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Occasionally, as the upper muscle clamp is retracted upward and outward, a branch of the superior thyroid artery may be encountered, extending from the muscle to the surface of the thyroid gland in the region of the upper pole. This vessel should be carefully clamped and tied (Figure 22).

It is customary to begin a subtotal thyroidectomy at the right upper pole or on the larger side. Some surgeons prefer to divide the middle thyroid vein first (Figure 26), so as to improve mobility and exposure of the upper pole vessels. A narrow retractor is placed in the wound at the superior pole. Blunt dissection, which allows the thyroid capsule to be pushed away from the larynx, is best accomplished by opening a small, curved hemostat in the membranous tissue at this point (Figure 23). At the uppermost portion of the gland there is a thin fascia that almost encircles the trachea. This area must be clamped carefully, since it contains a small blood vessel that, if allowed to retract, is very dangerous to secure because of its proximity to the superior laryngeal nerve. Traction should be maintained on the thyroid gland by means of a curved hemostat or an umbilical tape snugged around the gland in the region of the upper pole. There is less chance of tearing a friable gland if curved hemostats or the umbilical tape, rather than a toothed tenaculum are used for traction. By sharp and blunt dissection the superior thyroid vessels are exposed well above their point of entry into the gland (Figure 23). The surgeon now decides whether to leave any thyroid tissue at the upper pole region and places the next clamp either at the upper limits of the gland or in the substance of the gland, perhaps 1 cm below the top of the pole. Hemostasis is ...

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