. Manual of operative surgery. {Kocher.) Step 2.—With the finger separate the fibrous capsule from the anterior sur-face of the gland, at the same time pulling the muscles and fibrous capsuleoutwards with blunt retractors. The goitrous thyroid now presents, coveredby a peritoneal-like membrane (Fig. 394). Any veins (accessory veins) passingfrom the fibrous capsule to the gland must be doubly ligated and divided. Dothe same for the outer and posterior surfaces (Figs. 386, 387, and 388). Nowdislocate the goitre and pull it out of the wound. This removes pressure from 17 ^5^ goitre; bronchocele;
. Manual of operative surgery. {Kocher.) Step 2.—With the finger separate the fibrous capsule from the anterior sur-face of the gland, at the same time pulling the muscles and fibrous capsuleoutwards with blunt retractors. The goitrous thyroid now presents, coveredby a peritoneal-like membrane (Fig. 394). Any veins (accessory veins) passingfrom the fibrous capsule to the gland must be doubly ligated and divided. Dothe same for the outer and posterior surfaces (Figs. 386, 387, and 388). Nowdislocate the goitre and pull it out of the wound. This removes pressure from 17 ^5^ goitre; bronchocele; struma trachea. If a general anesthetic is being used, warn the anesthetist beforedislocating the gland. Step 3.—Systematic ligation of vessels. (a) With Kochers director push the fibrous capsule inwards and outwardsfrom the upper pole of the thyroid until the superior thyroid artery and veinare isolated like a pedicle. Divide these between ligatures applied tightly(Fig. 389).. Fig. 387.—(Kocher.) (b) Vigorously retract the muscles (sternomastoid, etc.) of the afifected pull the goitre over towards the sound side (Fig. 388). The inferiorthyroid artery lies on the deep muscles of the neck and may be felt as a trans-verse or oblique pulsating cord running from the outer side, under the carotidto the thyroid gland, where that structure is attached to the trachea. Isolatethe artery with great care and precision, because close to it is the recurrentlaryngeal nerve. Only apply one ligature to the vessel. Many surgeons ligateeach branch of the inferior thyroid close to the gland and so avoid the nerve. -^x
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