Thyroidectomy

1. Thyroidectomy KaidyWaterman & Derek Woodruff

2. The thyroid • The thyroid sits anteriorly to the trachea and the esophagus • Contains two types of hormone-producing cells • Follicular Cells: produce thyroxine and triiodothyronine • Parafollicular Cells: produce calcitonin • The adult thyroid weighs anywhere from 12 to 25 grams • “H” shaped • The organ shrinks as you age • Two lobes

3. The parathyroids • Range from 2 to 6 • Small, flat, oval structures that lie on the dorsal side of the thyroid gland • Produce parathormone which maintains the normal relationship between blood and skeletal calcium • Removal of these glands would result in tetany and death • Care must be taken not to damage these glands during a thyroidectomy

4. Pathophysiology of the thyroid and parathyroids • Hyperthyroidism (thyrotoxicosis): when the thyroid gland produces too much thyroxine hormone • Symptoms: nervousness, tachycardia, sweating, tremors, arrhythmias, hair loss, and dyspnea • Thyroid Carcinoma: cancer of the thyroid • Symptoms: hoarseness, may show signs of hyper- or hypothyroidism depending on tumor type, may be asymptomatic • Hyperparathyroidism: when the parathyroid glands produce an excess of parathyroid hormone • Symptoms: asymptomatic in early stages, skeletal damage • Hypoparathyroidism: parathyroid glands don’t produce enough parathyroid hormone • Symptoms: anxiety, depression, brittle nails, dry skin, thin hair, tetany (a severe complication)

5. Diagnostic exams and preoperative testing • Patient history and physical • Ultrasound • Laryngoscopy • Biopsy • Scans • Serum levels of TSH

6. Anesthesia and positioning • Anesthesia is general • The patient is positioned in the supine position with neck extended

7. Skin Prep, draping, and incision • Skin is prepped from the point of the chin down to the mid-chest of the patient and laterally as far as possible • Wadded absorptive towels are placed bilaterally and the thyroid sheet is used • The incision is symmetrical and transverse following the Langer lines over the thyroid. The size of incision varies, it is generally done two fingerbreadths above the clavicular head.

8. Supplies, equipment and instruments • Basic set, prep set, #10 and #15 blades, sutures, dressings, Bovie, basin set • Thyroid drapes and ¼” Penrose drain • Suction, ESU, roll or thyroid rest for extending the neck • Thyroidectomy set, bipolar forceps with cord, liga clip appliers and clips

9. Special considerations • Great care must be taken to ensure that the parathyroid glands are spared and protected • A Queen Anne’s dressing or thyroid collar may be used along with the drain

10. The procedure

11. Step one Operative procedure Technical considerations Hemostasis will be secured as the procedure progresses Usually via Bovie May clamp and tie some vessels May use ligating clips • The incision is made and extended through the subcutaneous tissues and the platysma muscle. • Superior and inferior flaps are mobilized and retractors are placed

12. Step two Operative procedure Technical considerations Keep fresh, dry sponges available, mosquito hemostats may be used Ligation may require the use of small right angle clamps and ligature on a passer • The strap muscles are separated and the thyroid lobe is exposed. The middle thyroid vein is exposed, divided, and ligated • Vessels are identified, divided and ligated (laryngeal nerves and superior vessels must be identified)

13. Step three Operative procedure Technical considerations Keep two clamps, scissors, and ties ready • Parathyroid glands, inferior thyroid artery and recurrent laryngeal nerve are identified. • Parathyroid glands are mobilized and vascular supply is preserved

14. Step four Operative procedure Technical considerations May alternate between sharp dissection, blunt dissection and ESU • Branches of the inferior thyroid artery are divided and ligated. The superior connective tissue is divided. Hemostasis is achieved with ESU. (Recurrent nerve must be spared)

15. Step five Operative procedure Technical considerations If only one lobe is taken, the isthmus is divided so that it is removed with resected lobe as is the pyramidal lobe. • The thyroid is dissected from the trachea.

16. Step six Operative procedure Technical considerations Sequence is irrigation, placement of wound drain, and closure. Initiate count. • Hemostasis is achieved after lobe or lobes are removed, a drain may be placed. The wound is closed.

17. Postoperative considerations

18. Postop considerations • Immediate postoperative care: • Check voice as soon as possible • Transport to PACU • Tracheotomy tray available • Prognosis • Return to normal activities • Medications usually required for life • Complications: • Hemorrhage • Wound Infection • Damage to nearby structures

19. Pearl of wisdom Maintain the integrity of the sterile field until the patient is extubated, breathing freely, and has been transported to the PACU. Emergency tracheotomy is a possibility.