Patients should be suitable candidates for general anesthesia. Prepare hyperthyroid patients with antithyroid medications, beta-blockers, and Lugol’s iodine or supersaturated potassium iodide solution (sometimes steroids are also added) to avoid thyroid storm. Patients with medullary thyroid cancer or concerning symptoms should be screened for pheochromocytoma. Documentation of vocal cord function by direct or indirect laryngoscopy is paramount in those already suspected of having vocal cord dysfunction (i.e., those with prior neck surgery or altered phonation), because bilateral injury may lead to airway obstruction.

Position the patient supine. Keeping the patient in a “beach-chair” position, with a moderate reverse Trendelenburg and with the knees flexed, will help reduce venous pressure. Place a sandbag or roll between the scapulae allowing the shoulders to fall backward. Extend the neck and place the head on a donut cushion. The use of silk suture to secure the drapes helps in maintaining a sterile field, but is not absolutely necessary.

Make a Kocher transverse collar incision in a natural skin crease approximately 1 cm below the cricoid cartilage. A 2-0 silk suture may be pressed against the skin to mark out the planned course of the incision. Take care to measure the distance on each side of the midline to ensure symmetry. A 4- to 5-cm incision is generally adequate; however, patients with a short neck, large thyroid gland, or limited neck extension may require a longer incision. Carry this incision through the skin, subcutaneous tissues, and the platysma. It is generally easier to identify the fibers of the platysma along the lateral aspect of the incision.

Raise flaps in the subplatysmal plane. Place straight Kelly clamps, skin hooks, or rake retractors on the dermis to elevate the flaps anteriorly. Provide countertraction with a finger or gauze as the flaps are elevated both sharply with electrocautery or a scalpel and bluntly with a finger or Kitner. Extend this elevation superiorly to the level of the thyroid cartilage and inferiorly to the level of the suprasternal notch. Take care not to injure the superficial network of veins that lie beneath the platysma. This often extensive collection of veins, including the paired anterior jugular veins, external jugular veins, and communicating veins, lies beneath the platysma muscle overlying the sternocleidomastoid and midline strap muscles. Place towels along the skin edges to protect them, and a use a self-retaining retractor to aid in exposure.

Identify the whitish-colored midline raphe between the paired strap muscles. Separate the paired sternohyoid and sternothyroid muscles in the midline from the sternal notch to the thyroid cartilage to expose the underlying thyroid gland. On the side to be approached first, bluntly dissect the sternohyoid muscle from the deeper sternothyroid muscle lying just beneath it. This step often assists with exposure, particularly when working via smaller incisions. Identify and preserve the ansa cervicalis as it courses over the lateral aspect of the sternothyroid if possible. The strap muscles rarely require division to gain exposure to the thyroid gland, particularly in large goiters. In the rare occasion that division is necessary, divide the muscles as high as possible to preserve the strap muscles’ innervation by the ansa cervicalis. These muscles can then be sutured together at the end of the operation. If tumor directly invades into the strap muscles, resect the strap muscle en bloc with the underlying thyroid tissue. Then dissect the sternothyroid muscle off the thyroid bluntly. Identify the internal jugular vein by gently retracting laterally on the sternocleidomastoid muscle.