Thyroidectomy for Multinodular Goiter 
Kristin L. Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Thyroidectomy can be performed for 
numerous reasons, including hyper- or hypo 
functioning glands, concern for malignancy, or 
compressive symptoms from a multinodular goiter.  
Thyroid goiters can present in many ways, and along 
a wide spectrum of enlargement.  This can include 
unilateral nodular enlargement, which can be treated 
with a thyroid lobectomy and often preserves thyroid 
function, or may include severe diffuse enlargement 
requiring subtotal or total thyroidectomy.   
Growth of the gland, particularly in iodine-
deficient regions, can extend anteriorly and is quite 
easily appreciated.  Importantly, however, the gland 
can also grow into the retropharyngeal space or 
substernally, requiring additional evaluation prior to 
surgical intervention to thoroughly assess the extent 
of enlargement.   
Ultrasound remains the mainstay of thyroid 
imaging assessment, and can provide optimal 
evaluation of thyroid nodules and parenchyma, as 
well as central and lateral neck lymphadenopathy.  
However, if the full extent of the gland cannot be 
clearly seen with ultrasound or confidently palpated 
on physical examination, cross sectional imaging 
should be performed to demonstrate possible 
substernal extension that would require sternotomy 
for safe excision.   
Patients with large goiters must be counseled 
about potential for postoperative bleeding, injury to 
recurrent laryngeal nerves, and hypoparathyroidism, 
all of which are legitimate surgical risks in massively 
enlarged thyroid glands.  Potential lifelong need for 
thyroid hormone should also be reviewed, and 
preoperative assessment of thyroid function is 
critical for safe anesthesia and surgery.  
The general steps to perform a thyroidectomy 
for a multinodular goiter include:   
● Creating a transverse cervical incision at the level 
of the thyroid isthmus 
● Developing subplatysmal flaps and separation of 
strap muscles  to create a working space 
● Isolation and division of the superior pole vessels 
of the larger side of the thyroid gland 
● Medial rotation of the thyroid and ligation of the 
middle thyroid vein 
● Clear identification of the recurrent laryngeal 
nerve 
● Dissection of the gland away from the nerve, 
including ligation of inferior pole vessels 
preserving inferior parathyroid glands 
● Division of the ligament of Berry and removal of 
the lobe from the tracheal attachments.   
● Repeat the procedure for the contralateral lobe, 
only after ensuring recurrent laryngeal nerve is 
intact and functional.   
 
Steps: 
1. Preoperative evaluation of a thyroid goiter must 
include thyroid function tests and ultrasound to 
begin assessment of the degree of enlargement.   
Thyroid enlargement can extend in numerous 
directions, each of which create unique surgical 
challenges. The thyroid gland can extend 
superiorly, vascular collaterals that can be 
dangerously large and difficult to visualize.  
 
This CT scan (coronal view) shows a very large goiter with 
massive superior extension, making superior pole vessel 
isolation technically challenging.  
 
Thyroidectomy for Multinodular Goiter 
Kristin L. Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
This CT scan (axial view) demonstrates the severe extent of 
substernal extension that can occur in large thyroid goiters.  As 
the gland extends well below the clavicles and widens in size 
once in the thoracic cavity, cervical excision was felt to be 
unsafe and this patient required a sternotomy.   
 
2. Unilateral goiter enlargement rarely creates 
significant 
airway 
compromise, 
however 
bilateral enlargement can severely narrow the 
trachea, complicating endotracheal intubation.  
Ultrasound can be used to assess the trachea for 
compression in asymptomatic patients, however 
many patients with massive goiters present with 
respiratory compromise.  
 
This CT scan (axial view) demonstrates severe narrowing of the 
tracheal lumen from a large goiter, causing notable shortness 
of breath for the patient. Intensive preoperative preparation 
from an anesthetic standpoint is required, including likely 
awake fiberoptic intubation as was necessary in this case.  
 
 
Airway compromise can be unexpected, as well, noted in this 
ultrasound image taken in a low resource setting, showing 
another example of extreme tracheal narrowing requiring 
higher levels of anesthesia care.  
 
3. Once 
general 
endotracheal 
anesthesia 
is 
obtained, the patient is positioned in a supine 
position, with a shoulder roll to extend the neck.  
The head should be supported and arms tucked at 
the patient’s side. Adequate IV access is critical 
given potential for blood loss.  If the goiter is 
extremely large and surgery is anticipated to take 
more than 2 hours, a foley catheter and orogastric 
tube should be considered.   
 
Thyroidectomy for Multinodular Goiter 
Kristin L. Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Patient in Semi-Fowler, also called “Beach Chair” position. 
Raising the head and torso like this decreases venous distention 
and bleeding. The surgeon must be cautious to avoid venous air 
embolism: in case of any injury to large veins, air can be drawn 
into the venous system when the patient is in this position.  
 
4. Once sterile prep is complete, a large transverse 
cervical incision should be made over the thyroid 
isthmus.  This is carried down to the platysma, 
and subplatysmal flaps are created.  Large goiters 
may cause attenuation of the strap muscles, 
which may be separated or divided if necessary. 
Likewise, large anterior jugular veins and 
collaterals should be identified and tied off if 
necessary.  
 
 
A transverse incision through the skin (shown) and platysma is 
made at least  two fingerbreadths above the sternal notch. 
 
 
Sub-platysmal flaps are raised superiorly to the level of the 
cricoid cartilage and inferiorly to the level of the suprasternal 
notch (shown.) The sternothyroid and sternohyoid (“strap”) 
muscles, seen in the center of the incision, are often very thin due to 
the enlarged thyroid underneath.  
 
 
This photo, with the patient’s head to the upper left, shows 
anterior retraction of the sternothyroid and sternohyoid 
(“strap”) muscles and capsular dissection of the thyroid gland. 
It is important to enter into this plane immediately upon 
separating the strap muscles, and to remain in this plane, 
separating muscle tissue from the capsule as you proceed 
laterally.  
 
5. Once the gland is exposed and strap muscles 
retracted away, the superior pole vessels should 
be isolated and tied securely. There are often 
several large posterior vessels in very large 
thyroid lobes, which can be difficult to identify. 
Gentle downward retraction of the superior pole 
of the thyroid and meticulous dissection will 
allow this to be done safely, and these large 
vessels often require several ties or clips. 
 
Thyroidectomy for Multinodular Goiter 
Kristin L. Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
In this photo, the upper pole vessels of the left thyroid lobe are 
individually ligated adjacent to the parenchyma of the gland.  
   
6. After securely dividing superior pole vessels, the 
thyroid lobe should be medially rotated, middle 
thyroid vein divided, and the recurrent laryngeal 
nerve clearly identified and protected.  On the left 
side, the nerve is usually encountered in the 
tracheoesophageal 
groove, 
running 
nearly 
straight up and down after recurring around the 
aortic arch. On the right side, the nerve path can 
be more variable, as the recurrence is around the 
subclavian artery, resulting in a more lateral to 
medial path to the trachea. Nerves may also have 
more than one branch, and identifying the nerve 
low in the neck and tracing it in its entirety 
towards the point of insertion helps to minimize 
injury to smaller branches.  
 
As you dissect within the capsular plane of the thyroid, one 
large vein will pass through the capsule as you rotate the gland 
medially: this is the middle thyroid vein. This structure may be 
encountered either before or after ligation of the upper pole 
vessels, depending on how laterally it is positioned.  
 
 
As you continue to dissect laterally, rotate the gland towards 
the midline. You will find the capsular plane is now pulled 
upwards with the gland. Stay in this plane by gently inserting a 
right angle clamp next to the parenchyma of the gland. This 
maneuver causes the tissue around the capsule to fall away, 
including the recurrent laryngeal nerve and the parathyroid 
glands.  
 
 
A large left thyroid goiter retracted medially, with the recurrent 
laryngeal nerve (Black arrow) clearly visible during its 
dissection away from the gland.  
 
7. Dissection should proceed to isolate and divide 
the inferior pole vessels, with great care to stay 
directly on the thyroid capsule and protect the 
inferior parathyroid glands.  
Thyroidectomy for Multinodular Goiter 
Kristin L. Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Division of the inferior thyroid vessels usually occurs in the 
later stages of the operation, after mobilization of the gland and 
visualization of the recurrent laryngeal nerve and parathyroid 
glands.  
  
8. Once the gland has been completely dissected 
away from the recurrent laryngeal nerve and 
medialized, the ligament of Berry should be 
divided carefully. The lobe should then be 
removed from the tracheal attachments. In many 
cases, the isthmus can be divided and each lobe 
sent as a separate specimen to optimize working 
space.   
9. After the first lobe is removed, the recurrent 
laryngeal nerve should be confirmed intact, and 
then dissection can proceed to the contralateral 
side, mirroring the dissection performed on the 
first side.  
10. After the gland has been removed in its entirety, 
meticulous attention to hemostasis should occur, 
including 
anesthesia-performed 
Valsalva 
maneuvers to increase venous pressure and test 
integrity of vessel ligatures. Particular attention 
should be paid to the superior pole vessels, 
pyramidal lobe region, and inferior pole/thyroid 
ima vessels.  
11. Parathyroid glands should be assessed if 
visualized, and if bruised or devascularized, they 
should be minced into a slurry and reimplanted 
in a well-vascularized muscle pocket (usually 
sternocleidomastoid 
muscle) 
as 
an 
autotransplant.   
12. The thyroid specimen should be placed in saline 
to soak, and then visually assessed for any 
possible retained parathyroid glands along the 
capsule so that these could be reimplanted if 
identified.  
 
A large left thyroid lobe after excision.  
 
Once meticulous hemostasis is obtained, a drain 
is often placed for very large goiters, particularly 
in lower resource settings. Bulb suction 
overnight can help to minimize seroma formation 
and identify hematoma/chyle leak should it occur 
in the immediate perioperative period. A drain 
should be secured with a nylon suture at the skin. 
13. To close the thyroidectomy incision, the strap 
muscles are re-approximated with absorbable 
braided suture, as are the platysmal flaps. The 
skin edges can be closed in several different 
ways, however absorbable monofilament suture 
is often preferred.  
 
Pitfalls 
● Failure to obtain imaging and definitively assess 
the extent of thyroid enlargement can lead to 
significant intraoperative challenges, particularly 
if the patient requires thoracic exposure with 
substernal 
extension. 
Extent 
of 
thyroid 
enlargement may or may not be visible 
externally. 
Thyroidectomy for Multinodular Goiter 
Kristin L. Long 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
 
The first figure shows the patient’s external appearance, with 
no visible goiter.  The second photo shows the CT scan (axial 
view), with extensive substernal extension requiring sternotomy 
to resect.  
 
● Failure to identify and clearly protect the 
recurrent laryngeal nerve, which can often be in 
unusual locations with thyroid extension, 
including stretched over thyroid parenchyma, as 
seen in the figure below.  
 
Here, in this right thyroid lobectomy specimen, the dark blue 
line drawn on the thyroid specimen and shown by the White 
arrow represents the path of the right recurrent laryngeal 
nerve, which was draped over the large posterior nodule.   
 
● Lack of hemostasis can lead to a life-threatening, 
airway-compromising hematoma. In particularly 
large multinodular goiters, there are often 
multiple, aberrant collateral vessels and several 
maneuvers to assess hemostasis must be 
performed at case completion.  
● If available, neuromonitoring of the recurrent 
laryngeal nerve should be performed to eliminate 
the dreaded complication of a bilateral injury, 
which could cause respiratory compromise.  
 
Kristin L. Long, MD MPH  
University of Wisconsin School of Medicine and 
Public Health 
USA 
 
September 2023 
