Ventilation-assisted functional visualization: a stepwise workflow for planned management of a preoperatively identified tracheal diverticulum during thyroidectomy

Introduction

Background

Tracheal diverticulum represents a paratracheal air-containing outpouching arising most commonly from the right posterolateral membranous wall of the trachea, particularly near the thoracic inlet, typically at the level of the T1–T3 vertebrae (1,2), and is frequently detected incidentally on cross-sectional imaging. Although typically asymptomatic, a tracheal diverticulum can pose a significant intraoperative hazard when it lies within the thyroid operative field—particularly during posterior capsular-plane dissection and/or central compartment (level VI) lymph node dissection—where dissection occurs adjacent to the trachea and the recurrent laryngeal nerve (RLN). This risk is amplified when the RLN crosses over or lies adjacent to the diverticulum, thereby altering familiar dissection planes and increasing the likelihood of nerve or airway complications. Currently, there is limited guidance and no consensus on a standardized intraoperative workflow to (I) functionally localize a preoperatively identified tracheal diverticulum before definitive posterior dissection and (II) verify tracheal integrity after diverticulectomy and repair.

Rationale

Although tracheal diverticula may be identified on preoperative imaging, existing intraoperative management during thyroidectomy largely relies on correlation with computed tomography (CT) anatomy and careful posterior capsular-plane dissection. This conventional approach is widely available and requires no dedicated equipment, but it lacks functional confirmation of tracheal communication; a non-aerated diverticular sac may collapse and become indistinguishable from surrounding soft tissue, increasing the risk of inadvertent rupture, operative-field contamination, and RLN injury. The proposed workflow is a modified adjunct to standard open thyroidectomy: it introduces a ventilation-assisted functional visualization maneuver combined with predefined cuff-depth boundaries (D_cuff/D_cuff2) for reproducible localization and standardized airway integrity verification, without modification of the endotracheal tube (ETT) or other key devices.

Objective

We present a stepwise operative workflow for intraoperative identification and controlled management of a tracheal diverticulum identified preoperatively and anticipated during thyroidectomy, intended for cases in which the diverticulum is expected to lie within or adjacent to the thyroid surgical field and therefore warrants planned, controlled intraoperative management. This is particularly relevant in cases requiring central compartment (level VI) lymph node dissection, where dissection proceeds along the paratracheal plane and early recognition of a diverticulum is critical to avoid inadvertent airway injury and field contamination. The workflow combines preoperative imaging-based risk stratification, ventilation-assisted functional visualization for early localization, followed by RLN identification/protection and systematic airway integrity verification, with emphasis on intraoperative decision-making and risk control. This is an open transcervical adjunct technique performed as part of standard open thyroidectomy with concomitant tracheal diverticulectomy, with curative intent. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0038/rc).

Preoperative preparations and requirements

The procedure was performed in a standard sterile operating room under general anesthesia with endotracheal intubation. Routine skin preparation and sterile draping were applied. Brief, controlled ventilation maneuvers and ETT repositioning were coordinated in real time between the thyroid surgeon and the anesthesiology team.

Purpose and scope

The primary objective of this workflow is early and reliable intraoperative identification of a tracheal diverticulum that has been identified on preoperative imaging and is anticipated to lie within or adjacent to the thyroid surgical field, enabling controlled posterior capsular-plane dissection and/or level VI dissection with RLN protection. The method is intended for planned unilateral or total thyroidectomy when diverticular manipulation or injury is anticipated. Coordination with anesthesiology is needed for brief, controllable manual ventilation and ETT repositioning within recorded cuff-depth boundaries (D_cuff/D_cuff2). Although presented in the setting of thyroidectomy with anticipated diverticulectomy, the core principles (recorded cuff-depth boundaries, ventilation-assisted functional visualization, and systematic integrity verification) may also be adapted to selected stand-alone planned transcervical diverticulectomy. In thyroidectomy cases, the workflow is most applicable when the diverticulum is expected to be encountered during posterior capsular-plane and/or level VI dissection.

Materials and equipment

This workflow requires no specialized devices beyond standard open thyroidectomy and routine anesthesia equipment. Key materials and equipment include:

• Required;
• Videolaryngoscope for endotracheal intubation and for documenting the cuff-vocal cord relationship to record D_cuff (ETT incisor depth reference);
• Absorbable sutures for diverticular neck ligation and membranous tracheal closure (interrupted; 5-0 Vicryl, polyglactin 910; Ethicon, Johnson & Johnson, Ciudad Juarez, Mexico);
• Optional: intraoperative nerve monitoring (IONM), per surgeon preference and institutional practice.

Indications and contraindications

Indications: (I) preoperative CT suggests a cervical tracheal diverticulum adjacent to the posterior thyroid capsule or central compartment dissection plane; and (II) planned thyroidectomy where diverticular manipulation or injury is anticipated. Contraindications: (I) absence of preoperative imaging localization; (II) inability to coordinate controlled ventilation maneuvers with anesthesia; or (III) unstable airway or ventilation status precluding brief manual ventilation adjustments.

Operator requirements

The workflow should be performed by a thyroid surgeon experienced in posterior capsular-plane dissection and deliberate RLN identification, supported by an anesthesiologist able to deliver brief, gentle manual ventilation and to reposition the ETT within predefined depth limits (D_cuff and D_cuff2). A scrub nurse familiar with open thyroidectomy instrumentation and airway-repair contingency supplies is recommended. A formal learning curve was not quantified in this single-case report; because the technique is an adjunct to standard open thyroidectomy, the key training requirement is team rehearsal of the communication steps, depth-boundary checks, and abort criteria before clinical use.

Step-by-step description

Step 1. Preoperative imaging and risk stratification

Preoperative contrast-enhanced multidetector CT with multiplanar reformats and three-dimensional reconstruction is obtained to delineate the relationship between the diverticulum, trachea, and thyroid gland. Particular attention is directed toward the location, caliber, and orientation of the diverticular neck and its proximity to the posterior thyroid capsule to inform intraoperative risk stratification and posterior capsular dissection strategy (3,4), with representative images shown in Figures 1-3. The index patient was a 58-year-old woman with a preoperatively identified right posterolateral cervical tracheal diverticulum adjacent to the posterior thyroid capsule on contrast-enhanced CT. She had no symptoms attributable to the tracheal diverticulum, and her thyroid nodules had been detected incidentally on ultrasound 1 year earlier and followed radiologically. After interval surveillance, she elected surgery for bilateral thyroid nodules; after discussion of the operative process, extent, and potential risks, she also requested planned concomitant resection of the tracheal diverticulum. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this surgical technique and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Preoperative 3D reconstruction. Spatial relationship among the thyroid gland (yellow), trachea (green), tracheal diverticulum (purple), and carotid artery (light orange). 3D, three-dimensional.

Figure 2 Preoperative 3D reconstruction. Relationship between the trachea (green) and the tracheal diverticulum (purple), demonstrating the diverticulum in the right posterolateral paratracheal region. 3D, three-dimensional.

Figure 3 Axial contrast-enhanced CT. Axial view demonstrating the trachea and the tracheal diverticulum with an identifiable communicating ostium (connection site) to the tracheal lumen. CT, computed tomography.

Step 2. Operative setup, intubation strategy, and initial exposure

Under general anesthesia, endotracheal intubation was performed using videolaryngoscopy. During intubation, the ETT incisor depth at which the proximal cuff margin was visualized just distal to the vocal cords was recorded as D_cuff. This reference depth was subsequently used as the standardized proximal withdrawal boundary during ventilation-assisted identification and integrity testing.

To reduce inadvertent pressurization or mechanical friction on a thin-walled diverticulum during the initial dissection, the ETT was temporarily advanced beyond the preoperatively localized diverticular level to a recorded deep protective position, D_cuff2. After advancing the tube, bilateral breath sounds were confirmed by auscultation to exclude endobronchial intubation. D_cuff2 was defined as the recorded deeper ETT incisor depth at which the cuff had advanced beyond the diverticular level, so that it remained distal to the diverticular ostium.

Thus, D_cuff and D_cuff2 represented the proximal (upper) withdrawal boundary and distal (lower) readvancement boundary, respectively.

This deep insertion strategy was considered anatomically feasible because tracheal diverticula are predominantly located at the thoracic inlet, typically at T1–T3 levels or 4–5 cm below the vocal cords, whereas acceptable adult ETT tip positioning is generally at the T2–T4 level (1,3,5,6). Accordingly, advancing the tube to D_cuff2 helped keep the cuff distal to the anticipated diverticular ostium during the early dissection phase. This, in turn, reduced the diverticulum’s exposure to positive-pressure effects while preserving a reproducible reference D_cuff for subsequent controlled withdrawal.

Intraoperative monitoring: standard anesthesia monitoring was applied continuously (e.g., oxygenation, ventilation, and hemodynamics per institutional practice). During the brief ventilation-assisted maneuvers and submerged air-leak testing, the anesthesiologist maintained slow, gentle manual breaths and avoided high peak airway pressures. The ETT position was confirmed by incisor-depth markings and clinical ventilation adequacy; cuff inflation was maintained within routine safe ranges per anesthesia practice.

The patient was then positioned supine with mild neck extension. A transverse cervical (Kocher) incision was made, and thyroidectomy exposure and capsular-plane dissection were performed in a standard fashion, proceeding inferiorly as usual.

Step 3. Identification and exposure (inspection before manipulation)

When approaching the CT-predicted diverticulum region during posterior capsular-plane and/or level VI dissection, the surgeon performs deliberate inspection and imaging correlation before applying traction, cautery, or direct manipulation. A suspected thin membranous structure at the predicted location is evaluated for anatomic consistency with the preoperative CT findings (Figure 4).

Figure 4 Initial intraoperative exposure. Intraoperative view after thyroid mobilization showing the suspected membranous diverticular tissue in the predicted posterior capsular-plane region (white arrow).

Step 4. Ventilation-assisted functional visualization/localization maneuver

When the dissection approaches the CT-predicted diverticulum region and/or when a thin membranous tissue is suspected, the anesthesiology team transitions to manual ventilation to allow brief, highly controllable pressure delivery to functionally localize and visualize the diverticular sac.

Under direct communication, the ETT was gently withdrawn from its initial deep protective position, D_cuff2 toward D_cuff to reposition the cuff relative to the suspected diverticular ostium and prevent the cuff from blocking the diverticular opening. Withdrawal beyond D_cuff was avoided to reduce the risk of inadvertent extubation. With the ETT held at this withdrawn position, the anesthesiologist delivered several slow, gentle manual positive-pressure breaths for a brief interval. Visual confirmation that the membranous structure or surrounding tissue expanded synchronously with airway pressure was used to functionally identify the diverticulum and to estimate its intraoperative location and extent (Figure 5).

Figure 5 Ventilation-assisted functional visualization. During brief manual positive-pressure ventilation, the diverticular tissue expands synchronously, facilitating localization; the RLN is seen crossing the diverticular surface. RLN, recurrent laryngeal nerve.

Immediately after functional identification, the ETT was re-advanced to the recorded deep protective position D_cuff2, with the cuff again distal to the diverticular ostium, and mechanical ventilation was resumed. Together, D_cuff and D_cuff2 define the proximal (withdrawal) and distal (readvancement) boundaries for controlled tube repositioning during the workflow. This “withdraw-identify-readvance” sequence minimizes the duration of diverticular wall tension and exposure to positive-pressure effects, thereby reducing ventilation-related diverticular instability and intraoperative procedural interference, while enabling reliable localization.

Abort criteria (safety boundary): the maneuver should be avoided or immediately aborted if airway instability occurs (e.g., desaturation, significant ventilation difficulty, inability to maintain an adequate seal), if unusually high airway pressures are required to deliver a breath, or if there is concern for existing airway injury.

Step 5. RLN identification and protection after diverticulum localization

After diverticular identification, dissection prioritizes early and complete exposure of the RLN. Careful blunt dissection is performed along the surface of the diverticulum to delineate and skeletonize the RLN from the diverticular wall under direct visualization, preserving the neural sheath and minimizing traction (Figures 6,7). Adjunctive IONM may be used per surgeon preference and institutional practice, but it does not replace anatomical identification. Importantly, no dissection or manipulation of other diverticular regions should be performed until the RLN has been identified and protected.

Figure 6 Key anatomic relationships. Close-up view demonstrating the spatial relationship among the thyroid remnant, the RLN, and the tracheal diverticulum. RLN, recurrent laryngeal nerve.

Figure 7 RLN-diverticulum interface. Direct visualization of the thin-walled diverticular tissue (light gray) with the RLN traversing its surface, prior to mobilization. RLN, recurrent laryngeal nerve.

Step 6. Diverticular resection, repair, and integrity testing

With the RLN clearly identified and protected, the diverticulum was dissected circumferentially, preserving a short neck at its attachment to the posterior membranous tracheal wall (Figures 8,9). Ligation was performed close to the tracheal wall using absorbable suture (e.g., 5-0 Vicryl), followed by excision of the diverticulum. The resected specimen is shown in Figure 10. The membranous tracheal defect was approximated and closed with interrupted absorbable sutures. After tracheal repair, the planned thyroidectomy (unilateral or total) and, when indicated, central compartment (level VI) lymph node dissection were completed in a standard fashion, with care to minimize traction on the repaired membranous trachea. In the index case, right thyroid lobectomy with isthmusectomy was initially performed; after intraoperative frozen section demonstrated papillary thyroid carcinoma, completion thyroidectomy and central compartment (level VI) lymph node dissection were subsequently carried out.

Figure 8 Identification of the diverticular stalk. After RLN protection, the diverticulum is mobilized to reveal a distinct stalk/pedicle connecting the diverticulum to the trachea. RLN, recurrent laryngeal nerve.

Figure 9 RLN skeletonization. Fine blunt dissection delineating the plane between the RLN and the diverticular wall before diverticulectomy. RLN, recurrent laryngeal nerve.

Figure 10 Gross specimen of the resected tracheal diverticulum. On gentle compression, mucoid secretions were expressed from the diverticular lumen, consistent with communication with the tracheal airway.

Before wound closure, sterile water (or sterile saline) was poured to submerge the repair site. The ventilator was switched to manual mode, and the ETT was gently adjusted and withdrawn until the cuff was positioned proximal to the repair site, thereby exposing the repair site to controlled airway pressure. To avoid excessive withdrawal, the tube was not withdrawn beyond the D_cuff. Controlled manual positive-pressure breaths were then applied for several respiratory cycles. Absence of air bubbles from the submerged repair site suggested an intact closure. The ETT was subsequently re-advanced to the recorded deep protective position D_cuff2, and mechanical ventilation was resumed.

Abort criteria (safety boundary): if adequate ventilation cannot be maintained with gentle manual breaths, if high peak pressures are required, or if the repair appears to gap under pressure, testing should be stopped and the airway/repair reassessed before proceeding.

Workflow endpoints: successful application of this workflow may be considered achieved when (I) the diverticular sac is functionally localized at the CT-predicted region before definitive posterior dissection; (II) posterior capsular-plane and/or central compartment dissection proceeds with deliberate identification and protection of the RLN after localization, avoiding traction or cautery on the membranous sac; and (III) tracheal wall integrity is verified by standardized submerged air-leak testing under gentle manual ventilation following diverticulectomy and repair. Postoperative assessment focuses on airway stability, preservation of vocal function, and—when clinically indicated—imaging confirmation of an intact tracheal contour.

The total operative time was 150 minutes (anesthesia record).

Postoperative considerations and tasks

Evaluation (success/failure criteria)

Technical success is defined by completion of the key workflow endpoints (functional localization/confirmation prior to definitive posterior dissection, deliberate RLN identification and protection before diverticular mobilization, and a negative submerged air-leak test after repair). Clinical effectiveness is assessed by postoperative airway stability (absence of symptoms/signs suggesting air leak or airway compromise) and, when indicated, follow-up imaging demonstrating an intact tracheal contour. Patient-reported outcomes were not systematically collected in this single-case report; future series should include standardized symptom and pain assessment.

Airway monitoring

Observe for subcutaneous emphysema, cough, dyspnea, stridor, fever, or other signs of air leak or infection. Obtain prompt imaging (e.g., neck CT) if any symptoms suggest postoperative air leak or airway compromise.

Wound/drain management

A closed-suction cervical drain is routinely placed. In our institutional pathway, the drain is typically removed on postoperative day 2 if there is no clinical evidence of air leak, infection, or concerning drainage output; removal timing may be adjusted according to local practice and clinical course.

Imaging follow-up

Postoperative neck CT can be used to confirm an intact tracheal contour and absence of residual paratracheal air where clinically indicated (e.g., after diverticulectomy and repair). In the index case, final pathology confirmed papillary thyroid carcinoma in the right thyroid lobe and nodular goiter in the left lobe, with no central lymph node metastasis identified. No postoperative hoarseness, dysphagia, or clinical hypocalcemia occurred. Follow-up neck CT demonstrated an intact tracheal contour without residual paratracheal air or evidence of air leak (Figure 11). Follow-up was conducted in the outpatient clinic, focusing on respiratory symptoms, voice function, and imaging confirmation when clinically indicated.

Figure 11 Postoperative follow-up CT. Neck CT at follow-up demonstrating an intact tracheal contour with no residual paratracheal air collection or stenosis. CT, computed tomography.

Antibiotics and diet

Use perioperative antibiotics and dietary progression based on institutional practice and the extent of airway repair; consider a short antibiotic course if tracheal secretions contaminated the field.

Complication prevention and management

Potential postoperative complications include cervical subcutaneous emphysema/air leak, neck infection, hematoma, and RLN dysfunction. Prevention centers on gentle ventilation (avoiding high peak pressures), meticulous layered closure of the membranous trachea, and secure hemostasis. If an air leak is suspected clinically, promptly obtain imaging (CT) and consider flexible endoscopy/bronchoscopy; institute airway precautions, antibiotics as appropriate, and re-exploration/repair if a persistent leak or clinical deterioration is identified. Post-thyroidectomy hematoma requires emergent airway and wound decompression per standard practice.

Tips and pearls

• Record the proximal cuff-depth reference D_cuff under videolaryngoscopy and the deep protective position D_cuff2 after advancement with bilateral breath sounds confirmed; use D_cuff and D_cuff2 as standardized withdrawal/readvancement boundaries for controlled tube repositioning; keep the cuff distal to D_cuff2 except during the brief visualization/testing maneuvers to minimize the diverticulum’s exposure to positive-pressure effects.
• During ventilation-assisted identification, transition to manual ventilation and deliver slow, gentle breaths; avoid high peak pressures to minimize the risk of rupturing thin diverticular walls.
• After functional visualization/localization, prioritize RLN identification and protection before any traction on the sac or dissection around the diverticular neck/ostium (diverticulum-trachea junction).
• If an inadvertent rupture occurs with subsequent sac collapse, stop dissection, promptly control the rupture site to limit airway secretion spillage and field contamination, then irrigate, regain exposure, and re-establish landmarks before continuing dissection.
• Absence of synchronous expansion during gentle positive-pressure ventilation does not exclude a tracheal diverticulum; interpret the maneuver alongside preoperative CT landmarks and proceed with meticulous anatomic dissection under RLN protection.
• If synchronous expansion is absent, reassess airway conditions and ETT/cuff position within the recorded D_cuff boundary; avoid high peak pressures and repeat the maneuver only when ventilation is stable.

Discussion

Surgical highlights

This technique provides a standardized intraoperative workflow for reliable intraoperative localization and confirmation of a preoperatively identified tracheal diverticulum anticipated within the thyroid surgical field.

Key highlights include: (I) standardized safety boundaries using recorded cuff-depth references (D_cuff/D_cuff2) to define reproducible withdrawal/readvancement limits for controlled ETT repositioning; (II) ventilation-assisted functional visualization via a brief “withdraw-identify-readvance” maneuver to induce synchronous expansion and confirm localization at the CT-predicted region before deep posterior dissection; (III) stepwise risk control with a strict sequence of functional localization first, deliberate RLN identification/skeletonization second, and diverticular mobilization last (a nerve-first strategy to avoid premature traction on a thin-walled sac); and (IV) immediate integrity verification by submerged air-leak testing under gentle manual ventilation prior to wound closure.

Strengths and limitations

The primary strength of this workflow is converting a high-risk, experience-dependent intraoperative event into a controlled and visualized sequence. Functional localization and confirmation of tracheal communication at the critical moment may help avoid inadvertent rupture, loss of sac tension, and operative-field contamination, while supporting deliberate RLN-protected dissection. The method adds minimal direct cost, requires no specialized devices beyond routine anesthesia equipment, and introduces only a brief additional maneuver. Limitations should be acknowledged. First, this report is derived from a single representative case, and larger cohorts are required to define generalizability and safety across variable diverticular anatomy and operative contexts. Second, effectiveness depends on disciplined anesthesia-surgery coordination. Excessive ventilation pressure or uncontrolled ETT movement could theoretically increase airway risk; therefore, the maneuver should be brief, gentle, and bounded by a recorded depth reference and explicit safety boundaries and predefined depth limits (D_cuff/D_cuff2). Third, the workflow is intended for planned management when a diverticulum is identified preoperatively and a compatible tube-depth strategy is feasible; applicability may be limited for unexpected intraoperative findings or settings in which cuff-depth referencing cannot be established. Fourth, patient-reported outcomes were not systematically collected in this single-case report, which limits patient-centered assessment of postoperative recovery. Fifth, flexible bronchoscopy was not used in this index case, and direct bronchoscopic confirmation of the cuff-ostium relationship was therefore not obtained. From a practical perspective, for teams experienced in thyroidectomy and RLN identification, the incremental learning curve mainly involves timing, communication, and maintaining a brief, gentle maneuver rather than adopting new dissection planes.

Comparison with other surgical techniques and research

Conventional thyroidectomy in the presence of a tracheal diverticulum relies predominantly on preoperative CT correlation and intraoperative anatomical landmarks. This approach is often effective when the diverticulum is readily identifiable anatomically, and the tissue planes are clear; however, a non-aerated sac may collapse, and the interface between the diverticular wall and adjacent soft tissue may become poorly demarcated, which can make localization uncertain at the critical moment of dissection. Recent clinical experience has highlighted that tracheal diverticula encountered during thyroidectomy may be vulnerable to inadvertent rupture or misidentification as lymph node tissue, particularly during central compartment dissection (7). Prior reports often emphasize careful dissection around the diverticulum and the RLN, but generally do not provide a functional method to distinguish diverticular tissue from non-airway structures before traction or posterior mobilization (8).

In contrast, the present workflow adds a functional dimension (synchronous expansion under controlled ventilation) to complement anatomical dissection. By facilitating identification before diverticular dissection and mobilization, it helps preserve sac tension, which can be advantageous when establishing safe planes for RLN skeletonization.

Flexible bronchoscopy should also be considered in the peri-intubation management of tracheal diverticulum, particularly when airway-related problems or difficult intubation are anticipated or encountered (9,10). In the index case, the contrast-enhanced CT images were reviewed preoperatively by the surgical, anesthesiology, and radiology teams, consistent with the recognized importance of detailed preoperative assessment and CT-based anatomical evaluation in patients with tracheal diverticulum (3). Based on this multidisciplinary assessment, videolaryngoscopic intubation was considered a reasonable initial approach, and the CT-defined anatomical relationship was used to guide tube positioning; such a CT-based positional strategy is also supported by the reported relationship between tracheal diverticulum anatomy and ETT/cuff positioning (11). In our actual practice, videolaryngoscopic intubation was accomplished uneventfully, and the preoperative CT findings were helpful in guiding tube positioning. On postoperative reflection, however, direct bronchoscopic assistance might have provided more precise confirmation of the relationship between the cuff and the diverticular ostium (12). At the same time, the limitations of flexible bronchoscopy should also be recognized, as the diverticular opening may not always be identified when the communication is very narrow (3,4,7). Therefore, in similar patients, both preoperative CT-based planning and the potential adjunctive role of flexible bronchoscopy should be taken into account during perioperative airway planning.

Implications and actions recommended

This workflow suggests that the planned management of tracheal diverticulum encountered during thyroid surgery may be standardized. Conceptually, it shifts practice from experience-guided, incremental decision-making that occurs in parallel with dissection to a workflow that establishes functional confirmation and explicit safety boundaries before critical posterior dissection steps are undertaken, thereby improving procedural control in appropriately selected cases.

We recommend that in thyroidectomy cases with preoperatively suspected/identified tracheal diverticula—particularly when posterior capsular-plane and/or central compartment dissection is anticipated—teams conduct a structured preoperative briefing with anesthesiology. Recording a cuff-depth reference (D_cuff) during videolaryngoscopic intubation, defining a deep protective position (D_cuff2), and applying these boundaries during a brief, gentle “withdraw-identify-readvance” maneuver may improve intraoperative localization and procedural control. Incorporating a standardized submerged air-leak test under gentle manual ventilation provides immediate verification of tracheal integrity before closure and may reduce avoidable airway morbidity in appropriately selected cases.

Impact and cost considerations

Impact: By making diverticulum localization, RLN-first dissection, and airway integrity verification explicit and reproducible, this workflow may reduce avoidable airway injury, operative-field contamination, and downstream morbidity in selected high-risk cases, while improving intraoperative communication between surgery and anesthesia. Cost: No additional proprietary devices are required beyond routine thyroidectomy instruments and standard anesthesia equipment (videolaryngoscope-guided intubation, ETT, and absorbable sutures). The predominant incremental cost is staff time for structured preoperative briefing and the brief ventilation-assisted maneuver and leak test; therefore, implementation is mainly limited by team coordination rather than capital investment.

Conclusions

In thyroidectomy cases with a preoperatively identified tracheal diverticulum expected within the operative field, a ventilation-assisted functional visualization maneuver to localize the diverticulum, followed by RLN-protected posterior dissection and systematic airway integrity verification, provides a reproducible approach for controlled diverticular management and airway integrity preservation. The same principles may also inform stepwise planning in selected stand-alone transcervical diverticulectomy.

Acknowledgments

AI assistance: the authors used ChatGPT (GPT-5.2, OpenAI) for English-language editing and consistency polishing of the manuscript text. The tool was not used for clinical decision-making, data collection/analysis, or image generation/manipulation. Queries were performed between 14 and 15 January 2026 (GMT+8) using the following prompts (complete list): (I) identify absolute/overly definitive wording in the manuscript and revise to a neutral, evidence-consistent tone without changing meaning; (II) standardize terminology and formatting throughout (e.g., D_cuff/D_cuff2, withdraw-identify-readvance, figure citations, en dashes, parentheses, and style consistency); (III) polish figure legends to match journal conventions and ensure consistency with in-text figure citations; and (IV) renumber references to match first-appearance order and update the reference list accordingly. The authors reviewed and edited all AI-assisted outputs and take full responsibility for the content.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0038/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0038/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0038/coif). W.S. is the Vice Chair of the Thyroid Committee of the Hangzhou Medical Association, Vice Chair of the Thyroid Committee of the Zhejiang Minimally Invasive Oncology Alliance, Executive Council Member of the Hangzhou Anti-Cancer Association, and Vice Chair of the Breast & Thyroid Tumor Committee of the Hangzhou Anti-Cancer Association. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this surgical technique and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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