• Visualization/dissection1. Parathyroid gland
2. Vascular pedicle
3. Recurrent laryngeal nerve
4. Posterior fascia
After retracting the thyroid lobe medially and lifting it up, the fascia can be opened by gentle spatula retraction. The recurrent laryngeal nerve generally appears at this point, lying in the thyrotracheal groove and posterior to the Zuckerkandl tuberculum (posterior lobe), which is an excellent landmark.
In conventional surgery, the recurrent nerve is generally prepared at its emergence from the thoracic outlet, but this area can be difficult to visualize with the endoscope while the middle part of the thyroid gland is clearly visible and nerve dissection is ideal.
Also, both parathyroid glands are generally easily visualized because of the endoscope magnification. Their vascular supply is preserved by selective ligature of the branches of the inferior thyroid artery. Hemostasis is achieved during dissection by vascular clips or ultrasonic scalpel, when dealing with large vessels or small vessels close to the nerve. In this way, the recurrent nerve and the parathyroid glands are dissected and freed from the thyroid gland.
The surgeon should always remember to keep the inactive blade of the ultrasonic scalpel posteriorly oriented during the division of the artery to avoid jeopardizing the nerve, which always lies posterior to it and is very sensitive to heat transmission.