3) Thyroidectomy with all associated notes.pptx

Notes

1. THYROIDECTOMY

2. Thyroid Gland. The thyroid gland is a butterfly-shaped organ composed of two cone-like lobes or wings connected via the isthmus . The gland regulates metabolism by secreting hormones . When diseases affect the thyroid, its size or activity may become abnormal

3. What Does Your Thyroid Gland Do for You?

4. Functions of thyroid gland Produces Two Hormones Called • Thyroxine (T4) • Thyronine (T3 ) (trio iodol thyronine) • Regulates Metabolism to enable Cells Function Properly Affects Every Cell in the Body

5. Goitre Enlargement Of The Thyroid Gland (Local Or Diffuse) Based On Hyperplasia Or Degeneration.

6. Classification Diffuse Goitre. Multi-Nodular Goitre. Solitary Thyroid Nodule.

7. Diffuse Goitre More Commonly Non-Toxic. May be Toxic .

8. Diffuse Non-Toxic Goitre Compensatory Hypertrophy & Hyperplasia due to Decrease in T3 & T4. Diffusely Involves Whole Gland. Not Associated With Hypo OR Hyperthyroidism .

9. Multi-Nodular Goitre Progression from Diffuse Simple Goitre. Up to 2 kg. Multinodular Focal Hyperplasia. Mostly Euthyroid .

10. Solitary Thyroid Nodule 5% of Adult Population. 50 % True Solitary. 80 % are Adenomas. 10 % Carcinomas. 10 % Cyst / Fibrosis / Thyroiditis.

11. Causes of goiter 1) Physiological Goitre: Puberty OR Pregnancy. 2) Dietary Iodine Deficiency: In a reas f ar f rom s ea . 3) Dietary Goitrous Agents: Cabbage & Turnips. Calcium or Fluoride in water. Lithium , Phenylbutazone, Thiouracil, Carbimazole. 4) Hereditary . 5) Treated Graves’ Disease.

12. Rare Causes: Lymphoma . Anaplastic . Thyroiditis ( Autoimmune).

13. Treatment Small : No Treatment. Reassurance . Iodine Support . Large/Pressure Symptoms OR Cosmetic management is by surgery.

14. THYROIDECTOMY

15. Definition A thyroidectomy is an operation that involves the surgical removal of the whole or part of the thyroid gland. A thyroidectomy is traditionally a minimal invasive surgery performed through a small horizontal incision in the front of the neck.

16. INDICATIONS Toxic multinodular goiter; does not respond well to antithyroid drugs or radio-active iodine Toxic solitary nodule; it may be neoplastic Malignant goiter Presence of pressure symptoms Large goiter; does not respond to drugs and relapse is likely Male patient; likely have relapse after prolonged therapy Failure of patient to take drugs regularly or follow-up Complications during drug therapy Relapse after previous drug therapy Exophthalmus Cosmetic

17. Contraindications Recurrent thyrotoxicosis after subtotal thyroidectomy Thyrotoxicosis without a palpable thyroid Drug induced goiter Children

18. TYPES OF THYROIDECTOMY Hemi thyroidectomy Subtotal thyroidectomy Total thyroidectomy Near total thyroidectomy Isthmusectomy

19. Types of thyroidectomy: Sub-total : A bout 8gms , or a tissue, size of pulp of finger is retained on lower pole on both sides and rest is removed. Commonly done in toxic thyroid, multinodular goiter. Total : E ntire gland is removed. Done in malignancy.

20. Near-total: both lobes except the lower pole which is very close to recurrent laryngeal nerve and parathyroid is removed. Here <2gm of tissue is left behind . Hemi: along with removal of one lobe, entire isthmus is removed. Done in benign disease of only one lobe, thyroid cyst, solitary nodule.

21. PRE-OP PREPARATION Preoperative investigations: Thyroid function tests (TFT) especially T3,T4 and TSH levels in blood High resolution USS Laryngoscopy Serum calcium level is obtained because hyperparathyroidism may coexist . Thyroid antibodies

22. Book atleast 2nits of blood Thyrotoxic patient are rendered euthyroid; Carbimazole 10-15mg 8hourly, when patient become euthyroid ( in about 4weeks) they are maintained on 5-10mg Propranolol 80mg 6hourly 4-7days before operation. Symptoms and signs are usually controlled within 24hours. Continued 8-10days post op Lugol’s iodine; 2weeks pre-operatively to reduce the vascularity of the gland Informed consent is obtained

23. ANAESTHESIA • Anaesthesia is general with cuffed endotracheal tube

24. POSITION • Patient is placed in a supine position initially with the neck extended by placing a ring beneath the head and a sandbag roll beneath the shoulder. • The table is tilted 20–30 degrees “head up” to aid in emptying the neck veins. • The skin is prepared from the chin to the upper thorax • Drapes are applied; head scarf, sides of the neck, chest- abd , large covering the legs. The are secured with clips • Surgeon and assistant scrub and gown, they stand on the opposite side of the patient to be operated upon(usually the larger gland first)

25. T able is tilted 20–30 degrees “head up”

26. During the procedure

27. During the procedure

28. NB. During surgery; Extent of the resection depends on: ◦ The size of the gland ◦ The age of the patient ◦ Experience of the surgeon ◦ The need to minimise the risk of recurrent toxicity ◦ And, wish to avoid postoperative thyroid replacement .

29. During closure E nsure absolute haemostasis is achieved Suction drain to thyroid bed (beneath the strap muscles) Close loosely in layers with absorbable sutures Close the skin with sutures or clips Check vocal cords on extubation by direct laryngoscopy

30. POST OPERATIVE MGT Half-hourly observation until conscious At the bed side Michel clip remover in case of respiratory distress due to hematoma 10ml of 10% calcium gluconate in case of acute hypocalcemia Keep semi-recumbent Review indirect laryngoscopy(especially if there is cord impairment on extubation)

31. post op con’t Check serum calcium regularly in the postoperative period Check thyroid function tests at 6weeks postoperatively Remove Drain when dry, 24-48hours postoperatively Sutures/clips , 2-3days postoperatively

32. COMPLICATIONS EARLY Haemorrhage Recurrent laryngeal nerve palsy Respiratory obstruction Thyroid insufficiency Parathyroid insufficiency Thyroid crisis, if thyrotoxic patient is inadequately prepared; rare with modern technique Wound infection

33. LATE COMPLICATION Keloid (Hypertrophic scar) Hypothyroidism- 20% Recurrent thyrotoxicosis- <5% of patients undergoing thyroidectomy for grave disease Stitch granuloma.

34. Haemorrhage Tension haematoma deep to cervical fascia occurs due to reactionary haemorrhage Requires urgent decompression by opening the layers of the wound. Sub cutaneous haematoma require evacuation in the following 48hrs

35. Respiratory obstruction: Mostly due to laryngeal oedema. Other causes: trachea malacia and trauma peri operatively . Try releasing tension haematoma and if it still persists an intubation should be done and kept for several days. Give steroids to reduce oedema. If necessary, tracheostomy.

36. Right laryngeal nerve (RLN) palsy and voice change: May be Unilateral or Bilateral. Injury to ext. branch of superior LN is more common and leads to loss of tension in the vocal cord with diminished power and range in the voice. Can be detected by postoperative laryngoscopy .

37. Thyroid insufficiency: Occurs within two years following subtotal thyroidectomy . This results from a change in the autoimmune response from stimulation to destruction of thyroid cells . Parathyroid insufficiency: This is due to removal of parathyroid glands or infarction.

38. Thyrotoxic crisis: Acute exacerbation of hyperthyroidism due to inadequate preoperative preparation. Administration of iv fluids, cooling the patient with ice packs , O2 administration, Administer diuretics , digoxin, sedation and iv hydrocortisone. Specific Rx: Carbimazole 10-20mg 6hrly ; Lugol's iodine 10 drops 8hrly ; propranolol 1-2mg iv.

39. Wound infection: cellulitis- antibiotics; abscess drained. Hypertrophic or keloid scar: intradermal injection of corticosteroid once monthly . Stitch granuloma: due to non absorbable suture material .

40. NURSING CARE PLAN FOR A PATIENT DONE THYOIDECTOMY Nursing dx Acute Pain RT Surgical manipulation of tissues/muscles, Postoperative edema AEB Reports of pain, guarding behavior, restlessness. Risk for Impaired Airway Clearance RT Tracheal obstruction, swelling, bleeding, laryngeal spasms. Impaired Verbal Communication RT Vocal cord injury/laryngeal nerve damage, Tissue edema, pain/discomfort AEB Impaired articulation, does not/cannot speak; use of nonverbal cues such as gestures Risk for Injury Deficient Knowledge