What is the operative technique for a Sistrunk procedure?

Sistrunk Procedure: Operative Technique

The Sistrunk procedure involves en bloc resection of the thyroglossal duct cyst, the central portion of the hyoid bone body, and a core of deep tongue musculature extending to the foramen cecum, which reduces recurrence rates from approximately 50% to 3-5%. 1, 2

Patient Positioning and Incision

• Position the patient supine with neck extension using a shoulder roll 1
• Make a transverse cervical incision in a natural skin crease overlying the cyst, typically in the midline of the anterior neck 1, 2
• The incision should be centered over the palpable mass, usually adjacent to the hyoid bone 2

Dissection and Cyst Mobilization

• Develop subplatysmal flaps superiorly and inferiorly to expose the operative field 1
• Identify and carefully dissect the cyst from surrounding structures, avoiding rupture during mobilization 2
• Trace the cyst tract superiorly toward the hyoid bone, as the tract typically passes through or adjacent to this structure 1, 2

Hyoid Bone Resection

• Resect the central portion (body) of the hyoid bone—this step is mandatory and non-negotiable to prevent recurrence 1, 2, 3
• Remove approximately 1-2 cm of the central hyoid bone body using bone-cutting instruments 1
• Preserve the lateral greater horns of the hyoid to maintain structural integrity 1

Suprahyoid Dissection to Foramen Cecum

• Continue dissection superiorly through the hyoid defect into the tongue base musculature 1, 2
• Remove a central core of deep tongue musculature (geniohyoid and genioglossus muscles) extending to the foramen cecum at the base of tongue 1
• This core tissue removal addresses the embryologic tract and multiple potential duct pathways 2
• Ligate or cauterize the tract at the foramen cecum level 1

Closure

• Achieve meticulous hemostasis throughout the operative field 1
• Place a small drain if significant dead space remains 1
• Close the wound in layers: reapproximate strap muscles, close platysma, then skin 1

Critical Technical Points to Prevent Recurrence

• Avoid operating during active inflammation or infection—this significantly increases recurrence risk 2
• Prevent cyst rupture during dissection, as spillage of cyst contents increases recurrence rates 2
• Ensure complete resection of the hyoid bone body—incomplete hyoid resection is a primary cause of treatment failure 2, 3
• Extend dissection adequately into tongue base to the foramen cecum—inadequate superior dissection leaves residual tract tissue 1, 2

Alternative Approaches for Selected Patients

• Endoscopic techniques via bilateral areolar approach or transoral vestibular approach (TEVAS) are emerging alternatives that eliminate visible neck scarring 4, 5
• These require specialized laparoscopic equipment and expertise, with operative times averaging 88 minutes 4
• The fundamental steps of cyst removal, hyoid resection, and tongue base core excision remain identical regardless of approach 4, 5
• Reserve these techniques for motivated patients seeking optimal cosmetic outcomes in centers with appropriate expertise 5

Expected Outcomes

• Recurrence rate with proper Sistrunk technique: 3-5% 1, 2
• Recurrence rate with simple cyst excision alone: approximately 50% 1, 3
• The Sistrunk operation remains the gold standard with the lowest recurrence rates when performed correctly 3