Thyroidectomy for Nursing Students

Lecture deivered to nursing students in Victoria Hospital, Seyclelles in 2005

1. Thyroidectomy
Dr Sanjoy Sanyal
Consultant Surgeon
Victoria Hospital, Ministry of Health, Seychelles
2005
Lecture for nursing students, Victoria Hospital, MOH, Seychelles 2005

2. Thyroid gland surgical anatomy
•Location: Thyroid is situated in the neck
in relation to 2
nd
3
rd
and 4
th
tracheal rings
•Two lobes: Right and left, joined by an
‘isthmus’
•Arteries: Supplied by superior and inferior
thyroid arteries
•Veins: Drained by superior, middle and
inferior thyroid veins

4. Surgical anatomy – cont’d
•Important nerves in relation to thyroid
–External laryngeal nerve: Close to
superior pole of thyroid.
•Injury produces voice weakness
–Recurrent laryngeal nerve: Related to
lower pole of gland as it runs upwards in
the tracheo-esophageal groove.
•Injury produces vocal cord paralysis.

5. Surgical anatomy – cont’d
•From superficial to deep:
–Skin
–Platysma (a muscle in superficial fascia
of neck)
–Investing layer of deep cervical fascia
–Pre-tracheal layer of deep cervical
fascia
–Strap muscles of neck (thin flat
muscles)

6. Thyroidectomy – Indications
•Goitre (any non-neoplastic swelling of the
thyroid gland is classified as a goitre)
–Single swelling (Solitary nodular goitre)
–Multiple swellings (Multi-nodular goitre)
•Carcinoma
–Follicular carcinoma
–Papillary carcinoma
–Rare varieties

7. Thyroidectomy – Types
•Hemi-thyroidectomy: Removal of half of
thyroid gland (Hemi = Half)
•Lobectomy: Removal of either right of left
lobe of thyroid gland
Both these are done in solitary goitre
•Total thyroidectomy: Removal of whole
thyroid gland
This is done in cases of malignancy

8. Thyroidectomy types – cont’d
•Subtotal thyroidectomy: Removal of a
little less than total; done in multi-nodular
goitre
•Near-total thyroidectomy: Almost same
as total, but a little thyroid tissue around
one parathyroid gland is preserved
•Isthmusectomy: Dividing the isthmus

9. Pre-operative investigations
•Full blood count (CBC)
•Serum Urea, Electrolytes, Creatinine
•Thyroid Profile: T3, T4, TSH
•Ultrasound thyroid gland
•Radio-iodine (
99m
Tc /
131
I) scan of thyroid

10. Pre-operative investigations
•X-ray neck
•X-ray chest
–(Both AP / lateral)
•Fine Needle Aspiration Cytology (FNAC)
of thyroid nodule, if any palpable
•Indirect laryngoscopy to assess pre-
operative function of both vocal cords.

11. INFORMED CONSENT FOR
THE SURGERY IS
ESSENTIAL

12. Thyroidectomy Steps 1 – The
preliminaries
•Position of patient:
–Supine position,
–Neck slightly extended,
–Sand bag under shoulder
–Foot end slightly down

13. Thyroidectomy Steps 1 – The
preliminaries
•Preparing the part:
–The entire front of neck, from jaw line to
nipples, is cleaned with Cholorhexidine,
surgical spirit and Betadine.

14. Thyroidectomy Steps 1 – The
preliminaries
•Draping:
–Sterile sheets are draped above, below
and on either sides of neck, keeping
only neck portion visible.
–Some surgeons cover this area with
self-adhesive Opsite to enhance
sterility.

15. Thyroidectomy Steps 2–
Incision and raising flaps
•Incision:
–Size 22 blade on Bard-Parker handle
–Curvilinear skin incision along neck
crease, from one sterno-mastoid to
other, 1.5 cm above manubrium notch
–Incision is deepened through skin,
subcutaneous tissue, superficial fascia
and platysma

16. Thyroidectomy Steps 2–
Incision and raising flaps
•Skin flaps:
–Two skin flaps raised; one above and
below.
–Held in place with Joll’s retractor.
•Strict haemostasis (control of bleeding)
–Essential during entire procedure
–Achieved by coagulating diathermy and/
or ligation using 2-0 Vicryl sutures.

17. Thyroidectomy steps 3 –
Exposing the gland
•Investing deep cervical fascia is split open
•Strap muscles of neck divided between
clamps
•This exposes the thyroid gland enclosed in
pre-tracheal layer of deep cervical fascia.
•This layer of fascia is also opened and
thyroid exposed, with the nodule (or any
pathology) visible.

18. Thyroidectomy steps 4 –
Dealing with vessels
•Arteries before veins (to prevent venous
engorgement)
•Vessels clamped, divided and ligated with
2-0 vicryl
•Superior thyroid artery ligated close to the
upper pole of the gland.
•This is to prevent damage to external
laryngeal nerve.

19. Thyroidectomy steps 4 –
Dealing with vessels
•Inferior thyroid artery is similarly dealt with
far away from the lower pole of the gland.
•This is to safeguard recurrent laryngeal
nerve.
•Then superior, middle and inferior thyroid
veins are dealt with in a similar manner.

20. Thyroidectomy steps 5 –
Removing the gland proper
•Multiple artery forceps are applied around
the thyroid gland
•Appropriate portion (hemi-, subtotal, total
thyroidectomy, lobectomy etc) is removed.
•Be sure to preserve the excised specimen
in Formalin solution for biopsy.

21. Thyroidectomy steps 5 –
Removing the gland proper
•Cut edge of the gland usually bleeds
profusely.
•This is stopped by under-running with
multiple continuous 2-0 Vicryl sutures.
•Accurate haemostasis is essential, at all
times, now more than ever.

22. Thyroidectomy Steps 6 –
Winding up process
•Redivac (suction) drain is inserted in the
cavity left by the excised thyroid gland,
•Brought out through a separate stab
incision at the side of the neck,
•Sutured to the skin with 2-0 Silk sutures.

23. Thyroidectomy Steps 6 –
Winding up process
•Strap muscles are sutured with 2-0 Vicryl.
•Cut edges of deep cervical fascia are also
sutured with 2-0 Vicryl.
•Again, haemostasis is minutely checked.
•Joll’s retractor, which was holding the
skin-platysma flaps open, is removed.

24. Thyroidectomy steps 7 –
Closure
•Platysma and subcutaneous tissues are
closed with 2-0 Vicryl interrupted sutures.
•Skin closed with 3-0 Nylon, horizontal
mattress sutures or subcuticular sutures.
•The latter gives a finer scar, but it requires
more technical expertise, finesse and
time.

25. Post-operative management
•Patient is kept NPO/NBM (Nil Per Oral /
Nil By Mouth) on the day of surgery.
•Supplemental IV fluid usually given on day
of surgery; usually between 2.5 to 3 litres.
•Compatible blood may be transfused if
there had been excessive blood loss
during surgery.

26. Post-operative management
•Oral intake initiated from next day, starting
with ‘clear fluids’, going on to ‘free fluids’,
then to soft diet and finally to normal diet
•Analgesics essential in post-operative
period; there is invariably severe pain
during first night.
•Antibiotics avoided in clean elective
surgeries

27. Post-operative management
•Daily vital (PTR, BP) chart is maintained.
•Rise of temperature after 3
rd
post-
operative day indicates infection.
–This may require inspection of suture line.
•Careful note is made of daily output from
Redivac drain.
•Drain removed after 48 hours or when
drainage falls to few ml during last 24-hour
period, whichever is earlier.

28. Post-operative management
•Initial dressing changed after 48-72 hours
(to inspect for infection of suture line),
•Unless there is soakage, when it should
be removed earlier.
•Dry dressings sufficient every alternate
day, if suture line is clean and dry.
•Sutures usually removed on 5
th
post-
operative day.
–This gives minimum scarring.

29. Thyroidectomy – Possible
complications
•Hemorrhage
•Respiratory distress or stridor
•Hoarseness of voice
•Total vocal cord paralysis – aphonia
•Hypocalcemic tetany (due to accidental
removal of parathyroid glands during total
thyroidectomy)
•Wound infection: This may manifest after
48 hours of surgery