During total thyroidectomy, the recurrent laryngeal nerve (RLN) is at risk. At what point is the RLN most vulnerable to inadvertent ligation?

• A In the tracheoesophageal groove, 3–4 cm below the thyroid lower pole
• B At the Berry's ligament (posterior suspensory ligament of thyroid), where the RLN may be closely embedded in fibrous tissue ✓
• C At the cricothyroid membrane, as it enters the larynx between the cricoid and thyroid cartilages
• D At the aortic arch on the left side, where it loops under the ligamentum arteriosum

Explanation

The Berry's ligament (posterior suspensory ligament) attaches the thyroid gland to the trachea and cricoid cartilage, and the recurrent laryngeal nerve frequently passes through, behind, or is intimately adherent to this structure. This is the single most dangerous point of RLN injury during thyroid surgery, as the nerve may be difficult to identify within the dense fibrous tissue. Unilateral RLN injury causes ipsilateral vocal cord paralysis with hoarseness; bilateral injury causes respiratory obstruction requiring tracheostomy. The nerve runs in the tracheoesophageal groove for much of its course but injury there is more recognizable.

Reference: BD Chaurasia's Human Anatomy, 8th ed.

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Written and medically reviewed by the StethoPrep medical team.