Hemithyroidectomy: a heuristics perspective.

Heuristics describe the multiple small steps required for successful surgery, which are often taken for granted, enabling key manoeuvres, their correct order and their timely performance. Successful hemithyroidectomy is dependent on correct siting of the incision; tension to allow elevation of sub-platysmal flaps without damaging anterior jugular veins; strap muscle division with preservation of the ansa cervicalis; recognition of the importance of the sub-sternothyroid plane; superior mobility of the thyroid lobe, involving freeing the superior strap muscle layer and dissection of the pyramidal lobe; division of the isthmus to assist anteromedial mobility; dissection of the lateral thyroid space to free the posterior 'v' lip of the superior pole; medial to lateral dissection of the avascular cricothyroid space with preservation of the external laryngeal nerve, prior to ligation of the superior thyroid vessels; anteromedial rotation of the thyroid lobe with elevation of any retrosternal component; capsular dissection of the inferior pole with preservation of vascularity of the inferior parathyroid gland; dissection of the thyroid lobe off the recurrent laryngeal nerve, especially above the inferior thyroid artery in the region of greatest risk to the nerve, the region of the ligament of Berry; preservation of a vascularized superior parathyroid gland; capsular dissection, creating windows between vessels enabling their precise control, thereby minimizing haemorrhage. This paper aims to emphasize these heuristic components of thyroidectomy.