Surgical Technique Based on Cervical Fascial Anatomy for Systematic Resection of Lymph Nodes Posterior to the Right Recurrent Laryngeal Nerve

Introduction: Neck has typical and sophisticated facial structures. A good understanding of the anatomical features of cervical fascia and fascial space around thyroid can improve the surgical operation of the thyroid cancer and reduce accompanying complications. The alar fascia was described as a complete layer of fascia between the visceral and the prevertebral fasciae, which form the anatomic basis of the dissection of cervical lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) for thyroid cancer.1–3 Materials and Methods: A 42-year-old woman presented with a 1.2 cm clinically node-negative papillary thyroid cancer in the right thyroid lobe. Endoscopic thyroidectomy with central compartment neck dissection is performed. Surgical technique based on cervical fascial anatomy for systematic resection of LN-prRLN is illustrated. Results: After endoscopic thyroidectomy with dissection of prelaryngeal pretracheal lymph nodes and lymph nodes anterior to right RLN (not illustrated), we apply a six-step approach to the fascial anatomy of LN-prRLN. (1) Release the RLN from its initial segment; (2) open the alar fascia from anterior to posterior along the sympathetic trunk and carotid sheath; (3) isolate and protect the inferior thyroid artery and its branches, which is the primary blood supply of parathyroid glands; (4) disconnect the trachea and esophagus branch of the RLN; (5) dissect the alar fascia at the superior edge of the innominate artery and separate upward along the surface of the esophagus; (6) the lymphatic adipose tissue is then transferred to the lateral side of the RLN and then removed. Conclusion: A complete dissection of LN-prRLN, requires a thorough understanding of the anatomic relationship between the RLN and cervical fascia. According to our experience, this systematic six-step approach of fascial anatomy is a meticulous, complete, reproducible, and teachable approach to the endoscopic dissection of LN-prRLN with low morbidity. No competing financial interests exist. Funding Information: This research was supported by the Union funds in scientific and technological innovation of Fujian province (Grant Nos. 2018Y9093 and 2018Y0915); The Health Research Talents Training Project of Fujian province (Grant Nos. 2019-CX-16 and 2018-CX-17); the Guiding Social Development Project of Fujian province (Grant No. 2018Y0035). Additional supporting information may be found in the online version of this article. Authors' Contributions: W.-X.Z. is the corresponding author of this video. B.W. is the chief operator. J.W. and C.X. are the assistants of this operation. S.L., Y.-J.W., and T.-Y.W. prepared the article and helped to perform the narration. Brandon Wang is the English name of Bo Wang. Runtime of video: 8 mins 41 secs