thyroidectomy by loope magnification

1. Total thyroidectomy by loupe magnification: By Gouda Ellabban Professor of surgery SCU, egypt

2. Kocher • 1909 Nobel Prize for Medicine for his works in Physiology, Pathology and Surgery of the Thyroid gland

3. Total thyroidectomy has been accepted as current surgical therapy for benign and malignant thyroidal disorders but extensive resection might increase the risk of postoperative complications . Recurrent laryngeal nerve (RLN) dysfunction and hypoparathyroidism . • Complication rates of thyroidectomy have a varying range for both RLN injury (0–14%) and permanent hypoparathyroidism (1–11%) . • Intensive effort should be spent to prevent recurrent laryngeal nerve injury and hypoparathyroidism,

4. The surgical technique is one of the important factors affecting the outcome of thyroidectomy . • Other factors as the primary thyroid disease, weight of dissected tissue, etc . • In the past, most surgeons avoided dissections in close proximity to the recurrent laryngeal nerve (RLN) to prevent its injury. • The identification and preservation of the RLN together with meticulous hemostasis and delicate technique are required to prevent nerve injury. Once found, the nerve with all the identified branches must be followed superiorly through the entire course, until it enters the larynx .

5. The use of a loupe for operative field magnification could : • improve the outcome of total thyroidectomy in comparison with conventional technique with regard to identification of both the recurrent laryngeal and superior laryngeal nerves and the parathyroids. Aim of the work

6. Patients in this study were divided randomly into two main groups A and B. Group A Group B Patients and methods patients were subjected to total thyroidectomy by loupe magnification were subjected to conventional total thyroidectomy

7. The total number was 242 patients: • 121 for each group, their ages ranged between 19 and 52 years. • The study started from January 2005 to November 2007 • the study included all patients having bilateral benign multinodular goiter (BMNG)

8. All patients of both sexes diagnosed as benign multinodular goiter with no previous neck surgery or radiation therapy were subjected to total thyroidectomy either by loupe magnification or without. • The indications of surgery in the present study were compression symptoms and huge neck swelling. Inclusion criteria

9. Preoperative workup • The status of vocal cords of patients was checked preoperatively by direct rigid laryngoscope. • All patients were subjected to laryngoscopic evaluation to demonstrate the cord status during maximum phonation and maximum inspiration (full adduction and full abduction) to ensure intact both SLN and RLN.

10. The preparation for surgical treatment of the patients included the following investigations: • neck ultrasound • determination of free T3, free T4 • thyroid stimulating hormone and serum calcium concentration, and fine-needle aspiration cytology.

11. Instruments used • Simple binocular loupe with 2.5 magnification and small non-microsurgical instruments were used in all operations. • Rigid laryngeal endoscope (Storz 70 with video monitor) was used for laryngoscopic evaluation.

12. Showing the superior thyroid artery identified and dissected meticulously as close to the thyroid capsule as possible to avoid damaging the superior laryngeal nerve

13. Showing the external branch of the superior laryngeal nerveidentified and preserved

14. Showing two of the parathyroid glands were identified and preserved

15. Showing branches of the inferior thyroid artery entering the thyroid (a) only were cut between ligatures (b) to preserve the blood supply of the parathyroids

16. Results

17. Sex distribution of both groups

18. Incidence of injury of both recurrent laryngeal and superior laryngeal nerves in both groups

19. Incidence of injury of both permanent and transient hypoparathyroidism in both groups

20. Total thyroidectomy by loupe magnification is feasible, improves the outcome and should be done by experienced surgeon. • Great care should be taken in patients undergoing total thyroidectomy to preserve the recurrent laryngeal nerves and parathyroid glands. Conclusion

21. Thank you G. ELLABBAN ellabbang@yahoo.com