Chapter 13
Thyroid Surgical Diseases
Reynaldo O. Joson, MD
1986
Thyroidectomy – How I Do It
1.0 Preoperative Considerations
1.1 Benign or malignant neoplasm
1.2 Size of tumor
1.3 Possibility of neck dissection
2.0 Position
2.1 Supine position with neck hyper-extended using a shoulder pad
2.2 Face positioned at a midline axis with chin in line with the sternal notch
3.0 Prepping
3.1 Antiseptic prepping of the anterior and lateral aspects of the neck extending to the chin and lower jaw superiorly and to the nipple line inferiorly
4.0 Draping
4.1 Double head-drape
4.1.1 Two towels, one on top of the other, laid behind the head and neck
4.1.2 Top towel used to wrap around the face and secured at chin level
4.2 Four towels enclosing the neck and the planned incision
4.2.1 One on each side
4.2.2 One at the level of the chin
4.2.3 One just below the clavicles
4.3 Usual large sheet and lap sheet draping
5.0 Incision
5.1 Level
5.1.1 About 2 cm above the sternoclavicular joints
5.1.2 On a skin crease just above the clavicle
5.2 Length
5.2.1 Influenced by size and nature of tumor
5.2.2 Usually from lateral border of one sternocleidomastoid muscle to the other
5.2.3 May be extended upward along the posterior border of the sternocleidomastoid muscle to the mastoid are in case of concomitant neck dissection
5.3 Perpendicularly cut wound edges
5.4 Points of emphasis: adequate incision and resultant symmetrical, fine postoperative incisional scar
6.0 Flaps
6.1 Subplatysmal flaps, superior and inferior
6.2 Superior flap developed up to the level of thyroid notch
6.3 Stabilization of flaps by suturing to drapes for constant exposure
7.0 Strap muscles
7.1 Split along vertical midline between the 2 pairs of strap muscles starting from below going up. It is easier to look for the midline just above the sterna notch. The 2 pairs of muscles diverge at this area.
7.2 Retract strap muscles laterally to expose the thyroid gland
7.3 If strap muscles need to be transacted for better exposure, do so at the upper third to avoid injury to the motor nerve supply
8.0 Assessment of the thyroid gland and pathology
8.1 Exploration of the whole thyroid gland and adjacent tissues by palpation and inspection
8.2 Intraoperative evaluation of the nature and extent of tumor
8.3 Determination of extent of resection
9.0 Mobilization and resection of thyroid gland
9.1 Depends on contemplated area and extent of resection
9.2 Usually, start from the inferior pole, then identify the position of the recurrent laryngeal nerve and the parathyroid(s) from the lateral lower part of the thyroid gland along the trachea-esophageal groove, then proceed to the superior pole
9.3 Large and medium sized vessels are ligated after transaction using non-absorbable sutures (3-0, 4-0, or 5-0); small sutures can be cauterized.
9.4 The recurrent laryngeal nerves, the superior laryngeal nerves, and at least one parathyroid on each side are identified and preserved as much as possible.
9.5 After mobilization of the inferior pole and the lateral aspect of the thyroid gland, the gland is retracted medially. The tracheo-esophageal groove is identified by palpation. The recurrent laryngeal nerve is located along the groove by creating small openings on the fibroareolar tissues adjacent to the inferior thyroid artery. Care should be taken not to lacerate the blood vessles and compromise the parathyroids nearby. The nerve is identified through these openings and its position noted. Do not traumatize the nerve by pinching it with a forcep. Keep a distance away from the nerve during dissection unless a compartmental dissection for malignancy is to be performed.
9.6 For near-total lobectomy, the tissues anterior to and adjacent to the inferior thyroid artery and the parathyroid(s) are selected for preservation. This holds true for subtotal lobectomy unless this area is grossly diseased. In such a situation, the superior pole is selected for preservation, if possible.
9.7 For total thyroidectomy, ensure viability of the parathyroids by preserving their blood supply. Use sharp knife to separate thyroid tissues from the tracheal fascia.
10.0 Hemostasis
10.1 Cautery
10.2 Fine non-absorbable sutures
10.3 Bleeding raw edges of a thyroid remnant after a subtotal lobectomy or subtotal thyroidectomy may be controlled with a running chromic 4-0 suture
11.0 Drain
11.1 Not routinely placed unless indicated
11.2 If required, provide wide skin opening from drain to ensure adequate drainage
12.0Wound closure
12.1 Strap muscle apposed at midline (absorbable sutures)
12.2 Wound closed in 2 layers
12.3 Platysmal – subcutaneous approximation (absorbable suture – Dexon or Vicryl 4-0 or 5-0)
12.4 Skin approximation (non-absorbable suture – silk or nylon 5-0 or 6-0)
13.0 Dressing
13.1Light dressing
14.0 Suture removal
14.1 2 to 3 days postop
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