Ann Thorac Surg 2006;82:759-760
© 2006 The Society of Thoracic Surgeons
How to do it
Marzouk's Procedure: A Novel Combined Cervical and Anterior Mediastinotomy Technique to Avoid Median Sternotomy for Difficult Retrosternal Thyroidectomy
Sridhar Rathinam, FRCS (Ed),
Ben Davies, MRCS (Eng),
Joseph F. Khalil-Marzouk, MCh, FRCS (CTh)*
Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, United Kingdom
Accepted for publication July 5, 2005.
* Address correspondence to Dr Khalil-Marzouk, University Hospitals Coventry and Warwickshire, Clifford Bridge Rd, Coventry, United Kingdom CV2 2DX. (Email: khalilmarzouk{at}btinternet.com).
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Abstract
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Surgery for retrosternal goiter is uncommon. Most of the benign retrosternal goiters can be delivered and resected through a standard cervical incision. However, there are cases in which resection of the retrosternal goiter requires additional thoracic access to the standard transverse cervical incision in the form of partial or complete median sternotomy or even a thoracotomy. We propose and describe a novel technique of combining anterior mediastinotomy to the cervical incision as an adjunct to facilitate delivering the difficult retrosternal goiter by bi-manual manipulation. This technique avoids the trauma and postoperative morbidity of a median sternotomy or thoracotomy and proves effective in solving the technical, functional, financial, and aesthetic problems.
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Introduction
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Surgery for extensive, benign, retrosternal goiter is uncommon. Most (97%) can be resected through a standard cervical incision [1]. However, if the retrosternal component is particularly large, invasive, or is situated in a retrotracheal or subaortic position, access to the thorax is required. The median sternotomy, thoracotomy, and transclavicular approaches have been used, but they seem overly invasive for this purpose [2–5].
We describe a new strategy to deliver these difficult goiters by performing anterior mediastinotomy to aid the mobilization of the deep, retrosternal element of the goiter.
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Technique
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An 80-year-old woman was referred with a history of intermittent dysphagia and choking sensation. She was found to have a retrosternal goiter. A chest roentgenogram (Fig 1) and computed tomographic scan (Fig 2) demonstrated a large retrosternal goiter with significant extension to the level of the right pulmonary hilum. Biochemistry and thyroid function tests were normal. She was consented for a retrosternal thyroidectomy.
Preoperative bronchoscopic evaluation showed extrinsic compression reducing the tracheal diameter by 50%. A cervical collar incision was performed. There was marked enlargement of both lobes of the thyroid gland with characteristic multi-nodularity. There was significant retrosternal extension with the right lobe extending to the aortic arch and the right pulmonary hilum, which could not be reached; therefore we entertained a mediastinal exploration, but endeavoured to avoid any extensive procedure.
A right anterior mediastinotomy was performed through the second intercostal space, preserving the costal cartilage and the internal thoracic vessels. The mediastinal thyroid extension was explored extrapleurally. The right thyroid lobe was mobilized and delivered into the neck. The thyroid vascular pedicles were ligated and divided in the usual manner and customary care was taken to preserve the recurrent laryngeal nerves.
She was extubated in recovery with an uneventful 8 days of postoperative hospital stay. As an outpatient at interval follow-up, she was completely asymptomatic and she was in an euthyroid state on a replacement daily dose of 100 mcgs of thyoxine with a satisfactory chest roentgenogram (Fig 3).
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Comment
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Thyroid extension through the thoracic inlet as in substernal or retrosternal goiters leads to tracheal compression and deviation. Local mass effect can cause dysphagia, dyspnea with or without stridor, superior vena cava syndrome, arterial compression, and neurologic deficit [6].
The management of symptomatic benign retrosternal goiter is surgical resection to relieve compression symptoms. In most cases, blunt finger dissection inferiorly from the cervical approach suffices [1, 2]. Occasionally the mediastinal mass may be too bulky, deep, or fragile to use instruments or sutures to deliver it into the neck. Traditionally this necessitates additional surgical access through median sternotomy or partial upper manubriotomy or a thoracotomy [3]. Clavicular dislocation or division to increase the space of the thoracic inlet has been described to deliver large retrosternal goiters [4, 5]. All these procedures carry a significant surgical trauma, prolong the operation, increase the postoperative morbidity and extend the hospital stay.
Anterior mediastinotomy is commonly used in staging lung cancer and biopsies of mediastinal masses [7]. It is a relatively straightforward procedure that it has been done under local anaesthesia [8].
In this article we described our use of the anterior mediastinotomy as an adjunct to the cervical incision for resection of retrosternal goiters to facilitate delivery of retrosternal elements and hence avoided the need for a more invasive procedure.
In conclusion, anterior mediastinotomy in addition to the cervical incision should be a useful technique in the surgeon's armamentarium to deal with difficult retrosternal goiters. This procedure is simple and provides a safe alternative to more invasive approaches.
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References
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- Torre G, Borgonovo G, Amato A, et al. Surgical management of substernal goiteranalysis of 237 patients. Am Surg 1995;61(9):826-831.[Medline]
- Katlic MR, Grillo HC, Wang CA. Substernal goiteranalysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985;149(2):283-287.[Medline]
- Michel LA, Bradpiece HA. Surgical management of substernal goitre Br J Surg 1988;75(6):565-569.[Medline]
- Picardi N, Di Rienzo M, Annunziata A, Bartolacci M, Relmi F. Transclavicular approach for delivery of intrathoracic giant goiteran alternative surgical option. Ann Ital Chir 1999;70(5):741-748.[Medline]
- D'Alia C, Tonante A, Lo Schiavo MG, et al. Transclavicular access as an adjunct to standard cervical incision in the treatment of mediastinal goitre Chir Ital 2002;54(4):576-580.[Medline]
- Anders HJ. Compression syndromes caused by substernal goitres Postgrad Med J 1998;74(872):327-329.[Abstract/Free Full Text]
- McNeill TM, Chamberlain JM. Diagnostic anterior mediastinotomy Ann Thorac Surg 1966;2(4):532-539.[Medline]
- Rendina EA, Venuta F, De Giacomo T, et al. Biopsy of anterior mediastinal masses under local anesthesia Ann Thorac Surg 2002;74(5):1720-1722discussion 1722-3.[Abstract/Free Full Text]
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Abstract
Introduction
