This operation is one of the most difficult of the thyroid operations. To one degree or another, the pristine surgical planes have been violated, which greatly increases the odds of damage to vital structures: RLN, parathyroid glands, trachea, and esophagus. The first step is to get a clear understanding of the previous operation. If the contralateral lobe was resected for a nodule of indeterminate pathology and returned as cancer, returning to the operating room within the week is imperative so as to access the remaining lobe before the scarring sets in. If a different surgeon operated on the first side, then the details of the operation are needed, especially to ascertain if the RLN and parathyroids were already dissected on the remaining side. Even through scar, the important structures may once again be dissected free, but a wider exposure is needed and the surgeon must prepare for a longer, more tedious dissection. Also, active monitoring of the RLN with a specialized probe on the endotracheal tube must be considered to increase the likelihood of safely finding the nerve.
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