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With the lateral hemostats in place, the right lobe is pushed laterally, and the isthmus is exposed. If this has not already been done, the isthmus is divided. The inferior border immediately over the trachea is grasped with mouse-toothed forceps and pulled upward as a curved clamp is inserted between the trachea and the posterior portion of the gland (Figure 34). A similar clamp is inserted from the upper side. After the cleavage plane between the thyroid gland and the anterior surface of the trachea has been developed, the entire isthmus is divided between curved clamps. If the clamps enter the tracheal fascia, there will be added discomfort in the postoperative period. The isthmus is divided close to the right side of the clamps (Figure 35). The clamps remain on the left portion of the thyroid as the right lobe margin is retracted laterally (Figure 36). Curved clamps are inserted across the trachea into the parenchyma of the gland and pointed toward the lateral row of clamps (Plate 183, Figure 32). If the clamps are placed horizontally across the trachea, the points will not injure the recurrent laryngeal nerve (Figure 37). The portion to be removed is now lifted and dissected free (Figure 38). The bleeding points in the center of the remnant are clamped. Only small amounts of tissue are included. Actively bleeding points that retract, especially along the tracheal margin of the remnant, are controlled by lateral compression with the index finger. Blind clamping of thyroid tissue, particularly at the superior edge, may result in injury to the recurrent laryngeal nerve (Figure 39, point x). All bleeding points are carefully ligated. Blind, deep placement of transfixing sutures is avoided because of the risk of injury to the underlying structures. The surgeon must tie beneath these clamps with great care, preferably using a surgeon's knot on the first throw of the tie, so that the subsequent knots ...

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