The upper pole of the thyroid gland can then be bluntly dissected and grasped. The superior thyroid artery and vein can then be identified. The superior pole vessels are then dissected away from the larynx medially to avoid injuring the external branch of the superior laryngeal nerve (Fig. 7.3). These vessels are then ligated with the Harmonic device. If the external branch of the nerve is identified close to the superior thyroid artery, the artery should be ligated with clips and then divided to avoid injuring the nerve. The lower pole of the gland is then grasped and retracted in a cephalad direction. This exposes the adipose tissue and cervical thymic tissue inferior to the thyroid gland, which can then be dissected and divided. Care should be taken to avoid injuring the inferior parathyroid gland, which often rests in this area. Allowing it to fall inferiorly with the surrounding adipose and thymic tissue can preserve the parathyroid gland.

After releasing the inferior aspect of the gland, it is then retracted medially, and the perithyroidal fascia is incised using endoscopic scissors. In doing so, care must be taken to avoid injuring the recurrent nerve. The recurrent laryngeal nerve can usually be identified between the trachea and the carotid artery (Fig. 7.4), often in close proximity to the inferior thyroid artery. In this procedure, the lateral view from the axillary port helps to ensure complete visualization of the nerve (Fig. 7.5). After the nerve is clearly exposed, the inferior thyroid artery can be divided. The remaining attachments of the gland to Berry’s ligament can then be dissected and divided with careful manipulation of the endoscopic scissors and the dissector. Berry’s ligament then needs to be transected in order to complete the release of the thyroid gland from the trachea. To prevent thermal injury when using the dissector, great care is taken to maintain a distance of at least 5 mm from the major neurovascular structures and the trachea. When there is not adequate space to use the Harmonic device to manage Berry’s ligament, endoscopic clips are placed across the ligament before it is divided (Fig. 7.6). Some patients are anxious about having clips left in the neck. In these patients, the clips are removed after tightening with a ligating loop just under the clip. During the course of this dissection, the superior parathyroid gland is typically identified and preserved. After the thyroid gland is freed from the trachea, the isthmus is divided using the Harmonic device. Complete hemostasis is then assured.