What is the incision location and step‑by‑step operative technique for the Sistrunk procedure to excise a thyroglossal‑duct cyst in a child or young adult with a midline neck mass and normal thyroid function?

Sistrunk Procedure: Incision and Operative Technique

The Sistrunk procedure involves a transverse incision over the thyroglossal duct cyst in the midline neck, followed by excision of the cyst, the central portion of the hyoid bone (approximately 10 mm), and a core of tissue extending superiorly to the foramen cecum at the base of the tongue. 1, 2

Preoperative Preparation

• Position the patient supine with neck extended to ensure complete exposure of the anterior neck 3
• Administer local anesthesia with 1-2% lidocaine, with consideration for systemic sedation in patients with reduced pain tolerance 3
• Document normal thyroid anatomy preoperatively using ultrasound imaging, as concomitant thyroid agenesis (though extremely rare) must be excluded 4, 1

Incision Location

• Make a transverse incision in the midline of the anterior neck directly over the palpable thyroglossal duct cyst 1, 5
• The incision should be positioned to allow adequate exposure of the cyst and hyoid bone
• For cosmetically-conscious patients, alternative approaches such as bilateral areolar endoscopic technique have been described, though this requires specialized equipment and expertise 6

Step-by-Step Operative Technique

Step 1: Exposure and Cyst Identification

• Incise skin and subcutaneous tissues transversely to expose the cyst 2
• Identify and mobilize the thyroglossal duct cyst from surrounding tissues 1
• The cyst characteristically moves with tongue protrusion and swallowing 1, 5

Step 2: Hyoid Bone Resection

• Expose the central portion of the hyoid bone 2, 7
• Excise approximately 10 mm of the central body of the hyoid bone 2
• This step is critical—simple cyst excision without hyoid resection results in recurrence rates of approximately 33%, whereas the Sistrunk technique reduces recurrence to 3-5% 4, 7

Step 3: Suprahyoid Dissection

• Dissect a core of tissue in the suprahyoid region extending from the hyoid bone superiorly toward the base of the tongue 2
• Continue dissection to the foramen cecum at the base of the tongue, removing all thyroglossal duct remnants along this tract 1, 2
• This suprahyoid dissection is the defining feature of the Sistrunk operation and distinguishes it from inadequate procedures 7

Step 4: Specimen Removal and Closure

• Remove the specimen en bloc (cyst, hyoid bone segment, and suprahyoid tissue core) 2
• Achieve hemostasis (average blood loss is approximately 35 mL) 6
• Close the wound in layers 2

Critical Technical Points

• The Sistrunk operation remains the gold standard with the lowest recurrence rate (3-5%) compared to simple excision (33% recurrence) 4, 7
• Complete excision of the tract to the foramen cecum is essential—incomplete removal of thyroglossal duct remnants is the primary cause of recurrence 1, 7
• Resection of the central hyoid bone must be performed routinely, not selectively 7

Common Pitfalls to Avoid

• Never perform simple cyst excision alone—this results in unacceptably high recurrence rates 7
• Do not omit hyoid bone resection—consensus exists that this step must be performed routinely 7
• Ensure adequate suprahyoid dissection—variations in this step account for differences in recurrence rates between surgeons 7
• Consider fine needle aspiration preoperatively if malignancy is suspected (firm, fixed mass with rapid growth), as 4% of cases may harbor carcinoma 4, 5

Postoperative Management

• Average hospital stay is 2-3 days 2, 6
• No blood transfusion is typically required 2
• Postoperative imaging follow-up is not required if clinical evolution is favorable, but ultrasound or CT with contrast may be indicated if recurrence is suspected 4
• Monitor for complications including bleeding, localized swelling, and hoarseness, though significant morbidity is rare with experienced surgeons 3, 2