Divided Total Thyroidectomy with Medial to Lateral Dissection

Background: Traditional total thyroidectomy is still associated with serious complications, especially when abnormal recurrent nerve anatomy is present. In divided thyroidectomy, dissection is started from medial to lateral, saving every structure passing through the thyroid gland or from it. 

Methods: Our study included 20 patients suffering from multinodular goiter (15 females and 5 males). Under general anesthesia with an endotracheal tube. The thyroid gland is divided in medline infrant of trachea, and dissection starts from medial to lateral using bipolar diathermy, until freeing the gland from all blood supply and adhesion directly on the thyroid capsule. The wound is closed in layers with a drain.

Results: The mean patient age is 42.7 years (ranging from 25 to 52 years). The mean operative time was 45 minutes. The skin incision lies at the lower neck crease and extends from the medial border of one sternomastoid muscle to the other. No complications were observed intra-operatively or postoperatively, which extended to 4 months. 

Conclusion: Our technique is minimally invasive, easy to learn, and safe even with the presence of abnormal anatomy in or around the thyroid gland. 

*Traditional total thyroidectomy starts dissection from the lateral side, facing the medial thyroid veins, which are ligated, making the gland more congested, the field bloody, the procedure more difficult, and liable to injuries to important structures.

*Our technique starts dissection from medial to lateral, facing arteries first and distal parathyroid glands, avoiding injuries to important structures near or inside the thyroid parenchyma. 

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Total thyroidectomy is the most common modality for treating many thyroid disorders [1]. The thyroid gland is a highly vascular organ. With traditional must, the middle thyroid vein is ligated first because it anchors the gland, which makes the gland more congested and the surgical field more bloody [2]. Good visualization of the field becomes more difficult and makes complications more liable to occur [3]. Also, in this situation, needs to infrahyoid muscle cutting and extension to the skin incision makes the technique more invasive and complicated [4,5]. In our technique, the thyroid gland is divided in front of the trachea, and dissection starts from medial to lateral, close to the thyroid capsule using bipolar diathermy.

Patients and methods

This study was done in the general and laparoscopic surgery department, Zagazig University Hospital, Egypt, from January 2026. Twenty patients (15 females and 5 males) were included in this research, suffering from multinodular goiter based on ultrasonography and biopsy. The patients' ages ranged from 25 to 52 years (mean, 42.7 years). This study was discussed and approved by the Ethical Committee of Zagazig University in January 2026. All information about the technique was discussed with all patients, and they gave written consent for inclusion of their data in this study.

Surgical technique

(Figure 1) Under general anesthesia with an endotracheal tube and neck extension, a skin incision is made in one of the lower neck creases. The incision is extended from the medial border of the sternomastoid to the other, and the thyroid gland is exposed by infrahyoid muscle separation in the midline. After exposure og the gland, only the use of bipolar diathermy is allowed. The gland is divided into two parts at the narrowest connection between the isthmus and one thyroid lobe; at this plane is less bloody. Dissection starts with the big part from medial to lateral directly on the gland capsule. The dissection separates the inferior thyroid vessels first, and then the superior thyroid vessels. All steps were done with the other thyroid part. After good haemostasis, the wound was closed in layers with a drain for three days. All patients were received spectrum antibiotic for five days. Thyroid hormone replacement was given to all patients directly after the operation. The follow-up period was 4 months. The clinical examination of the neck and generalized for any local and general complications at 1, 2, 4 weeks, and 3 months postoperative was done. Ultrasonography of the neck was done for all patients after 3 months. Laboratory investigations, thyroid function tests (T3, T4, TSH), and parathyroid function tests (Ca level) were done regularly (Figures 2,3).

Figure 1: After exposure, of thyroid gland was divided into the narrowest part in front of trachea starting by biggest part.

Figure 2: Dissection of both lobes is about finished using bipolar diathermy only and close on the thyroid capsule starting from medial to lateral, beginning with the inferior thyroid vessels, the superior thyroid vessels, & lastly the middle thyroid vein .

Figure 3: Total excision of the thyroid gland with good homeostasis, the wound was closed in layers with a drain.

A.E. Lasheen, Farag A, Wasefy T, Ramadan A, Foad A, Negm S, and O.A. Lasheen have no conflicts of interest or financial ties to disclose.

Ethical approval

This research was discussed and approved by the Ethical Committee of Zagazig University in January 2026.

Author contribution

*Ahmed Lasheen: His idea and all steps for manuscript preparation under his supervision. Ahmed Farag, Tamer Wasefy, Alaaelden Ramadan, Amer Foad, Said Negm, and Omar Lasheen shared in the clinical application of the idea and in writing the manuscript.

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