Chapter 8

Anterior Region 
(Robbins Level VI – Inferior Part) 8
The lymph node stations of this compartment
Core Messages include the prelaryngeal lymph node (Delphian
■ In this chapter we shall discuss above lymph node), the pretracheal lymph nodes, and
all the surgical anatomy of the thyroid. the recurrent lymph nodes.
The essence of the exercise consists of re- In order to balance out the topic more evenly
moving the gland after having identified for teaching purposes, in our dissection we have
and followed the inferior laryngeal nerve divided the median region into an inferior part,
(or recurrent nerve) with the intention corresponding to the trachea, esophagus, and
of preserving it. The correct preparation thyroid gland, and a superior part, corresponding
of the area of operation and the precise to the larynx and hypopharynx (Fig. 8.1).
knowledge of the landmarks must en- Significant anatomical structures: anterior
sure that the finding of the nerve is not jugular veins, infrahyoid muscles, thyroid gland,
arrived at by chance. parathyroid glands, inferior thyroid artery, re-
■ The cervical trachea will then be exam- current nerve, trachea, cervical esophagus, bra-
ined and we shall make a few consider- chiocephalic artery (or innominate artery), va-
ations on tracheotomies. The dissection gus nerve, subclavian artery, thyrocervical trunk,
of this region will conclude with the ex- vertebral artery.
ploration of the large vessels at the base of Landmarks: jugulum, infrahyoid white line,
the neck and of the cervical oesophagus. carotid tubercle, cricothyroid articulation.

  
8.2 Dissection
■ 8 .2.1  First, we identify the main landmarks
8.1 Anatomic Layout of this region, that is, the body of the hyoid
The anterior region that we shall explore in this bone and its greater cornua, the laryngeal
chapter and in the following one corresponds prominence, the cricoid ring, and the inter-
to what anatomists call the anterior infrahyoid cricothyroid space, and finally, the jugulum
region, since the suprahyoid region, which we (Fig. 8.2).
called submandibular and submental, has already
been dealt with in a previous chapter. ■ 8.2.2  Dissection begins lateromedially by el-
It coincides approximately with Robbins level evating the superficial and middle fasciae of
VI, and has as its upper limit the hyoid bone and the infrahyoid muscle plane (Fig. 8.3).
lower limit the medial end of the clavicles, the Below are some important data on the su-
acromioclavicular articulation, and the jugular perficial fascial plane:
incisure of the manubrium sterni. Laterally it 1. The medial margin of the platysma takes
extends from the anterior margin of one sterno- a divergent downward course and is conse-
cleidomastoid muscle to that of the contralateral quently not present in the medioinferior part
muscle. Robbins’s classification specifies superfi- of the region.
cial lateral limits, which are the lateral margins 2. The superficial and middle cervical fasciae
of the sternocleidomastoid muscles, and the deep fuse on the midline into a single aponeurosis,
limits, which are the common carotid arteries. a sort of raphe extending from the hyoid bone
68 Anterior Region (Robbins Level VI – Inferior Part)

Fig. 8.1  Boundaries of the anterior region Fig. 8.2  Anterior region: orientation

m = mandible 1 = body of hyoid bone

 i = hyoid bone 2 = laryngeal prominence
 c = clavicle 3 = cricoid ring
  s = sternum 4 = intercricothyroid space
 1 = anterior belly of digastric muscle 5 = jugular notch
 2 = thyrohyoid muscle 6 = anterior jugular vein
 3 = omohyoid muscle 7 = sternocleidomastoid muscle (sternal head)
 4 = sternohyoid muscle 8 = mental prominence
 5 = sternocleidomastoid muscle (clavicular head)
 6 = sternocleidomastoid muscle (sternal head)

to the sternum, which is referred to as the in- posterior border of the manubrium sterni.
frahyoid white line. They delimit a space called the suprasternal
3. The superficial vessels are negligible, except space (Gruber’s recess)—it contains cellulo–
for the anterior jugular veins, which run verti- adipose tissue with a few lymph nodes and an
cally to the neck along the paramedian line. anastomosis joining the anterior jugular veins
At approximately 2 cm from the sternum they that cross it.
bend laterally and become embedded, passing
posteriorly to the sternal tendon of the ster- ■ 8 .2.3  Fascia resection extends superiorly to
nocleidomastoid muscle and empty into the the hyoid bone, thereby exposing the muscle
brachiocephalic veins. plane formed by the omohyoid, sternohyoid,
4. A few centimeters superior to the sternum, and thyrohyoid muscles (Fig. 8.4).
the cervical fascia divides into two sheets, one We can see that the middle cervical fascia
directed to the anterior and the other to the extends laterally from one omohyoid muscle
 8.2  Dissection 69

Fig. 8.3  Superficial fascial plane. Fig. 8.4  Infrahyoid muscles plane

pm = mental prominence i = hyoid bone

 ms = manubrium sterni ms = manubrium sterni
 1 = platysma muscle 1 = omohyoid muscle
 2 = superficial cervical fascia 2 = sternothyroid muscle
 3 = anterior giugular vein 3 = sternohyoid muscle
 4 = internal jugular vein 4 = infrahyoid white line
 5 = sternothyroid muscle 5 = sternocleidomastoid muscle
 6 = sternohyoid muscle
 7 = sternocleidomastoid muscle (sternal head)
 8 = infrahyoid white line
 9 = Gruber’s recess

to the other, and that the sternothyroid mus- thyroid muscle, which is directly innervated
cle laterally overlaps more than the overlying by a branch of the hypoglossal nerve. At the
sternohyoid muscle. end of this maneuver, the thyroid gland is well
revealed (Fig. 8.5).
■ 8 .2.4  The infrahyoid muscles are then sec-
tioned at the sternoclavicular level and raised ■ 8.2.5  The next step is to examine and dissect
from the thyroid gland, and cricoid and thy- the thyroid gland and parathyroid glands.
roid cartilages by applying cranial traction. The thyroid is an endocrine gland lying
The sternohyoid muscles are elevated up to the medially to the base of the neck, whose front
hyoid bone and the sternothyroid muscles up view has an open H shape and on cross-sec-
to the line of attachment to the thyroid lamina. tion a horseshoe shape, enclosing the cervical
The innervation of these muscles derives from trachea in its concavity and the larynx and
the ansa cervicalis, with the exception of the esophagus laterally. It is invested by a slender,
70 Anterior Region (Robbins Level VI – Inferior Part)

Fig. 8.5  Thyroid (I) Fig. 8.6  Thyroid (II)

l = larynx   l = larynx

t = thyroid  t = thyroid gland
ms = manubrium sterni tr  = trachea
1 = sternohyoid muscle c = clavicle
2 = thyrohyoid muscle  1 = superior thyroid artery
3 = sternothyroid muscle  2 = inferior thyroid artery
4 = omohyoid muscle  3 = right thyroid lobe
5 = cricothyroid muscle  4 = isthmus of the thyroid gland
6 = superior thyroid artery  5 = left thyroid lobe
 

7 = medial branch of superior thyroid artery  6 = pyramidal thyroid lobe (Lalouette’s lobe)
8 = thyroid capsule vessel  7 = ima thyroid artery
9 = left sternocleidomastoid muscle  8 = inferior thyroid artery
  10 = pretracheal region  9 = pretracheal lymph nodes
  11 = common carotid artery

fibrous perithyroid sheath, which proceeds As in clinical practice, the gland is dissected
laterally along the pedicles and attaches to the after identifying and ligating the superior vas-
cervical vasculonervous bundle. This cover- cular pedicles. The superior thyroid artery
ing is part of the vascular sheath and is inde- (and vein), an upper branch of the external
pendent of the superficial and middle cervical carotid artery, initially runs horizontally, par-
fasciae [2]. Lying below the sheath is the thy- allel to the greater cornu of the hyoid bone,
roid capsule, which is an integral part of the then descends toward the homolateral thy-
parenchyma enclosing the gland’s superficial roid lobe; medially it gives rise to the superior
vessels (Fig. 8.6). laryngeal artery and then divides into three
 8.2  Dissection 71

identified. It consists of an ascending process

of the thyroid parenchyma. It has the follow-
ing characteristics. It saddles the thyroid car-
tilage of the larynx, generally in a left para-
median position; it is present three times out
of four; it extends upward like a more or less
evident fibrous cord passing just posteriorly
to the corpus ossis hyoidei; and ascends to-
ward the foramen cecum linguae. Lalouette’s
lobe is the embryonic remnant of the thyro-
glossal duct that shows the descent of the thy-
roid gland from its embryonic anlage situated
in the corpus linguae at the base of the neck
(Fig. 8.8).
Remarks: Cysts and median fistulae of the
neck develop along the path of the thyroglos-
sal duct, like “aberrant” thyroids or accessory
Fig. 8.7  Thyroid vascular pedicles thyroids. Their removal requires the complete
exeresis of these structures and, to avoid re-
1 = ima thyroid artery currences, of the median portion of the hyoid
2 = inferior thyroid artery
3 = superior thyroid artery bone with which the thyroglossal duct estab-
4 = superior laryngeal artery lishes close relations.
5 = superior thyroid artery (medial branch)
6 = superior thyroid artery (posterior branch) ■ 8 .2.7  Before beginning to look for the recur-
7 = superior thyroid artery (lateral branch) rent nerves, we free the anterior surface of the
8 = cricothyroid artery
9 = middle cervical ganglion (sympathetic cervical
trachea. The thyroid gland/cervical trachea
chain) complex needs to be stretched as far as pos-
sible cranially in order to expose an extensive
tract of the trachea (Fig. 8.9).

■ 8 .2.8  The subthyroid pretracheal space is

branches: one medial, which is the largest occupied by the so-called thyropericardial
and runs along the superior thyroid margin, lamina, which is sectioned to expose the ante-
one posterior and one lateral, from which the rior trachea wall. We section the tissue that is
cricothyroid artery arises and takes a medial on a more superficial plane than the anterior
course, perforating the homonymous mem- surface of the trachea, that is, we avoid going
brane (Fig. 8.7). any deeper laterally because, in doing so, we
Complications: In thyroid surgery, the su- would risk encountering the recurrent nerves
perior thyroid pedicle must be ligated down- (Fig. 8.10).
stream from the laryngeal artery origin and, The middle cervical fascia is attached su-
above all, should not involve the external periorly to the hyoid bone and laterally to the
branch of the superior laryngeal nerve. Once omohyoid muscles. Inferiorly, it adheres to
the upper pedicle has been ligated, we must the osteofibrous contour of the superior open-
avoid proceeding downward with the eleva- ing of the thoracic cavity (sternum, clavicle,
tion of the thyroid from the larynx, because and upper ribs). Inferiorly, the fascia contin-
we would arrive immediately near the recur- ues downward with more or less consistent
rent nerve just where it enters the larynx. thickness associated with the large vessels of
the mediastinum and pericardial serosa. This
■ 8 .2.6  Near the isthmus of the thyroid gland, median fascial structure takes the name of
the pyramidal lobe (Lalouette’s lobe) is then thyropericardial lamina and encloses the fol-
72 Anterior Region (Robbins Level VI – Inferior Part)

Fig. 8.9  Pretracheal area

t = thyroid gland
 c = clavicle
ms = manubrium sterni
1 = inferior thyroid veins
2 = thyropericardial lamina
3 = trachea
4 = ima thyroid artery
Fig. 8.8  Thyroglossal duct and Lalouette’s lobe

bl = tongue base
 i = hyoid bone
t = thyroid gland
  tr = trachea
 1 = Lalouette's lobe
 2 = thyroglossal duct
 3 = foramen cecum

lowing: the arteria thyroidea ima, which arises Complications: Perfect familiarity with
directly from the innominate artery or aortic this anatomic site is essential to ensure a risk-
arch (with inconsistent presence and caliber), free subthyroid tracheotomy. In some cases
and the pretracheal lymph nodes. the inferior thyroid nerves may be rather large
On exposure, proceeding craniocaudally, and numerous. The accidental interruption
the trachea can be seen increasingly embed- and downward loss of a sectioned inferior
ding below the cutaneous plane. thyroid vein, which naturally tends to retract
 8.2  Dissection 73

Fig. 8.11  Recurrent nerves

Fig. 8.10  Thyropericardial lamina   i = hypopharynx

 t = thyroid gland
t = thyroid gland tr = trachea
ms = manubrium sterni 1 = parathyroid gland
1 = inferior thyroid veins 2 = common carotid artery
2 = thyropericardial lamina 3 = subclavian artery
3 = trachea 4 = inferior thyroid artery
4 = ima thyroid artery 5 = aortic arch
6 = thyrocervical trunk
7 = vagus nerve
8 = left recurrent nerve
9 = right recurrent nerve

into the mediastinic adipose tissue and to trachea and esophagus, with slight asymme-
bleed, may become a serious problem. try insofar as the esophagus protrudes further
to the left than does the trachea. In this tract,
■ 8 .2.9  At this point we can turn our attention it gives rise to numerous collateral branches
to the recurrent nerves. The inferior laryngeal (middle cardiac branches serving the cardiac
nerve, or recurrent nerve, originates in the plexus, pharyngeal branches serving the pha-
first intrathoracic tract of the vagus nerve: it ryngeal plexus, in addition to tracheal and
arises more cranially to the right than to the esophageal branches). It penetrates the larynx
left, and immediately encloses the subclavian behind the articulation between the inferior
artery anteroposteriorly and inferosuperiorly. cornu of the thyroid cartilage and the cricoid
To the left it takes a similar course, enclosing ring.
the aortic arch. The recurrent nerves reascend, The recurrent nerve is a mixed nerve. It in-
running through the dihedral angle between nervates all intrinsic laryngeal muscles, except
74 Anterior Region (Robbins Level VI – Inferior Part)

for the cricothyroid muscle, which is inner-

vated by the superior laryngeal nerve; sensory
fibers innervate the mucosa of the inferior as-
pect of the vocal folds, the hypoglossal region,
and the upper tracheal rings (Fig. 8.11).
Complications: Thyroid and tracheal
surgery present the surgeon with the risk of
recurrent nerve injury. Such lesions are gen-
erally manifested by vocal fold fixity in a para-
median or intermediate position. If the lesion
is not bilateral (in which case tracheotomy is
often required, with subsequent surgery to ex-
tend the glottis), the main symptom is dyspho-
nia owing to incomplete glottal closure. When
the lesion is incomplete, because, for example,
the nerve has been excessively stretched, the
8 paralysis may regress spontaneously.
Where, instead, paralysis persists, the voice
may spontaneously improve through com-
pensation by the healthy voice fold, which
exceeds the midline during phonation. This
compensatory mechanism, which develops Fig. 8.12  Exercise 7: recurrent nerve
over a period of months, is helped by speech
rehabilitation.

■ 8 .2.10  First, we look for the inferior thyroid

artery. It arises from the thyrocervical trunk by passing posteriorly to the common carotid
and enters the recurrent region, passing pos- artery; this knowledge should avoid serious
teriorly to the common carotid artery. Its rela- trouble in surgical movements that in these
tions with the recurrent nerve are important cases are often agitated.
for the surgeon who, on ligating the inferior
thyroid pedicle during thyroidectomy, should ■ 8.2.11 Exercise 7: Recurrent Nerve (Fig. 8.12).
be careful not to impair the nerve. Unfortu- The search for and isolation of the inferior
nately, relations between the two structures laryngeal nerve (recurrent nerve) is the focal
are variable—the artery is often already di- point of this dissection exercise. To be suc-
vided when it crosses the nerve, which may cessful, we must prepare the field of operation
run between its branches. The right recurrent precisely.
nerve more commonly runs anteriorly to the First, we must apply traction medially on
artery and the left one posteriorly. In routine the thyroid lobe and identify, farther down,
surgical practice, ligation of the inferior thy- the hypopharynx and the cervical esophagus.
roid pedicle should only be performed after Laterally we seek the common carotid artery,
definitely identifying and isolating the homo- which is lateralized with a Farabeuf. Deep
lateral recurrent nerve. down, by palpation, we can identify the pre-
Complications: In vivo the inferior thy- vertebral plane.
roid artery must be ligated with particular at- We then seek tangentially in the triangle
tention. It is a vessel of considerable caliber, between the trachea (medially), the common
and if its ligature comes undone, considerable carotid artery (laterally), and the inferior thy-
difficulties may arise in recovering the inter- roid artery (superiorly) (whose name is Lorè’s
rupted and bleeding vessel. It is useful to re- triangle). This is the recurrent region in which
member that it enters our field of operation the recurrent nerve and inferior thyroid artery
 8.2  Dissection 75

are found, embedded in the celluloadipose between the thyroid capsule and the cricoid
connective tissue and crossing each other at perichondrium, and the residual pedicles.
right angles. To seek the nerve we divaricate We follow the upward course of the recurrent
the adipose tissue with scissors in the dihedral nerve, checking in particular the point of em-
angle between the esophagus and the trachea, bedment behind the cricothyroid articulation
proceeding craniocaudally. Once it has been (Fig. 8.14).
found it must be isolated and followed until To conclude the dissection of the thyroid
it enters the larynx, posterior to the cricothy- gland, we recall that there are two methods of
roid articulation. In this region, we can also thyroidectomy, at least in the benign pathol-
find some lymph nodes of the recurrent chain, ogy, which differ in whether or not the recur-
which form the lymphatic drainage of the thy- rent nerve is identified beforehand. The most
roid gland, of the hypoglossal region, and of
the cervical trachea. Last, we shall try to iden-
tify the parathyroid glands.
Complications: If it is difficult to identify
the right recurrent nerve, we must also con-
sider the possibility of a “nonrecurrent” recur-
rent nerve (0.5–1% of cases) [1]. That means
that, due to a congenital anomaly of the right
subclavian artery, the right nerve starts di-
rectly from the vagus nerve next to the thy-
roid gland.

■ 8 .2.12  At the point where the recurrent nerve

and the inferior thyroid artery cross, we can
try to identify some of the parathyroid glands,
of which there are generally four. The inferior
ones are generally more voluminous; the di-
mensions are about the size of a lemon seed,
and they are brown in color (Fig. 8.13).
Complications: The removal of the thyroid
gland must normally be performed preserving
both the recurrent nerve and the parathyroid
glands, which control the calcium and phos-
phorus metabolism through the parathyroid
hormone. Their removal leads to tetany, and
the replacement therapy must associate cal-
cium and vitamin D.
It is believed that their number can be Fig. 8.13  Recurrent region
halved without causing imbalance due to cal-
cemia. The correct procedure is to identify 1 = hypopharynx
2 = cervical esophagus
them and preserve them together with the 3 = recurrent nerve (esophagus branches)
actual vascular pedicle. If removed acciden- 4 = recurrent nerve
tally, they may be reimplanted in a niche in 5 = recurrent nerve (tracheal branches)
the sternocleidomastoid muscle, after having 6 = inferior thyroid artery
been finely chopped on a slide with a scalpel. 7 = inferior thyroid artery (superior branch)
8 = inferior thyroid artery (inferior branch)
9 = inferior thyroid artery (tracheal branches)
■ 8 .2.13  The completely isolated thyroid gland 10 = trachea
is now removed, after having sectioned the 11 = common carotid artery
lateral Berry–Gruber ligaments, extending 12 = recurrent lymph nodes
76 Anterior Region (Robbins Level VI – Inferior Part)

The first thing to control is the course of the

vagus nerve, already observed in the dissec-
tion of the sternocleidomastoid region, which
passes anteriorly to the artery and gives rise to
the recurrent nerve in proximity to its inferior
border; the recurrent nerve ascends posteri-
orly to the vessel toward the junction with the
inferior thyroid artery, where it was isolated
beforehand. The arterial branches of the sub-
clavian artery, particularly the thyrocervical
trunk, lying just medially to the anterior sca-
lene muscle, are then isolated. The transverse
cervical, transverse scapular, ascending cervi-
cal, and inferior thyroid arteries all arise from
this main branch of the subclavian, and the
latter two often have a common origin.
8 The origin of the vertebral artery, which
ascends medially (reemerging in the prever-
tebral region) is sought at roughly the same
level, on the posterosuperior border of the
subclavian artery. Just after its origin, it ac-
companies the vertebral vein, which descends
and passes anteriorly to the subclavian artery
(Fig. 8.15).
The internal thoracic artery, instead, arises
Fig. 8.14  Esophagotracheal angle from the inferior margin of the subclavian.
The subclavian artery then embeds itself,
if = hypopharynx passing posteriorly to the anterior scalene
cr = cricoid cartilage
 tr = trachea muscle and inferiorly to the brachial plexus,
 e = esophagus overstriding the first rib. The lateral portion
t = thyroid has already been examined in supraclavicular
 1 = cricothyroid muscle dissection.
 2 = cricopharyngeal muscle
 3 = Killian’s mouth
 4 = recurrent nerve
■ 8 .2.15  The subclavian artery and right com-
 5 = tracheal vascular arches mon carotid artery arise from the brachioce-
 6 = parathyroid gland phalic trunk or innominate artery; on the left,
the origins of the subclavian and common
carotid arteries are instead separate from the
recent case histories say that the percentage arch of the aorta. The adipose and fascial con-
of paralysis is considerably lower when the nective tissue enclosing the great paratracheal
recurrent nerve is sought, identified, and pre- vessels continues with the mediastinal cellu-
served. lar tissue (upper mediastinum). It abounds in
lymph nodes, some anthracotic, in continu-
■ 8 .2.14  Isolation of the major arteries of the ity with the overlying recurrent lymph node
base of the neck starts from the bottom, with chains. The innominate artery, hidden below
exposure concentrating in particular on the the manubrium sterni, is short and fat and
common carotid artery in relation to the su- may be a major source of danger during per-
perior opening of the thorax. Following the formance of low tracheotomy (Fig. 8.16).
common carotid caudad, the subclavian artery Complications: Tracheostomy, as a pre-
can be reached from the right and isolated. liminary stage in oncological surgery of the
 8.2  Dissection 77

Fig. 8.15  Inferior peri-

visceral area

1 = brachial plexus 7 = sympathetic cervical chain

2 = anterior scalene muscle 8 = inferior thyroid artery
3 = phrenic nerve 9 = subclavian artery
4 = internal jugular vein 10 = recurrent nerve
5 = vagus nerve 11 = trachea
6 = common carotid artery

Fig. 8.16  Brachioce-

phalic trunk (innomi-
nate artery)

 tr = trachea 3 = subclavian artery

 lr = recurrent lymph nodes 4 = vagus nerve
 c = clavicle 5 = common carotid artery
 ms = manubrium sterni 6 = brachiocephalic trunk (innominate artery)
ma = upper mediastinum 7 = anterior jugular vein
  1 = thyrocervical trunk 8 = brachiocephalic vein
  2 = internal thoracic artery
78 Anterior Region (Robbins Level VI – Inferior Part)

larynx and hypopharynx, is preferably per- cided to reduce this low tracheotomy-related
formed below the isthmus of the thyroid risk by protecting the upper mediastinum
gland. This mode of access is more explor- with an everted, lower-hinge tracheal flap, su-
atory than the trans- and supraisthmic routes tured to the cutis (Bjork’s flap) (Fig. 8.17).
since the trachea is deeper than the cutaneous Remarks: One disadvantage of systematic
plane, but there are two advantages: (1) it en- tracheostomy in preservative surgery of the
ables the surgeon to operate at a distance from larynx is the need for plastic surgery to close
the neoplasia and, as has been demonstrated, the tracheostoma, requiring a minor operation
this reduces the incidence of paratracheosto- under local anesthetic. One certain benefit is,
mal recurrences; and (2) the surgeon remains instead, the ease with which the tracheotomy
at a considerable distance from the hypoglot- tube can be replaced in the postoperative pe-
tic cone, which is often the site of secondary riod by nursing staff. The tracheal flap joined
cicatricial stenoses. This applies also in func- to the cutis provides a handy “slide” by which
tional surgery of the larynx or for provisional to access the tracheal lumen and the risk of
tracheostomies, which are usually performed taking the wrong mediastinal route is practi-
in the third/fourth tracheal ring. cally nonexistent.
8 Besides, the proximity of the tracheotomy The current tendency regarding tracheoto-
to the innominate artery exposes the patient mies is the following:
to the risk of this vessel rupturing, generally 1. Confirmation of the tracheostomic rather
because of tracheotomy tube decubitus. This than the tracheotomic procedure, that is, the
event invariably has a fatal prognosis due both trachea is always joined to the cutis (for safety
to the extent of hemorrhaging, and to the fact when changing the tube, even at home, and
that there is no effective form of emergency ease of managing the tracheostoma).
compressive plugging. It has thus been de- 2. Tracheostomas are increasingly smaller and
are closed much earlier.
3. The use of cuffed or fenestrated tubes is
avoided, unless in exceptional cases.

■ 8 .2.16  The great veins of the base of the neck

are sought in this area, anteriorly to the great
arterial trunks. A useful guide for this purpose
is the internal jugular vein, whose descending
course leads to the subclavian vein and me-
dial course to the bilaterally present brachio-
cephalic vein.
To conclude this dissection phase, the tra-
chea is completely skeletized; the prevertebral
plane is at once exposed laterally to the me-
dian organs (Fig. 8.18).

■ 8 .2.17  After removing the thyroid gland, the

complete cervical esophagus can be examined.
The esophagus can immediately be seen pro-
truding more to the left than does the trachea.
Fig. 8.17  Tracheostomy Its superior end can be clearly identified near
the cricoid cartilage. Its caliber narrows at
cr = cricoid cartilage this point (more markedly than the constric-
 tr = trachea
1 = common carotid artery tion present on crossing the aortic arch and
2 = subclavian artery diaphragm) and takes the name of Killian’s
3 = innominate artery mouth (Fig. 8.19).
 8.2  Dissection 79

Fig. 8.18  Prevertebral perivisceral area

ppv = prevertebral plane

t = thyroid gland
 tr = trachea
 ap = apex of the lung
 c = clavicle
m = manubrium sterni
 1 = phrenic nerve
 2 = anterior scalene muscle
 3 = branches of cervical plexus
 4 = internal jugular vein
 5 = thyrolinguofacial trunk
 6 = superior thyroid pedicle
 7 = lateral hypopharyngeal wall
 8 = vagus nerve
 9 = cervical sympathetic chain
 10 = common carotid artery
 11 = inferior thyroid artery
 12 = subclavian artery
 13 = vertebral vein
 14 = vertebral artery
 15 = recurrent nerve
 16 = recurrent lymph nodes
 17 = pretracheal lymph nodes
 18 = innominate artery

Fig. 8.19  Trachea and cervical esophagus

if = hypopharynx
 tr = trachea
 e = esophagus
ppv = prevertebral plane
 1 = cricopharyngeal muscle
 2 = Killian’s mouth
 3 = recurrent nerve
 4 = tracheal vascular arches
 5 = tracheal ring
 6 = pars membranacea of the trachea
80 Anterior Region (Robbins Level VI – Inferior Part)

Remarks: Killian’s mouth has a sphincteric interrupted along the contact surface with the
function provided by the action of the crico- esophagus. The posterior wall (pars membra-
pharyngeal fibers of the inferior constrictor nacea) is devoid of cartilage; it does instead
muscle of the pharynx. These muscle fibers possess smooth muscle fibers (tracheal mus-
play a part in establishment of the neoglottis, cle) which, on contraction, approximate the
which produces the esophageal voice in total ends of the cartilage arches, thereby decreas-
laryngectomees. This is when selective my- ing the transverse diameter of the trachea
otomy is performed in the event of excessive during respiration. Finally, we consider that
esophageal stricture after supraglottic, subto- the sixth cervical vertebra represents the level
tal reconstructive, or total laryngectomy with of passage between the hypopharynx and the
a phonatory fistula. cervical esophagus, as also between the larynx
and the trachea and, indirectly, between Rob-
■ 8 .2.18  The esophagus is then isolated from bins level III and IV. The transverse processes
both the prevertebral plane and the trachea. of the sixth cervical vertebra are known as the
It is worth noting that the tracheal rings are carotid tubercles.
8
Take Home Messages
■ The white line is an important landmark: ■ The trachea is nourished segmentarily,
(a) in thyroid surgery, it allows access to above all by branches of the inferior
the thyroid gland simply by divaricating thyroid arteries. When a temporary tra-
the infrahyoid muscles on this line, with- cheostomy is being performed, it is good
out necessarily sectioning them, and (b) practice to limit the skeletization of the
as the “tracheotomy rhombus”, since in tracheal rings to what is strictly indis-
that spot only two planes, the cutis and pensable to avoid peritracheostomal
the fascia, cover the laryngotracheal chondronecrosis induced by ischemia,
duct; the surgeon passes through these especially in patients treated with radio-
planes when he or she wants to open the therapy.
trachea. ■ The dissection of the recurrent region is
■ The tracheotomy may be performed very important and is often overlooked
with a vertical or transverse incision of in laryngeal tumors with hypoglottic ex-
the cutis. We usually prefer the trans- tension. This factor may explain cases of
verse incision for aesthetic reasons. The peritracheostomal recurrence after total
vertical incision tends to adhere to the laryngectomy. Moreover, it must not be
scar of the infrahyoid white line, which forgotten that the recurrent region is in
is necessarily opened craniocaudally. In continuity with the upper mediastinum;
this way, an unattractive adherence is hence the indication for postoperative
formed between the cutis and the mus- radiotherapy even in this seat in hypo-
cular plane, which is clearly seen during glottic tumors.
deglutition.

  

thyroid surgery (7 cases). [In French.] Ann Chir

References 31:917–923
1. Blondeau P, Neouze GL, Rene L (1977) The in- 2. Testut L, Jacob O (1977) Trattato di Anatomia
ferior non-recurrent laryngeal nerve; hazards of Topografica, UTET, Turin