ansa
cervicalis

Superior root

Cricothyroid muscles

Inferior root

Common carotid artery

Cricoid cartilage

Cricothyroid artery

Pyramidal lobe
(often absent
or small)
Right lobe
Left lobe
Isthmus

Internal jugular vein
Phrenic nerve
Middle thyroid vein
Inferior thyroid veins
Ascending cervical artery

Thyroid
gland

Pretracheal lymph nodes

Inferior thyroid artery

Phrenic nerve

Superficial cervical artery

Anterior scalene muscle

Suprascapular artery

Vagus nerve (X)

Thyrocervical trunk

External jugular vein

Subclavian
artery and vein

Anterior jugular vein
1st rib (cut)

Vagus nerve (X)

Left recurrent laryngeal nerve
Right recurrent
laryngeal nerve
Brachiocephalic trunk
Brachiocephalic veins
Superior vena cava
Aortic arch

Thyroid cartilage
Cricothyroid ligament
Common carotid artery
Medial margin of
sternocleidomastoid muscle
Cricothyroid muscle
Cricoid cartilage
Thyroid gland
Cupula (dome) of pleura
Trachea
FIGURE 3–1 Thyroid gland, anterior view.

23

24

SECTION

2

ENDOCRINE

Surgical Anatomy for Thyroidectomy—Cont’d
Determining the surface anatomy of the neck is necessary for proper placement of the skin
incision (Figs. 3-1 and 3-2). The patient is positioned supine on the operating room table with
the arms tucked at the side, a soft roll placed lengthwise beneath the shoulders, and the head
in a soft-foam headrest with the neck extended (Fig. 3-2). Important landmarks that should
be palpated include the prominence of the thyroid cartilage, the cricoid cartilage, and the
sternal notch. The isthmus of the thyroid gland lies immediately below the cricoid cartilage. A
transverse skin incision is made in a normal skin crease below the cricoid cartilage for an
optimal cosmetic result.

CHAPTER

3

Thyroidectomy and Parathyroidectomy

25

Digastric muscle (anterior belly)
Mylohyoid muscle

Parotid gland

Submandibular gland
Platysma muscle
(cut away)

Fibrous loop for
intermediate
digastric tendon

Mastoid process

Stylohyoid muscle
Digastric muscle
(posterior belly)

Hyoid bone

External carotid artery

Carotid sheath

Internal jugular vein
Fascia of infrahyoid
muscles and cut edge

Thyrohyoid muscle
Omohyoid muscle
(superior belly)

Thyroid cartilage

Sternohyoid muscle

Investing layer of (deep)
cervical fascia and cut edge

Sternothyroid muscle
Scalene muscles

Cricoid
cartilage

Trapezius muscle
Omohyoid muscle
(inferior belly)
Clavicle

Deltoid muscle
Clavicular head
Sternal head

Pretracheal layer of
(deep) cervical fascia over
thyroid gland and trachea

Sternocleidomastoid
muscle

Pectoralis major muscle

Suprasternal space (of Burns)

Manubrium of sternum

The patient is positioned supine on the
operating room table with the arms
tucked at the sides. To enhance the
accessibility of the thyroid gland, the
patient is positioned on a soft roll (arrow)
placed lengthwise under the houlders,
and the neck is extended on a soft-foam
headrest. The bed is placed in reverse
Trendelenburg position to decrease the
venous pressure in the neck and reduce
potential bleeding.

Jugular notch

Incision line

A silk suture is used to mark the site of the
incision. Important anatomic landmarks
are the thyroid cartilage, the cricoid cartilage,
and the sternal notch. The site for the incision
is being marked just below the cricoid cartilage.

FIGURE 3–2 Anatomic landmarks for thyroidectomy or parathyroidectomy incision.

26

SECTION

2

ENDOCRINE

Anatomy for Exposing the Thyroid Gland
It is necessary to create a working space to remove the thyroid gland. This is accomplished first
by dividing the subcutaneous tissue and platysma muscle to expose the sternal head of the
sternocleidomastoid muscles laterally and the sternothyroid muscles in the midline of the incision (Figs. 3-2 and 3-3, A). Superior and inferior skin flaps are raised in the subplatysmal plane,
anterior to the anterior jugular veins. The skin flaps are raised superior to the prominence of
the thyroid cartilage, inferior to the sternal notch, and lateral to the sternal head of the sternocleidomastoid muscles.
The right and left sternohyoid muscles are separated along the median raphe from the
thyroid cartilage superiorly to the sternal notch inferiorly. The median raphe is avascular and
consists of the pretracheal or deep cervical fascia over the thyroid gland and trachea. The sternothyroid muscle is freed from the anterior surface of the thyroid lobe by dividing the intervening loose areolar tissue. The sternothyroid and sternohyoid muscles are retracted laterally,
and the lobe of the thyroid gland is mobilized anteromedially. The sternohyoid and sternothyroid muscles may be divided when additional exposure is necessary, especially for patients with
large goiters. The muscles are divided at the level of the cricoid cartilage to avoid injury to the
ansa cervicalis, which enters the muscle inferiorly.
Anatomy for Mobilization of the Thyroid Lobe
Anteromedial traction is applied to the lobe of the thyroid gland, and the middle thyroid vein
is divided (Fig. 3-3, B). The areolar tissue between the thyroid gland and the common carotid
artery is separated using a combination of blunt and sharp dissection, allowing for further
anteromedial mobilization of the thyroid gland. The superior thyroid artery and the superior
thyroid veins are exposed by applying caudal and lateral traction to the thyroid parenchyma
at the superior pole. This helps expose the cricothyroid space and facilitates the individual
ligation of the superior-pole vessels close to the thyroid gland, staying lateral to the muscles
of the pharynx and the larynx to avoid injury to the external branch of the superior laryngeal
nerve (EBSLN).

CHAPTER

3

Thyroidectomy and Parathyroidectomy

27

A. Muscles of the neck (lateral view)
Mastoid process
Ramus of mandible

Styloid process

Parotid gland (cut)

Stylohyoid muscle

Masseter muscle

Digastric muscle
(posterior belly)

Submandibular gland
Hyoglossus muscle

Middle pharyngeal
constrictor muscle

Mylohyoid muscle

Longus capitis muscle

Body of mandible

Splenius capitis muscle

Digastric muscle
(anterior belly)

Sternocleidomastoid muscle

Hyoid bone

Levator scapulae muscle
Scalene muscles

Thyrohyoid muscle

Posterior
Middle
Anterior

Omohyoid muscle
(superior belly)
Sternohyoid muscle

Brachial plexus

Inferior pharyngeal
constrictor muscle

Trapezius muscle
Omohyoid muscle
(inferior belly)

Sternothyroid
muscle

Acromion

Sternal head

Clavicle

Clavicular head

Deltoid
muscle

Sternocleidomastoid
muscle

Pectoralis major muscle
Manubrium of sternum

B. Parathyroid glands (right lateral view)
External carotid artery

Internal branch of
superior laryngeal nerve

Superior thyroid vein
Superior laryngeal artery

External branch of
superior laryngeal nerve

Superior thyroid artery (cut)
Inferior pharyngeal
constrictor muscle
Common carotid artery

Superior parathyroid gland
Thyroid gland (right lobe)
(retracted anteriorly)

Internal jugular vein
Middle thyroid vein

Inferior parathyroid gland

Inferior thyroid artery
Right recurrent laryngeal nerve
Esophagus

Inferior
thyroid vein

FIGURE 3–3 Surgical anatomy for thyroidectomy and parathyroidectomy.

28

SECTION

2

ENDOCRINE

Anatomy of the Superior Laryngeal Nerve
The superior laryngeal nerve is a branch of the vagus nerve from high in the neck (Fig. 3-4,
A and B). At 2 to 3 cm above the superior-pole vessels, the superior laryngeal nerve divides
into an internal branch that provides sensory innervations to the supraglottic area of the larynx
and the base of the tongue and an external branch that provides motor innervation to the
cricothyroid muscle.
The EBSLN is not routinely identified during thyroidectomy or parathyroidectomy. It is a
thin nerve that usually travels along the medial border of the superior-pole vessels. It usually
crosses the superior-pole vessels 1 cm or more above the junction of the vessels and the thyroid
parenchyma. In 20% of patients the EBSLN crosses or is immediately adjacent to the superiorpole vessels at its junction with the thyroid gland, increasing the likelihood of injury and
underscoring the importance of individual ligation of the vessels to preserve the EBSLN.
Anatomy of the Recurrent Laryngeal Nerve
The recurrent laryngeal nerves (RLNs) are branches of the vagus nerve from within the thorax
(Fig. 3-4). The right RLN “recurs” around the right subclavian artery, and the left RLN recurs
around the arch of the aorta. The RLNs ascend into to the neck from the thoracic inlet, passing
from lateral to medial into the tracheoesophageal groove. The left RLN enters the neck in a
more medial location than the right RLN, which has a more oblique course.
The RLN is identified inferior to the inferior thyroid artery, where its location is most constant. In the neck the RLN crosses the inferior thyroid artery and then maintains a paratracheal
location for approximately 1 cm before passing posterior to the inferior edge of the inferior
pharyngeal constrictor muscle to enter the larynx (see Fig. 3-3, B).
In 85% to 90% of patients, thyroid parenchyma tissue protrudes from the posterolateral
margin of the lateral lobe of the thyroid gland, known as the tubercle of Zuckerkandl (Fig. 3-4,
C). This is an important anatomic landmark because the RLN passes in the tracheoesophageal
groove beneath the inferior portion of the tubercle of Zuckerkandl before it turns posteriorly
to enter the larynx. Before entering the larynx, the RLN divides into two or more branches in
40% to 80% of patients (Fig. 3-4, D). The RLN innervates all the muscles of the larynx except
the cricothyroid muscle.

CHAPTER

3

Thyroidectomy and Parathyroidectomy

A. Nerves of larynx

Internal branch of superior laryngeal nerve
Sensory branches to larynx

Superior
laryngeal nerve

Ansa of Galen
Aryepiglottic muscle
Thyroepiglottic muscle

Internal branch
External branch
Inferior pharyngeal
constrictor muscle

Transverse and oblique arytenoid muscles
Thyroarytenoid muscle
Vocalis muscle
Lateral cricoarytenoid muscle
Posterior cricoarytenoid muscle

Cricothyroid muscle
Cricopharyngeus muscle
(part of inferior
pharyngeal constrictor)

Thyroid articular surface
Anterior and posterior branches of
inferior laryngeal nerve
Right recurrent laryngeal nerve

Right recurrent
laryngeal nerve
Right lateral
view

Right lateral view:
thyroid cartilage lamina removed

B. Parathyroid glands (posterior view)

External carotid artery

Thyrohyoid membrane
Hyoid bone

Superior laryngeal nerve
Internal branch

Internal carotid artery
Superior thyroid artery

External branch
Vagus nerve (X)

Superior aryngeal artery

Epiglottis

Common carotid artery

Superior thyroid artery

Inferior pharyngeal constrictor muscle (cut)

Common carotid artery

Fibrous capsule of thyroid gland (cut)
Cricopharyngeus muscle (part of inferior
pharyngeal constrictor)
Superior parathyroid gland

Fibrous capsule of thyroid gland (cut)
Superior parathyroid gland

Right lobe of thyroid gland

Left lobe of thyroid gland

Inferior parathyroid gland (may be more
caudally located, even within mediastinum)
Inferior thyroid artery

Ascending cervical artery
Inferior parathyroid gland

Right recurrent laryngeal nerve
Transverse cervical artery

Left recurrent laryngeal nerve

Suprascapular artery

Esophagus

Thyrocervical trunk

Subclavian artery

Vertebral artery
Subclavian artery
Brachiocephalic trunk

Trachea

Trachea
Recurrent
laryngeal nerve
Tubercle of
Zuckerkandl

C. Tubercle of Zuckerkandl

29

TG

T

P

D. Intraoperative photograph
demonstrating the recurrent laryngeal
nerve (RLN). An anterior motor branch
and a posterior sensory branch are
present in the normal paratracheal
location (T=trachea). A normal right
superior parathyroid gland is depicted
(P). The thyroid gland (TG) has been
mobilized anteromedially.

LN

R

Esophagus

FIGURE 3–4 Anatomy of superior and recurrent laryngeal nerves.

30

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ENDOCRINE

Anatomy for Ligation of the Inferior Thyroid Artery
and Preservation of the Parathyroid Glands
Whenever possible, the parathyroid glands should be preserved in situ by dissecting them
downward, away from the capsule of the thyroid gland. Once the RLN has been exposed
superior to the inferior thyroid artery, the branches of this artery are ligated close to the thyroid
parenchyma, preserving the blood supply to the parathyroid glands. Truncal ligation of the
inferior thyroid artery should be avoided.
When a parathyroid gland cannot be preserved in situ, it is removed and a small portion
submitted for frozen-section examination to confirm the presence of parathyroid tissue. The
remainder of the gland is minced and autotransplanted into a pocket of the sternocleidomastoid
muscle. Ninety percent of freshly autotransplanted parathyroid glands retain function.
Once the thyroid lobe has been dissected away from the RLN, the ligament of Berry,
connective tissue that suspends the thyroid gland to the trachea, is divided sharply. A small
remnant of thyroid tissue can be left in place where the RLN contacts the thyroid parenchyma
at the ligament of Berry, to preserve the integrity of the RLN. For patients undergoing a thyroid
lobectomy and isthmusectomy, the thyroid gland is mobilized to the contralateral side of the
trachea and divided. The cut edge of the contralateral lobe of the thyroid gland is oversewn.
For patients undergoing total thyroidectomy, anteromedial mobilization of the contralateral
thyroid lobe is begun.
PARATHYROIDECTOMY
Parathyroidectomy is indicated for treatment of primary, secondary, and tertiary hyperparathyroidism (HPT). Approximately 85% to 90% of patients with primary HPT have a single
adenoma, whereas patients with secondary and tertiary HPT have parathyroid hyperplasia.
Minimally invasive parathyroidectomy (MIP) is used to treat patients with primary HPT caused
by a solitary adenoma, whereas bilateral neck exploration with subtotal parathyroidectomy or
total parathyroidectomy and parathyroid autotransplantation is the standard treatment for
parathyroid hyperplasia.
Photographs
Accurate preoperative parathyroid localization is a prerequisite for performing MIP. Technetium
99m sestamibi scintigraphy and high-resolution ultrasonography are the localizing procedures
of choice (Fig. 3-5). Intraoperative parathyroid hormone (IOPTH) measurement is used to
determine whether additional hyperfunctioning parathyroid tissue remains. A greater than
50% decline in IOPTH levels 10 minutes after excision of all hyperfunctioning parathyroid
tissue is indicative of a curative parathyroidectomy. Failure of IOPTH levels to decline by more
than 50% indicates that residual hyperfunctioning tissue remains and that further exploration
is necessary.

CHAPTER

Anterior immed

3

Thyroidectomy and Parathyroidectomy

Anterior 1 hr delay

Technetium 99m sestamibi scan demonstrating an abnormal focus of
radiotracer accumulation seen in the left side of the neck on immediate
and 1 hour delayed images.

Static sonographic image in the sagittal plane demonstrating a
homogeneous, hypoechoic mass inferior to the left lobe of the
thyroid gland that corresponded to a left inferior parathyroid adenoma.
FIGURE 3–5 Preoperative imaging of neck: scintigram (top) and sonogram (bottom).

31

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Anatomy and Embryology of Parathyroid Glands
A normal parathyroid gland is oval, bean shaped or spherical, yellow-tan in color, 5 mm in
maximum dimension, and weighs 35 mg or less. It is usually surrounded by adipose tissue
(Fig. 3-6, A). A parathyroid gland can be flattened in appearance, especially when it is within
the capsule or adherent to the thyroid gland.
The superior parathyroid glands are usually posterior and superior to the RLN, approximately 1 cm cephalad from the junction of the RLN and inferior thyroid artery at the level of
the cricoid cartilage, where the RLN enters posterior to the inferior pharyngeal constrictor
muscle (see Fig 3-3, B). The superior glands are often found in a subcapsular location. The
inferior parathyroid glands are usually anterior to the RLN along the posterolateral aspect of
the inferior pole to the thyroid gland, approximately 1 cm caudal to the junction to the RLN
and inferior thyroid artery. The inferior parathyroid glands are less often subcapsular. The
inferior thyroid artery is the principal blood supply to the parathyroid glands, although they
may also obtain blood supply from the superior thyroid artery and small vessels from the
capsule of the thyroid gland.
The steps necessary to expose the parathyroid glands are similar to those used for thyroidectomy, except a smaller incision is used (2.5 to 4.0 cm). Superior and inferior skin flaps are
raised; the strap muscles are separated in the midline; and the lobe of the thyroid gland is
mobilized and retracted anteromedially. The search for an enlarged parathyroid gland begins
with an exploration of the normal anatomic locations for the superior and inferior parathyroid
glands (Fig. 3-6, B). Division of the middle thyroid vein and the superior-pole vessels is generally unnecessary, but this may be helpful in exposing parathyroid glands, especially in ectopic
locations.
The inferior parathyroid glands and the thymus develop from the third bronchial pouch
(Fig. 3-6, C). The superior parathyroid glands and the lateral lobes of the thyroid gland develop
from the fourth bronchial pouch. Inferior parathyroid glands undergo extensive migration with
the primordium of the thymus and eventually become located on the dorsolateral surface of
the inferior pole of the thyroid lobe. These superior parathyroid glands undergo minimal migration and become located on the dorsomedial surface of the superior pole of the thyroid gland.

CHAPTER

3

Thyroidectomy and Parathyroidectomy

A

33

TG

TG
A
P

A. A normal superior parathyroid gland (P) surrounded by adipose tissue
(A) is demonstrated with the thyroid gland (TG) retracted anteromedially.

B. A left inferior parathyroid adenoma (A) is depicted in its normal
anatomic position with the thyroid gland (TG) mobilized anteromedially.

C. Development of the thyroid and parathyroid glands
1st pharyngeal pouch
1st branchial cleft
4th aortic arch

Internal
carotid
artery

4th branchial
cleft

1st aortic
arch

4th pharyngeal
pouch

Disintegrating
buccopharyngeal
membrane

Dorsal aorta

Maxillary
process

4th branchial arch

Thyroid gland

Trachea

1st branchial arch (mandibular)

Esophagus

Heart

Lung bud

I
II
III
IV
Trachea
Lung bud

Pharyngeal pouches

Pharynx (ventral view) 4th week
Mouth cavity
Thyroid gland

Pharynx and derivatives (between 6th and 7th weeks)
Pharyngeal
Foramen
cavity
cecum
1st pouch

Tongue

2nd pouch

Epithelium
of larynx

3rd pouch
Parathyroid III

Lateral
thyroid
lobe

Thymus
4th pouch
Parathyroid IV
Esophagus

Trachea

Esophagus
FIGURE 3–6 Anatomy and embryology of parathyroid glands.

Thyroid
isthmus

34

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ENDOCRINE

Anatomy and Embryology of Parathyroid Glands—Cont’d
The inferior parathyroid glands, because of their extensive embryologic migration, are more
often present in ectopic locations. The most common location for an ectopic inferior parathyroid gland is within the thymus (Fig. 3-7, top, circled A). Other sites include the thyrothymic
ligament and the anterosuperior mediastinum (B), undescended in a submandibular location
(C), or within the thyroid gland (D). The most common ectopic location for a superior parathyroid gland is in the tracheoesophageal groove (E). Ectopic superior parathyroid glands may
also be found in a retropharyngeal (F), retroesophageal (G), posterior mediastinal (H), or intrathyroidal (D) location. Preoperative localization is important to identify ectopic glands, particularly the retrosternal, intrathymic adenoma (Fig. 3-7, bottom scans and photo) or the undescended
submandibular adenoma.
When resecting abnormal parathyroid tissue, care should be taken not to enter the capsule
of the gland. Violation of the capsule of an abnormal parathyroid gland can lead to recurrent
HPT from soft tissue implantation of parathyroid cells, known as parathyromatosis. In patients
with a solitary adenoma, mobilization of the adenoma is completed before taking the blood
supply. Before taking the blood supply of the adenoma, blood is obtained from the internal
jugular or a peripheral vein for IOPTH measurement. The main blood supply to the adenoma
is ligated and additional blood obtained 5 and 10 minutes after excision of the adenoma
for IOPTH measurement. A greater than 50% decline in IOPTH compared with the preexcisional or preoperative value is indicative of cure of the HPT, and no additional exploration is
necessary.
The management of patients with parathyroid hyperplasia should consist of subtotal parathyroidectomy or total parathyroidectomy with parathyroid autotransplantation. The operative
approach is primarily based on surgeon preference. When a subtotal parathyroidectomy is
performed, the parathyroid remnant should be created first and its viability confirmed before
resecting other glands. A search for supernumerary glands, which occur in 10% to 15% of
patients, should be routinely performed with either approach. Because a supernumerary gland
is most often found in the thymus, a routine transcervical thymectomy should also be
performed.

CHAPTER

Sites for ectopic parathyroid glands.
Open circles depict the normal
location for the superior and inferior
parathyroid glands.

3

Thyroidectomy and Parathyroidectomy

35

C

F

E

D

Thyroid

G

H

B

A

Planar

Planar

Thymus

Technetium 99m sestamibi images demonstrating an abnormal focus
of radiotracer accumulation in a retrosternal location on the right. In the
first image, radiopaque markers are present on the cricoid cartilage (CC)
and the suprasternal notch (SSN).

CC
SSN

ant w marker
Planar

ant/1mm
w/o marker

Intrathymic parathyroid adenoma (arrow) that corresponds to the
abnormal focus of radiotracer accumulation seen on the technetium
images.
FIGURE 3–7 Anatomic sites for ectopic parathyroid adenoma, with images of abnormal focus and a corresponding specimen.

36

SECTION

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ENDOCRINE

SUGGESTED READINGS
Ander S, Johansson K, Lennquist S, Smed S. Human parathyroid blood supply determined by
laser Doppler flowmetry. World J Surg 1994;18(3):417-20.
Irvin GL 3rd, Prudhomme DL, Deriso GT, Sfakianakis G, Chandarlapaty SK. A new approach
to parathyroidectomy. Ann Surg 1994;219:574-9.
McHenry CR. Thyroidectomy for nodules and small cancers. In: Duh QY, Clark OH, Kebebew
E, editors. Atlas of endocrine surgery techniques. Surgical Techniques Atlas Series. Philadelphia: Saunders; 2010, pp 3-24.
Phitayakorn R, McHenry CR. Parathyroidectomy: overview of the anatomic basis and surgical
strategies for parathyroid operations. Clin Rev Bone Miner Metab 2007;5:89-102.
Phitayakorn R, McHenry CR. Incidence and location of ectopic abnormal parathyroid glands.
Am J Surg 2006;191(3):418-23.

C H A P T E R

4
Laparoscopic Adrenalectomy
Scott M. Wilhelm

INTRODUCTION

The adrenal glands reside in the retroperitoneum just above the kidneys (Fig. 4-1). Histologically, the adrenal glands are divided into an outer cortex comprising three layers—zona
glomerulosa, zona fasciculata, and zona reticularis—and an inner medulla (Fig. 4-2). These
histologic layers correspond to various hormones produced by the adrenal glands.
When considering which adrenal tumors may require surgical resection and which can
be monitored, physicians can determine the need for surgical intervention using the following three general categories:
1. Functional tumors based on excessive hormone production: hyperaldosteronism or Conn
syndrome, hypercortisolism or Cushing syndrome, sex hormone–producing tumors, or
pheochromocytomas, which lead to excess catecholamine production.
2. Tumors suspicious for malignancy: primary adrenocortical cancer (ACC) or adrenal
metastases.
3. Tumors that initially do not meet criteria for categories 1 or 2 but continue to increase in
size and volume on interval radiographic follow-up at a rate concerning for a malignant
process, or become hypersecretory on repeat laboratory testing.

37

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SECTION

2

ENDOCRINE

Esophagus

Diaphragm

Left suprarenal gland

Right suprarenal
gland

Celiac trunk

Right kidney

Left kidney

Right renal
artery and vein

Left renal artery
and vein

Right subcostal nerve

Superior mesenteric
artery (cut)

Transversus
abdominis muscle

Subcostal nerve
Abdominal aorta

Quadratus
lumborum muscle

Iliohypogastric nerve

Iliac crest

Ilioinguinal nerve

Psoas major muscle
Iliacus muscle

Lateral femoral
cutaneous nerve

Right ureter

Genitofemoral nerve
Left testicular
(ovarian) artery and vein

Right common
iliac artery

Inferior mesenteric
artery (cut)

Right external
iliac artery

Peritoneum (cut)

Right internal
iliac artery

Sigmoid mesocolon (cut)

Urinary bladder

Rectum

Esophagus

Gastrophrenic ligament

Inferior vena cava

Left suprarenal gland

Area for bare
area of liver

Splenorenal ligament

Right
suprarenal gland

Area for stomach
Area for spleen

Peritoneum
(cut)

Tail of pancreas

Area for liver
Duodenum

Transverse mesocolon

Peritoneum
(cut)

Area for small intestine
Area for descending colon

Area for colon
Area for
small intestine

Anterior relations
of kidneys
FIGURE 4–1 Adrenal glands in situ, anterior views.

CHAPTER

4

Laparoscopic Adrenalectomy

Capsule
Zona
glomerulosa

Clear cells (700,
H&E stain)

Zona
fasciculata

Zona
reticularis

Compact cells (700,
H&E stain)

C

Medulla
Normal human adrenal gland

V
G

Human adrenal gland after
administration of ACTH

Medulla (700,
chromaffin stain)

Adrenal artery
(one of many)
Capsular
plexus

V = Venous capillary
C = Capillary
G = Ganglion cell

Capsule

Capsule

Permanent
cortex

Glomerulosa
Cortical
capillaries
Fasciculata

Fetal
cortex
(containing
dark cells
destined
to form
medulla)

Medullary
arteriole
Reticularis
Medullary
capillaries
Medulla
Central
vein
Muscle
fibers

Schematic stereogram of intrinsic
adrenal circulation

Adrenal gland of newborn

FIGURE 4–2 Histology of adrenal glands. ACTH, Adrenocorticotropic hormone; H&E, hematoxylin and eosin.

39

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ENDOCRINE

SURGICAL PRINCIPLES
The “gold standard” for adrenalectomy has become the transabdominal laparoscopic adrenalectomy. The only current contraindication to the laparoscopic approach is malignancy in the
form of adrenocortical carcinoma, which should be approached by an open technique to ensure
adequate en bloc tumor resection.
To begin the transabdominal laparoscopic approach, the patient is positioned in the lateral
decubitus position to allow gravity to assist with the dissection. A patient requiring right adrenalectomy is placed into a left lateral decubitus position in a jackknife position. Four laparoscopic ports are used, with a 10- to 12-mm port along the lateral border of the right rectus
muscle at approximately the level of the umbilicus for the camera and three 5-mm ports along
the costal margin. The port closest to the xiphoid process is used for a liver retractor, and two
working ports are used for the operative dissection. For left adrenalectomy, the patient is
reversed into the right lateral decubitus position, and because there is no need for retraction
of the liver, three ports can be triangulated for the operative procedure (Fig. 4-3).

CHAPTER

4

Laparoscopic Adrenalectomy

41

Port site placement for left
laparoscopic adrenalectomy

Port site placement for right
laparoscopic adrenalectomy

5 mm

10 mm

5 mm

10 mm

FIGURE 4–3 Port site placement for transabdominal laparoscopic adrenalectomy. Patient is in lateral decubitus position with

ipsilateral arm supported.

42

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2

ENDOCRINE

SURGICAL TECHNIQUE
Right Laparoscopic Adrenalectomy
After the ports are placed (Fig. 4-3), a liver retractor is used to elevate the liver superiorly and
medially to expose the superior border of the right adrenal gland. The retroperitoneal fascia is
then incised from the lateral border of the inferior vena cava (IVC) out to the right triangular
ligament of the liver. Figure 4-4 shows a cutaway view of the retroperitoneum with the liver
removed to illustrate the right adrenal gland, kidney, and IVC. The line of incision would be
just inferior to the liver (Fig. 4-5).
Once the superior border of the adrenal gland is cleared, the next goal is identification of
the right adrenal vein as it enters the IVC. The vein generally enters along the medial border
of the right adrenal gland at about the 2 o’clock position on the gland, as viewed in a craniocaudal position (Fig. 4-6). The right adrenal vein should then be divided with surgical clips.
The remaining adrenal attachments and vasculature can then be divided in the retroperitoneum by standard techniques with surgical clips or an energy device such as the Harmonic
scalpel or Ligasure.

CHAPTER

Laparoscopic Adrenalectomy

Falciform ligament

Hepatic
veins

Superior recess of omental bursa (lesser sac)
Attachment of lesser omentum and
left gastric artery

Coronary ligament of liver

Esophagus

Right suprarenal gland
Right triangular
ligament

Left triangular
ligament
of liver
Gastrophrenic
ligament and
left inferior
phrenic artery

Attachment
of transverse
mesocolon
and right
gastro-omental
(gastroepiploic)
vessels

Short gastric
vessels
Splenorenal
(lienorenal)
ligament and
splenic vessels

Duodenum
Right kidney

Phrenicocolic
ligament

Parietal
peritoneum

Pancreas and
splenic artery
(retroperitoneal)

Root of
mesentery

Attachment of
transverse
mesocolon

Site of
ascending
colon

Superior
mesenteric
vessels

Common iliac
artery (retroperitoneal)

Site of
descending
colon

External iliac
artery (retroperitoneal)

Attachment of
sigmoid
mesocolon
and sigmoid
vessels

Testicular
vessels (retroperitoneal)

Superior
rectal vessels

Ureters (retroperitoneal)
Median
umbilical
fold
(contains
urachus)

43

Abdominal aorta and celiac trunk

Inferior vena cava
(Common) bile duct and
proper hepatic artery

4

Rectum

Urinary
bladder

Sacrogenital
fold (ligament)
Lateral
umbilical fold
(contains
inferior epigastric vessels)
Medial
umbilical fold
(contains
occluded part
of umbilical
artery)

FIGURE 4–4 Peritoneum of posterior abdominal wall.

44

SECTION

2

ENDOCRINE

A. The liver is retracted superiorly to expose the right adrenal mass. The
retroperitoneum overlying the mass would be incised between the two
arrows to expose the superior border of the gland.

B. Right adrenal vein exiting the right adrenal gland into the IVC (arrow).
FIGURE 4–5 Right laparoscopic adrenalectomy technique. IVC, Inferior vena cava.

CHAPTER

Liver (retracted superiorly)

4

45

Laparoscopic Adrenalectomy

Superior suprarenal arteries
(from inferior phrenic artery)
Inferior vena cava (retracted medially)
Suprarenal vein
Branches of middle suprarenal
arteries (from abdominal aorta)
Peritoneum (cut edge)

Pancreas and spleen
(retracted superiorly)
Left inferior phrenic artery
Superior suprarenal
arteries
Suprarenal gland
Renal (Gerota’s)
fascia
Left
kidney
Splenic
vein
Aorta

Renal
(Gerota’s)
fascia
Right kidney
(pulled down)
Suprarenal gland

Duodenum
(pulled down)
Inferior suprarenal artery
(from renal artery)

A. Abdominal exposure of right suprarenal gland.
Right adrenal vein can be seen entering the IVC.

Capsule
Cortex
Medulla

Duodenojejunal flexure
Left colic (splenic)
flexure (pulled medially)
Middle suprarenal artery

C. Cross section
through suprarenal
gland

Suprarenal vein
Inferior suprarenal artery

Left renal artery
and vein

Peritoneum
(cut edges)

B. Abdominal exposure of left suprarenal gland. Pancreas and
spleen are superior and medially to expose the left adrenal gland.

FIGURE 4–6 Arteries and veins of suprarenal glands in situ. IVC, Inferior vena cava.

46

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ENDOCRINE

Left Laparoscopic Adrenalectomy
After ports are placed (see Fig. 4-3), the first step is to “take down” the splenic flexure of the
colon and divide a portion of the gastrocolic ligament to expose the inferior border of the
pancreas and Gerota’s fascia overlying the left adrenal gland and kidney. Next, the lateral
attachments of the spleen are divided, allowing the spleen and pancreas to be rotated superiorly
off the left adrenal gland as a unit (Fig. 4-7, A).
The left adrenal vein is identified as it exits the left adrenal gland and enters into the left
renal vein (Fig. 4-7, B). The left adrenal vein is then divided with surgical clips. The remaining
attachments to the retroperitoneum and arterial branches can then be divided with an energy
device or surgical clips, as described previously for the right adrenalectomy. It is important to
note the left inferior phrenic artery and vein as they descend from the diaphragm to the superior pole of the left adrenal gland, which can be prominent and may need to be divided with
surgical clips (Fig. 4-7, C).

CHAPTER

4

Laparoscopic Adrenalectomy

Spleen

Splenic vein

Left adrenal gland
Pancreas
A. Pancreas, splenic vein, and spleen are seen rolled superiorly
off the left adrenal gland.

B. Left adrenal vein (black arrow) seen entering the left renal
vein (white arrow).

Left adrenal gland

Diaphragm

Inferior phrenic artery
Fundus of stomach
C. The left adrenal gland has been freed of all its attachments
except for the superior adrenal artery (also known as the inferior
phrenic artery) as it descends from the diaphragm. The fundus
of the stomach can also be seen.
FIGURE 4–7 Left laparoscopic adrenalectomy technique.

47

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ENDOCRINE

SUGGESTED READINGS
Assalia A, Gagner M. Laparoscopic adrenalectomy. Br J Surg 2004;91(10):1259-74.
Barresi R, Prinz RA. Laparoscopic adrenalectomy. Arch Surg 1999;134:212-7.
Kebebew E, Siperstein AE, Clark OH, Duh QY. Results of laparoscopic adrenalectomy for suspected and unsuspected malignant adrenal neoplasms. Arch Surg 2002;137:948-53.
Mazzaglia PA, Vezeridis MP. Laparoscopic adrenalectomy: balancing the operative indications
with the technical advances. J Surg Oncol 2010;101(8):739-44.
National Institutes of Health (NIH). 2002 Consensus Development program. http://
consensus.nih.gov/2002/2002adrenalincidentalomasos021html.htm

C H A P T E R

5
Esophagectomy
Lee L. Swanstrom

INTRODUCTION

Franz Torek performed the first successful esophagectomy in 1913, after this high-risk
surgery had been described 30 years with no patient survivors. Improvements in technique
and patient care have reduced the mortality and morbidity, but esophagectomy remains one
of the most dangerous surgeries performed, with a mortality rate of 4% to 10% and a complication rate of 20% to 60%. This dramatic risk profile results from (1) difficult anatomic
position of the esophagus (Fig. 5-1), (2) involvement of three body cavities in the resection,
(3) tenuous blood supply of all reconstruction options, and (4) nutrition impact on the surgical patient.
INDICATIONS
Because of the associated morbidity, most esophagectomies are performed on cancer patients
(Fig. 5-2, A and B). Benign indications arise from absolute loss of function caused by end-stage
motility disorders or from refractory strictures (Fig. 5-2, C). Worldwide, the primary esophageal
cancer is squamous cell type, the result of dietary insults or smoking. In North America,
however, this is no longer true: 80% or more of esophageal cancers are now adenocarcinomas
related to gastroesophageal reflux and Barrett syndrome (metaplasia).
Radical resectional surgery remains the only cure for invasive esophageal cancers that are
relatively resistant to radiation and chemotherapy. Neoadjuvant chemoradiation, however, is
gaining popularity as a treatment for stage II and stage III cancers, although the survival benefit
is not great. Overall, the 5-year survival rate for esophageal cancer is dismal: 18% for all
patients and 25% for those able to have surgery.
Preemptive esophagectomy for patients with Barrett syndrome with high-grade dysplasia
once was the most frequent indication for esophagectomy at most high-volume centers. This
is no longer the case; endoscopic treatments such as radiofrequency ablation and cryotherapy
are now effective low-morbidity alternatives.

51

52

SECTION

3

UPPER GASTROINTESTINAL

Longus colli muscle

Common carotid artery

Cervical part of esophagus

Anterior scalene muscle

Recurrent laryngeal nerves

Phrenic nerve

Thoracic duct

Posterior scalene muscle

Internal jugular vein (cut)

Brachial plexus

Subclavian vein (cut)

Subclavian artery

Left brachiocephalic vein (cut)

Thyrocervical trunk

Internal thoracic artery (cut)

Vagus nerve (X)

Phrenic nerve (cut)

1st rib (cut)

Common carotid artery

Brachiocephalic
trunk

Subclavian artery
Vagus nerve (X)

Trachea

Left recurrent
laryngeal nerve

Arch of
aorta
Arch of
azygos vein

Costal
pleura
(cut edge)

Right main
bronchus

Left main
bronchus

Thoracic part
of esophagus

Thoracic
(descending)
aorta

Esophageal
plexus

Mediastinal part of
parietal pleura
(cut edge)

Mediastinal
part of
parietal pleura
(cut edge)

Pericardium
(cut edge)
Diaphragm
Diaphragmatic
part of
parietal pleura

Inferior
vena cava
(cut)

Anterior
vagal trunk

Hepatic
veins (cut)
Inferior
vena cava
Right and
left crura of
diaphragm
Inferior phrenic arteries

Stomach

Celiac trunk

Abdominal
part of
esophagus

Abdominal aorta
FIGURE 5–1 Esophagus in situ.

CHAPTER

5

Esophagectomy

A. Malignant tumors of midportion of esophagus

Fungating
carcinoma

Ulcerative,
infiltrative
carcinomaa

Esophagoscopic view

B. Malignant tumors of distal portion of esophagus

Primary
carcinoma
of lower end
of esophagus

Adenocarcinoma of cardiac
end of stomach infiltrating
esophagus submucosally

Esophagoscopic view

C. Esophageal stricture

Lye structure

Peptic stenosis

FIGURE 5–2 Indications for esophagectomy.

53

54

SECTION

3

UPPER GASTROINTESTINAL

SURGICAL APPROACHES
Active controversy surrounds the necessity for surgery, with minimalists stressing the morbidity
of radical surgery and the poor survival statistics for patients with esophageal cancers. Recently,
however, the trend has been for more radical en bloc resections, which offer survival advantages for patients with some early-stage cancers.
The three main approaches to esophagectomy are transhiatal, Ivor Lewis, and “three-hole,”
or modified McKeown. Increasingly, all three approaches are performed with laparoscopy or
thoracoscopy for an approach called minimally invasive esophagectomy (MIE). Choosing among
the three approaches depends partly on the surgical indication (e.g., transhiatal approach for
benign and low-grade cases), stage of cancer, and location of the tumor. The approach is mostly
determined by institutional and surgeon preference, because no overwhelming evidence exists
to demonstrate that one approach is dramatically better than the others.
Reconstruction of the resected esophagus is most often performed using the stomach, either
tubularizing it or as a “whole-stomach” interposition. Less frequently, a colonic interposition
is used, and, rarely, a jejunal interposition, often with microvascular augmentation. Because
the vascularity of any of these conduits is tenuous at best, the surgeon needs to be familiar
with the other esophageal replacement options.
TRANSHIATAL ESOPHAGECTOMY
The transhiatal esophagectomy is performed with the patient supine and the left side of the
neck prepped and exposed. Either an upper midline incision or, increasingly, a five-port laparoscopic access is performed. Exploration is performed to rule out disseminated tumor, which
would obviate resection in most cases. The greater curvature of the stomach is retracted anteriorly, and the gastrocolic omentum is divided from the spleen to the hepatic flexure, wide of
the gastroepiploic blood supply, which is critical for the viability of the gastric graft (Fig. 5-3,
A). Once the greater curvature is fully mobilized, the retrogastric adhesions to the peritoneum
are divided. The lesser curvature of the stomach is then mobilized, a Kocher maneuver is performed to mobilize the duodenum, and the gastrohepatic ligament is divided near its attachment to the liver (Fig. 5-3, B). This exposes the D1 node area, which is routinely dissected.

CHAPTER

A. Arteries of stomach, liver, and spleen
Right and left inferior phrenic arteries
Abdominal aorta
Celiac trunk
Dorsal pancreatic artery
Left hepatic artery
Right hepatic artery

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55

Left gastric artery
Esophageal branch of left gastric artery
Splenic artery
Recurrent branch of left inferior
phrenic artery to esophagus

Short gastric arteries
Cystic artery
Cystic duct

Splenic branches of
splenic artery

Proper hepatic artery
(Common) bile duct
Hepatic portal vein

Left gastro-omental
(gastroepiploic) artery

Right gastric artery
Supraduodenal
artery
Posterior superior,
Anterior superior
pancreaticoduodenal
arteries

Common hepatic artery
Gastroduodenal artery
Right gastro-omental
(gastroepiploic) artery

B. Arteries of stomach, duodenum, pancreas, and spleen
Abdominal aorta
Common hepatic artery
Right gastric artery

Celiac trunk

Right and left inferior phrenic arteries
Left gastric artery
Splenic artery
Recurrent branch of left inferior phrenic artery
Fundic branch

Right gastroepiploic artery
Supraduodenal artery
Gastroduodenal artery
Anterior superior
pancreaticoduodenal artery
Posterior superior
pancreaticoduodenal
(retroduodenal) artery
Posterior inferior
pancreaticoduodenal artery (phantom)
Anterior inferior
pancreaticoduodenal artery
Superior mesenteric artery

Short gastric arteries
Left gastroepiploic artery
Caudal pancreatic artery
Inferior polar artery
Superior polar artery
Large pancreatic artery (pancreatica magna)
Dorsal pancreatic (superior pancreatic) artery
Transverse pancreatic artery
Middle colic artery
Inferior (common) pancreaticoduodenal artery
Jejunal arteries

FIGURE 5–3 Anatomy of the lesser curve, second portion of the duodenum, and gastrohepatic ligament (stomach is rotated

cephalad).

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Transhiatal Esophagectomy—Cont’d
Node dissection margins include the porta hepatis (hepatic portal) structures, the hepatic artery,
and the vena cava (Fig. 5-4, A). Dense nodal tissue around the base of the left gastric artery
is dissected, and the coronary vein and left gastric artery are divided with an energy sealing
device, stapler, or suture ligation. Node tissue is left in continuity with the specimen. The hiatus
is typically opened by excising a rim of the hiatal musculature and entering the mediastinum
in the plane of the mediastinal pleura, pericardium, and preaortic and prespinal planes. This
maneuver is more feasible with a laparoscopic approach and allows good lymphatic clearance
of the lower mediastinum.
Open transhiatal surgery is performed by the surgeon, with the smallest hand on the team
cupping the esophagus in the extended fingers and bluntly stripping the esophagus up to the
proximal mediastinum. Care must be taken at the upper end of the blind dissection to avoid
injury to the recurrent laryngeal nerve or membranous portion of the trachea (see Fig. 5-1).
Laparoscopic mediastinal dissection is performed by advancing the angled laparoscope into
the mediastinum with the surgeon’s instruments. At the same time, a 5- to 7-cm incision is
made in the left side of the neck from the sternal notch along the anterior margin of the sternocleidomastoid muscle (Fig. 5-4, B). The platysma muscle is divided and the sternocleidomastoid is retracted laterally (Fig. 5-4, C). After dividing the omohyoid muscle, the esophagus is
located and surrounded by a soft drain. The upper mediastinal dissection is performed with
lubricated gauze on a long, curved vascular clamp to meet with the dissection from below.
The gastric conduit is prepared by grasping the longest portion of the gastric cardia and
stretching it into the left upper quadrant. Starting at the “crow’s foot,” a green load linear
staple is used to divide the stomach parallel to the greater curvature to create a 3- to 4-cm
gastric conduit (Fig. 5-4, D). Once transected, the specimen is placed in a plastic specimen
bag and withdrawn through the neck. A chest tube is inserted through the neck and into the
abdomen, and the gastric conduit is sutured to it and pulled up into the neck. A hand-sewn
or stapled anastomosis is created to restore continuity.

CHAPTER

A. Lymph vessels and nodes of pancreas

Anterior view
Left gastric nodes

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57

B. Patient position
Head to side; incision along
anterior margin of
sternocleidomastoid muscle

Hepatic
nodes
Pyloric
nodes
Splenic nodes
Superior pancreatic nodes
Celiac nodes
Superior mesenteric nodes
(central superior group)

Celiac nodes

Posterior view
Cystic node
(of Calot)

Hepatic
portal vein

Pancreaticoduodenal
nodes
Superior
pancreatic nodes

Hepatic nodes
around bile ducts
and proper hepatic
artery

Splenic vein
Inferior
mesenteric vein

Pancreaticoduodenal
nodes

Superior mesenteric
artery and vein
Superior mesenteric nodes
(central superior group)

Esophagus

Platysma muscle Trachea

Sternocleidomastoid
muscle
Platysma muscle

C. Surgical approaches to esophagectomy

D. A green load linear staple is used to divide the stomach
parallel to the greater curve to create a 3- to 4-cm gastric
conduit.

FIGURE 5–4 Transhiatal esophagectomy.

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IVOR LEWIS AND MCKEOWN APPROACHES
The McKeown and Ivor Lewis approaches both require transthoracic access, either by a posterolateral thoracotomy in the 6th intercostal space or by thoracoscopy. The Ivor Lewis approach
is defined by an intrathoracic anastomosis, whereas the McKeown procedure brings the anastomosis up to the neck. The order in which the dissection is performed also differs between
techniques. The Ivor Lewis approach addresses the gastric mobilization first, then proceeds
with the thoracic (or thoracoscopic) mobilization and intrathoracic anastomosis. The modified
McKeown procedure uses right thoracoscopy or thoracotomy to dissect out the mediastinal
esophagus, with or without an en bloc lymph node dissection.
The patient is then repositioned to allow the abdominal dissection and gastric conduit creation. In this procedure the left side of the neck is exposed, often by a second operating team,
and a gastric conduit is created along the greater curve of the esophagus. This is then brought
to the neck to perform the anastomosis.
Ivor Lewis Esophagectomy
The patient is positioned supine for the Ivor Lewis esophagectomy, and in the case of a laparoscopic procedure, in split-leg position. The abdomen is accessed through an upper abdominal
incision or by five-port upper abdomen laparoscopic placement.
After a careful staging examination, the left lobe of the liver is retracted to expose the
stomach. For potentially curative resections for cancer, we routinely perform a D1 or D2 lymph
node dissection. For benign resections, the goal is to stay on the stomach and esophagus to
prevent ancillary damage.
The gastrocolonic omentum is divided, staying 1 to 2 cm away from the critical gastroepiploic vessels of the greater curvature of the stomach (see Fig. 5-3, A). This dissection is extended
medially past the second portion of the duodenum and laterally to the inferior pole of the
spleen. This allows the stomach to be reflected anteriorly, exposing the lesser sac to allow the
surgeon to check for metastatic disease, and exposes the right gastric artery to allow dissection
of station 8 lymph nodes, if indicated (see Fig. 5-4, A). The greater curvature of the stomach
is further mobilized by dividing the short gastric vessels, once again wide of the gastric margin.
This dissection is taken to the left crus. For the lesser curvature, the gastrohepatic omentum
is divided from the 2nd part of the duodenum up to the right crus. The base of the left gastric
artery is identified either from the right side of the stomach or from underneath the stomach.
It is skeletonized and divided to provide access to the preaortic plane, which will be extended
into the mediastinum.

CHAPTER

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Esophagectomy

FIGURE 5–5 Ivor Lewis esophagectomy: five-port laparoscopic placement.

Ivor Lewis Esophagectomy—Cont’d
The gastric interposition is created by stapling the stomach as described for transhiatal esophagectomy, except that the final staple load to separate the fundus is not fired. The esophageal
hiatus is dissected several centimeters into the mediastinum. Lastly, a feeding jejunostomy tube
is placed by tacking the jejunum to the anterior abdominal wall and accessing it percutaneously
with a guidewire and then a dilator with peel-away sheath that allows placement of a 12-Fr
catheter. Addition of a pyloroplasty to improve gastric emptying is controversial. In general, if
a wide gastric tube or whole-stomach pull-up is used, a pyloroplasty is performed. If a narrow
gastric tube is created, theoretically a pyloroplasty is unnecessary because physical properties
enable better emptying.
The patient is then repositioned in a left lateral decubitus position to allow access to the
right side of the chest (5th intercostal posterolateral thoracotomy or four-port thoracoscopy).
The right mediastinal pleura is widely excised in continuity with the esophagus. The esophagus
is isolated away from the tumor and surrounded by a plastic drain for retraction. A wide resection of the esophagus is performed, incorporating surrounding node-bearing tissues with the
specimen (Fig. 5-5). The esophagus is divided above the azygos vein, high in the mediastinum,
with an endoscopic linear cutting stapler. The specimen is pulled up into the chest, along with
the attached gastric conduit. A staple or hand-sewn anastomosis is performed, according to
surgeon preference.

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Modified McKeown (Three-Hole) Esophagectomy
The modified McKeown approach begins with thoracic mobilization. Therefore, if not routinely
used by the surgeon, it is certainly the best choice for middle and upper cancers or when thoracic staging is important to determine resectability.
The three-hole procedure begins with the patient in the left lateral decubitus position with
the arm carefully positioned overhead. A 5th or 6th intercostal posterolateral thoracotomy is
done or a four-port thoracoscopic access is created. Wide resection of the right mediastinal
pleura leaves the pleura with the esophagus, particularly over the area of the tumor. The azygos
vein is typically divided with ties or a vascular stapler (Fig. 5-6, A). The esophagus is surrounded
with a drain for retraction, and with the use of cautery or ultrasonic coagulating shears, the
esophagus with all of its surrounding lymph node–bearing tissues is progressively mobilized.
Controversy surrounds the required extent of the dissection. Some argue that both the
azygos vein and thoracic duct need to be resected with the periesophageal tissue, whereas
others believe that only the periesophageal nodes require resection (Fig. 5-6, B). The proximal
dissection should be taken as far as possible into the thoracic outlet and the distal dissection
down to the crura.
Particular care must be taken throughout the mediastinal dissection because there are multiple critical structures, particularly in the more proximal mediastinum. In the area of the carina
the particularly dense and vascular node tissue can bleed, and proximally the membranous
trachea can be easily injured, with disastrous results. The aortic arch, recurrent laryngeal nerve,
pulmonary hilum, and pericardium also must be safeguarded.

CHAPTER

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Esophagectomy

B. Lymph vessels and nodes of esophagus
Inferior deep cervical
(internal jugular) nodes

Thoracic duct

A. Mediastinum: azygos system of veins
Internal jugular vein

Paratracheal
nodes

Inferior thyroid vein
Internal jugular vein

Vertebral vein

Subclavian vein

External jugular vein
Subclavian vein

Superior and
inferior
tracheobronchial
nodes

Thoracic
duct
Juxtaesophageal
and superior
phrenic nodes
Left
brachiocephalic vein
Left superior
intercostal vein

Right
brachiocephalic
vein
Superior vena cava
Right superior
intercostal vein

Posterior
mediastinal
nodes
Intercostal
nodes

Posterior
parietal
nodes

Esophageal vein (plexus)
Accessory hemiazygos vein

Azygos vein
Junction of hemiazygos
and azygos vein

Superior phrenic
nodes

Hemiazygos vein
Left gastric nodes
(cardiac nodes of
stomach)

Left inferior phrenic vein
Short gastric vein
Inferior vena cava (cut)

Celiac nodes

Hepatic vein
Inferior
vena cava

Hepatic
portal vein
Right renal vein
Left gastric vein
Left gastro-omental
(gastroepiploic) vein

Right gastric vein
Esophageal branches
of left gastric vein

Left renal vein

Splenic vein
Inferior mesenteric vein

Superior mesenteric vein
Right gastro-omental
(gastroepiploic) vein

FIGURE 5–6 Modified McKeown esophagectomy: azygos system of veins and esophageal lymph nodes/vessels.

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Modified McKeown (Three-Hole) Esophagectomy—Cont’d
Once the thoracic dissection is complete, a chest tube is left inside the patient and the chest is
closed. The patient is repositioned supine as described for transhiatal esophagectomy. Gastric
mobilization is done and an interposition conduit is created as previously described. Once again,
the final staple load to transect the stomach is not done. A second team will typically open the
left side of the neck and surround the esophagus.
The upper esophageal dissection is performed by staying on the esophagus and using mostly
blunt dissection. Care must be taken to avoid the recurrent laryngeal nerve in this area as well
(Fig. 5-7, B). Small tumors can be brought out through the neck incision, pulling the interposition up at the same time. Larger cancers should be pulled into the abdomen, placed in an
impermeable specimen bag, and withdrawn through a small abdominal incision. The anastomosis is performed wit