Thyroidectomy

thyroidectomy

1. THYROIDECTOMY DR BASHIR YUNUS SURGERY RESIDENT AKTH 02-May-15 [email protected] 1

2. OUTLINE DEFINITION INDICATIONS TYPES PRE-OP PREPARATION ANAESTHESIA POSITION PROCEDURE CLOSURE POSTOP MGT COMPLICATIONS 02-May-15 [email protected] 2

3. DEFINITION Thyroidectomy is the surgical removal of all or part of the thyroid gland. INDICATIONS Toxic multinodular goiter; does not respond well to antithyroid drugs or radio-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 prolong therapy Failure of patient to take drugs regularly or follow-up Complications during drug therapy Relapse after previous drug therapy Exophthalmus Cosmesis 02-May-15 [email protected] 3

4. Contraindications Recurrent thyrotoxicosis after subtotal thyroidectomy Thyrotoxicosis without a palpable thyroid Drug goiter Thyrocardia Children 02-May-15 [email protected] 4

5. TYPES OF THYROIDECTOMY Hemithyroidectomy Subtotal thyroidectomy Total thyroidectomy Near total thyroidectomy Isthmusectomy 02-May-15 [email protected] 5

6. PRE-OP PREPARATION TFT- T3,T4 and TSH High resolution USS FNAC Indirect laryngoscopy Serum calcium level is obtained because hyperparathyroidism may coexist. GXM 2pint 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; 2weks pre-operatively to reduce the vascularity of the gland Informed consent is obtained 02-May-15 [email protected] 6

7. ANAESTHESIA Anaesthesia is general with cuffed endotracheal tube 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 prepped 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, the stands on the opposite side to be operated upon(usually the larger gland first) 02-May-15 [email protected] 7

8. INCISION Site of incision is indented with suture A transverse skin crease incision is placed 2-3cm above the sternal notch about 8cm long extending to the lateral borders of sternocleidomastoid. The scapel (with size 15 blade) is slanted to divide the skin and platysma at different level to give a neater scar Hemostasis is controlled with electrocautary or prior infiltration with lidocaine and adrenaline 02-May-15 [email protected] 8

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10. PROCEDURE Elevate the flap of skin with the platysma (the assistant lifts the skin and the platysma upward with double skin hooks to allow for the creation of a subplatysmal flap). Superiorly to the thyroid cartilage Inferiorly to the suprasternal notche Place Joll’s retractor to retract the skin flaps This procedure should be blood free, because the superficial veins lie beneath the cervical fascia. Divide the deep cervical fascia longitudinally in the midline, between the anterior jugular veins. At the lower part there is usually a transverse cervical vein that needs to be clamped, divided, and ligated with 3-0 silk sutures 02-May-15 [email protected] 10

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13. The strap muscles ( sternohyoid , and deeper sternothyroid ) are carefully separated to allow their retraction laterally. Assess goiter; The loose areolar tissue(capsule) overlying the thyroid gland is divided with electrocautery . After the anterior surface of the thyroid has been thoroughly exposed, the entire gland is carefully explored and palpated . The strap muscles are firmly retracted with a small loop retractor while the thyroid gland is drawn medially Ligate and divide in continuity Middle thyroid vein Superior thyroid vessels close to the gland(to avoid injury to the external laryngeal nerve) between two proximal and one distal ligature. The recurrent laryngeal nerve and the parathyroids are identified and preserved then the terminal branches inferior thyroid artery are ligated and divided close to the capsule. Or the inferior thyroid artery is identified far away from the gland ligated in continuity to avoid injury to the recurrent laryngeal nerve. 02-May-15 [email protected] 13

14. The thyroid is then mobilized and removed; Divide isthmus and place hemostats around margin of resection (run with interlocking 3-0 absorbable suture) leaving about 4g of thyroid from each lobe for subtotal If a total thyroidectomy is being performed, the remaining lobe is removed in a similar fashion, with division of the middle thyroid vein, identification of the recurrent laryngeal nerve and parathyroid glands, and ligation and division of the superior pole and branches of the inferior thyroid vessels . 02-May-15 [email protected] 14

15. CLOSURE Absolute haemostasis 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 02-May-15 [email protected] 15

16. 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 hypocalcamia Keep semi-recumbent Review indirect laryngoscopy(especially if there is cord impairment on extubation ) Serum calcium regularly in the postoperative period Thyroid function tests at 6weeks postoperatively Remove Drain when dry, 24-48hours postoperatively Sutures/clips, 2-3days postoperatively 02-May-15 [email protected] 16

17. COMPLICATIONS EARLY Haemorrhage Tetany In first 3 days from corrected thyrotoxicosis After 1 week with hypoparathyroidism Recurrent laryngeal nerve palsy 95% neurapraxia and resolves If bilateral, cord adduct to midline so needs immediate reintubation Thyroid crisis, if throtoxic patient is inadequately prepared rare with modern technique Wound infection LATE Keloid Hypothroidism - 20% Recurrent thyrotoxicosis- <5% of patients undergoing thyroidectomy for grave disease 02-May-15 [email protected] 17

18. QUESTIONS What is the blood supply to the thyroid gland What are the preoperative measures prior to thyroidectomy for thyrotoxicosis What are the types of thyroidectomy Outline the steps of thyroidectomy What are the complications of thyroidectomy What does the recurrent laryngeal nerve supply and what is the consequence of it division What does external laryngeal nerve supplies and what is the consequences of it division What is the Simon’s triangle 02-May-15 [email protected] 18

19. REFERENCES Graeme J. Poston; Principles of operative surgery. 2 nd edition 1996 Vijay P Khatri, Juan A Asensio ; Operative surgery Manual. 1 st edition 2003 Farquharson’s textbook of operative general surgery. 8 th edition 1995 Operative surgery Viva for MRCS Mahmud Sakr . www.slideshare .net 02-May-15 [email protected] 19