Inverse 'D' incision technique in treatment of pilonidal sinus disease; excision with minimal tissue loss, closure without tension and lateral location of the suture line.

PURPOSE: Surgical excision is the preferred treatment modality for sacrococcygeal pilonidal sinus (PS). Notably, the desirable features of an ideal surgical intervention are excision with minimal tissue loss, closure without tension, and a lateral suture line. The present study aimed to investigate early outcomes of surgical excision through the inverse D (ᗡ) incision based on tissue loss, wound tension, and suture line location. METHODS: This prospective study was comprised of 80 patients with PS in whom excision of PS was performed through the 'ᗡ' incision to minimize tissue loss with a tensionless primary surgical wound closure. The suture line was located laterally in all patients. Early and late postoperative complications, duration of hospital stay, return to work, and recurrence rates were investigated. The mean duration of the follow-up period was 36 months. RESULTS: Sixty-three patients (78.8%) were male. PS in all patients was surgically removed by subcutaneous excision through a 'ᗡ' incision. Laterally placed surgical wounds were closed primarily with interrupted vertical mattress sutures. No general complications were encountered. Five patients (6.3%) experienced early postoperative surgical site complications. On average, the duration of hospital stay and return to work were 2.4 days and 3.8 days, respectively. Recurrence was seen in 1 case (1.3%) during the follow-up period. Satisfaction score was high in 83.8% of patients. CONCLUSION: The method of sinus excision using the 'ᗡ' incision with a primary suture facilitates excision with minimal tissue loss and closure without tension with an off-midline suture. It is both a simple and effective surgical technique for the treatment of sacrococcygeal PS.

Visual and electrophysiological identification of the external branch of superior laryngeal nerve in redo thyroid surgery compared with primary thyroid surgery.

PURPOSE: Thyroid reoperations are surgically challenging because of significant anatomical variance. Visual and functional identification of the external branch of the superior laryngeal nerve (EBSLN) were studied in 2 groups of patients who underwent primary and redo thyroid surgery. METHODS: This study was conducted on 200 patients: 100 patients with redo and 100 patients with primary thyroid surgery. In addition to visual identification, nerve branches were functionally identified by intraoperative nerve monitoring (IONM). Visual, functional, and total identification rates of the EBSLN in both primary and redo surgery were determined and compared between the 2 groups. RESULTS: We attempted to identify 138 and 170 EBSLNs at risk in redo and primary surgery, respectively. Visual identification rates were 65.3% and 30.4% (P < 0.001) in primary and redo surgery groups, respectively. In total, 164 (96.5%) and 97 EBSLNs (70.3%) were identified in primary and redo surgery, respectively (P < 0.001), including the use of IONM. In primary surgery group, 53 nonvisualized EBSLNs of 164 identified nerves (32.3%) were determined by IONM alone. In redo surgery group, 55 of 97 identified nerves (56.7%) were determined by IONM alone (P < 0.001). CONCLUSION: Both visual and total identification rates of the EBSLN are significantly decreased in reoperative thyroidectomy. IONM increases the total identification rate of the EBSLN in primary and redo thyroid surgery. Electrophysiological monitoring makes a substantial contribution to the identification of the EBSLN both in primary and especially in redo thyroid surgery.

Displacement of the Recurrent Laryngeal Nerve in Patients with Recurrent Goiter Undergoing Redo Thyroid Surgery.

Thyroid reoperations are surgically challenging because of scarring and disturbances in the anatomy of the recurrent laryngeal nerve (RLN). This study was conducted on 49 patients who underwent redo surgery. 61 RLNs were identified and completely exposed. Their functional integrity was evaluated using intraoperative nerve monitoring (IONM). Indications for secondary surgery, anatomical changes secondary to recurrent goiter mass and prior surgery, and results of IONM were studied. Frequent indications for redo surgery were multinodular goiter (MNG) in 19 (38.8%) and results of cytology in 14 (28.5%) patients. The mean time interval between primary and redo thyroid surgery was 23.4 years. We laterally approached 41 (67.2%) thyroid lobes between the sternocleidomastoid and sternohyoid muscles. 16 (26.2%) RLNs were found to be adherent to the lateral surface of the corresponding thyroid lobe. The functional integrity of all RLNs was confirmed by IONM. The remnant thyroid tissue can then lead to goiter recurrence requiring secondary surgery after a long period of time. The indications for redo surgery were similar to primary cases. Lateral displacement of the RLN which is adherent to the lateral surface of recurrent goiter mass is common anatomic variation. Thyroid reoperations based on awareness of anatomical disturbances can be performed safely by an experienced surgeon with support of ancillary electrophysiological technology.

Toxic Adenoma in a Patient with Thyroid Hemiagenesis.

Thyroid hemiagenesis (TH) is a rare congenital anomaly that is usually asymptomatic. Functional disorders of the thyroid make the patient symptomatic. TH is usually and incidentally established during evaluation of patients with symptomatic thyroid pathology. We report the case of a patient of TH who became symptomatic with hyperactivity of the gland. The patient presented with signs and symptoms of thyrotoxicosis. Physical examination revealed asymmetric nodular goiter at the right lobe. Biochemical analysis established the diagnosis of hyperthyroidism. Ultrasound of the thyroid gland revealed the absence of the left lobe and a large, solitary hypoechoic solid nodule in the right lobe. Nuclear scan showed the absence of the left lobe and revealed a large, autonomous solitary nodule in the right lobe. The diagnosis was a toxic adenoma. After medical control of hyperthyroidism, the patient was surgically treated with hemithyroidectomy. We prescribed postoperative replacement medication with L-thyroxin. Hyperthyroidism makes TH cases symptomatic. Thyroid ultrasound and scintigraphy incidentally discover agenesis of one lobe during evaluation of thyrotoxicosis. Hemithyroidectomy, including the autonomous nodule, is the procedure of choice for patients with toxic adenoma. Hemithyroidectomy in TH cases technically becomes a total thyroidectomy with a need for postoperative thyroid replacement therapy.

Coexistence of Right Nonrecurrent Nerve and Bifurcated Recurrent Laryngeal Nerve Pointed by Zuckerkandl's Tubercle.

The recurrent laryngeal nerve (RLN) has many anatomical variations and various relations with adjacent structures. Identification and total exposure of the cervical part of the RLN was performed during operations on the thyroid gland. An extremely rare anatomical variation of the nerve was encountered during the surgical procedure. Coexistence of both right RLN and non-RLN was observed in one patient surgically treated with total thyroidectomy. We first exposed the right RLN with an extralaryngeal terminal bifurcation at its usual position. Thereafter, we also identified an ipsilateral non-RLN joining the anterior branch of the RLN just before laryngeal entry. A Zuckerkandl's tubercle has pointed out the junction of the two nerves. In this period, the incidence of coexistence of non-RLN and RLN was 0.2% in our series. A non-recurrent course is a rare anatomical variation of the inferior laryngeal nerve. The coexistence of both non-RLN and RLN is an extremely rare anatomical finding which should be taken into account during thyroid surgery.

Morphology and Functional Anatomy of the Recurrent Laryngeal Nerve with Extralaryngeal Terminal Bifurcation.

Anatomical variations of the recurrent laryngeal nerve (RLN), such as an extralaryngeal terminal bifurcation (ETB), threaten the safety of thyroid surgery. Besides the morphology of the nerve branches, intraoperative evaluation of their functional anatomy may be useful to preserve motor activity. We exposed 67 RLNs in 36 patients. The main trunk, bifurcation point, and terminal branches of bifid nerves were macroscopically determined and exposed during thyroid surgery. The functional anatomy of the nerve branches was evaluated by intraoperative nerve monitoring (IONM). Forty-six RLNs with an ETB were intraoperatively exposed. The bifurcation point was located along the prearterial, arterial, and postarterial segments in 11%, 39%, and 50% of bifid RLNs, respectively. Motor activity was determined in all anterior branches. The functional anatomy of terminal branches detected motor activity in 4 (8.7%) posterior branches of 46 bifid RLNs. The motor activity in posterior branches created a wave amplitude at 25-69% of that in the corresponding anterior branches. The functional anatomy of bifid RLNs demonstrated that anterior branches always contained motor fibres while posterior branches seldom contained motor fibres. The motor activity of the posterior branch was weaker than that of the anterior branch. IONM may help to differentiate between motor and sensory functions of nerve branches. The morphology and functional anatomy of all nerve branches must be preserved to ensure a safer surgery.

Pyramidal Lobe of the Thyroid Gland: Surgical Anatomy in Patients Undergoing Total Thyroidectomy.

Background. Anatomic variations, the presence of the pyramidal lobe (PL), may impact completeness of thyroidectomy and effect of surgical treatment. Method. This study included 166 patients who underwent total thyroidectomy. The anterior cervical region between the thyroid isthmus and the hyoid bone was dissected during thyroid surgery. The incidence, size, and anatomical features of the PL were established in these patients. Results. The incidence of PL was 65.7%. No gender difference was found for PL incidence. The base of the PL was located at the isthmus in 52.3%, the left lobe in 29.4%, and the right lobe in 18.3% of patients. The mean length of the PL was 22.7 (range, 5-59) mm. The PL was longer than 30 mm in 23% of patients. One-third of the patients with short PL were men whereas women accounted for 80% of patients with long PL. Conclusions. The high incidence indicates that the PL is a common part of the thyroid. The PL generally originates from the isthmus near midline and is of variable length, extending from the isthmus up to the hyoid bone. Considering that the PL is a common structure, the prelaryngeal region should be dissected to achieve the completeness of thyroidectomy.