lp 11 thyroidectomy

Procedures

Basic Format

Thyroidectomy

Objectives

• Assess the anatomy, physiology, and pathophysiology of the Thyroidectomy.

• Analyze the diagnostic and surgical interventions for a patient undergoing a _______________.

• Plan the intraoperative course for a patient undergoing_____________.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position• Identify the incision used for the procedure• Analyze the procedural steps for_____________.• Describe the care of the specimen• Discuss the postoperative considerations for a

patient undergoing _______________ .

Terms and Definitions

• Langer’s lines

Definition/Purpose of Procedure

• Total Thyroidectomy– removal of thyroid gland for malignancy or to relieve

compression on the trachea or esophagus

• Subtotal or Partial Thyroidectomy– removal of about 5/6’s of thyroid gland to treat

hyperthyroidism

• Purpose: – Total: to treat various diseases of the thyroid; usually

cancer by removal of gland (ablative)– Subtotal: enlarged glands affecting breathing or

swallowing problems; tracheal or esophageal obstruction

Relevant A & P

Pathophysiology

• Hyperthyroidism

• Goiter

• Cancer

Pathophysiology

Diagnostics

• Exams: H & P, Visual/ Palpation• Preoperative Testing

– TA test

– TSH test (sensitive assay)

– T4 test

– T3 test

– T3 uptake test

– RAI uptake test

– Thyroid suppression test

Surgical Intervention:Special Considerations

• Patient Factors– Maintain a calm, quite atmosphere

• Room Set-up

• Etc

Surgical Intervention: Anesthesia

• Method: General

• Equipment and considerations:– Lubricate and protect pt’s eyes

Surgical Intervention: Positioning

• Position during procedure– Supine with shoulder roll, head hyperextended– Possibly some reverse Trendelenburg

• Supplies and equipment– Sheet roll or thyroid rest/pillow for extending

the neck

• Special considerations: high risk areas

Surgical Intervention: Skin Prep

• Method of hair removal– Men need shave

• Anatomic perimeters– Begins w/anterior neck and extends to point of

chin or cheekbones (surg pref), to nipples, to bedline

• Solution options: Betadine or hibiclens or Duraprep

Surgical Intervention: Draping/Incision

• Types of drapes– Absorptive hand towels– OR Basic Pack and Thyroid SheetSheet

• Order of draping– Crushed/wadded absorptive towels on either side of neck, head drape, and split sheet

• Special considerations• State/Describe incision

– Transverse/Collar– Note: before procedure, surgeon may mark proposed

incision line by grasping line of suture and pressing against neck—guideline for nearly unnoticeable scar

Thyroid Sheet

Surgical Intervention: Supplies

• General: suction, ESU, prep set, basin set, gloves & gowns, marking pen, dissector sponges

• Specific– Suture: 3-0 & 4-0 for silk suture for ligation; 2-0 or 3-0

silk mounted on a fine needle (Ferguson or French-eye) for occlusion of large arteries; interrupted silk suture on a fine needle on muscle and fascial layers. Subcutaneous tissue is closed w/fine interrupted absorbable sutures

– Blades # 10, # 15– Medications on field (name & purpose)– Catheters & Drains

• ¼ “ Penrose

Surgical Intervention: Instruments

• General: Minor set or Thyroid set; Pull a tracheotomy tray for post-op standby– Include (2) Rt angle clamps w/fine points

• Specific: Specialty – Mastin muscle clamp Lahey thyroid tenaculum,

Green thyroid (loop) retractor, Lahey thyroid retractor, Beckman self-retaining retractor,

– Ligating clip appliers – Bipolar forceps w/cord

Thyroid Instruments

Surgical Intervention: Equipment

• General: standard room set-up

• Specific: N/A

Surgical Intervention: Procedure Steps

• Platysma muscle is incised symmetrically using a collar/transverse incision & # 10 blade and retracted* Hemostatis will be provided via ESU pencil or bipolar forceps

* Surgeon may prefer to clamp & tie some vessels, or may use ligating clips

• Incision is extended through the subcutaneous tissues & Platysma muscle divided. Superior and inferor flaps are mobilized and retractors are placed* Prepare self-retaining retractor of choice

• Strap muscles are separated w/blunt and sharp dissection

• Thyroid lobe is elevated & exposed with a Lahey tenaculum and the sternocleimastoid muscle is retracted with a Green retractor


* Because the knife (# 10 blade) is used so much during mobilization, it may be left on the field where he/she can pick it up freqently. STSR that if asked to leave on field, it is placed on a folded towel (or other platform) to prevent accidental injury


• The middle & inferior thyroid vein is exposed, divided, ligated.

• The superior and inferior thyroid arteries are identified, clamped, divided & ligated* Slow and methodical is the rule of thumb. Keep fresh, dry raytex

available

* Many (12) Mosquito hemostats or straight Kelly clamps may be used

• Care is taken to identify the parathyroid glands and preserve the recurrent laryngeal nerve. The parathyroid glands are mobilized & vascular supply is preserved.• Above steps may require use of small right angle clamps and ligature

on passer.• Many steps are repeated. Keep two clamps, scissors, and ties ready


ID of parathyroids & recurrent laryngeal nerve

Ligation of superior thyroid vessels


• Hemostasis is achieved w/ESU. * May alternate between sharp dissection, blunt dissection, & ESU.

• Thyroid gland is freed from trachea and delivered as a specimen* If only one lobe is taken, the isthmus is divided so that it is

removed w/resected lobe is the pryamidal lobe.


• Hemostasis is achieved after lobe or lobes removed.* Sequence is irrigation, placement of wound drain, closure, initiate

count.

• Strap muscles are approximated with an interrupted suture

• Penrose drain may be inserted in thyroid bed and brought to the outside

• Platysma is approximated

• Skin is closed w/staples, or nonabsorbable suture and collar-type dressing is applied

Counts

• Initial: sponges and sharps (instruments)

• First closing

• Final closing– Sponges– Sharps– Instruments

Dressing, Casting, Immobilizers, Etc.

• Types & sizes– Surgical wound may be left without a dressing to allow

for observation of swelling

– Thyroid collar (also “Queen Anne”) may be applied using a gauze strip around the pt’s neck OR after the wound is dressed, a collar is made with cloth towel folded in thirds lengthwise. The towel is wrapped around the neck and criss-crossed in front—secured w/tape

• Type of tape or method of securing

Specimen & Care

• Identified as thyroid or lobe of thyroid

(rt vs lt)

• Handled: Frozen section could be ordered if tissue looks suspicious; routine

Postoperative Care• Destination

– PACU: position in Fowler’s

– CAUTION:• STSR will maintain integrity of sterile field until pt leaves OR

proper

• Ensure tracheotomy tray is transported postop w/pt and stays at bedside for at least 24 hrs

• Expected prognosis (Good, Depends on Dx)– Surgeon will be assessing for voice capability asap

– Short recovery—normal activities asap

– Medications usually required for life

Postoperative Care

• Potential complications– Hemorrhage from major arteries in the neck– Infection– Tracheal edema w/resultant obstructed airway– Other: Damage to…

• Accidental removal of parathyroid glands with resulting tetany• Damage to one or both recurrent laryngeal nerves w/paralyzed

vocal cords and completely obstructed airway• Thyroid storm from excessive manipulation of toxic gland.

• Surgical wound classification: I

Resources

• www.allrefer.com• STST pp. 461-466 Procedure 14-13• Alexander’s pp. 629-631• Berry & Kohn p. 858• Fuller’s p. 171, 108, 322-324• MAVCC Unit 3 OBJ 12, 13, 14, 15• Complete Review of ST: Boegli. Rogers,

McGiness

http://www.allrefer.com/

Related H & N Procedures

• Parathyroidectomy– Removal of one or

more parathyroid glands for adenoma or hypersecretions of parathormone

Related H & N Procedures

• Thyroglossal Duct Cystectomy– Removal of pretracheal cystic pouch attached to the

hyoid bone, and when present, the sinus tract, an embryological remnant from the descent of the thyroid gland into the anterior neck. It is removed to prevent recurrent cystic formation and prevent infections

• Scalene Node Biopsy– Incision made just above clavicle & biopsy taken to

determine the spread of TB or CA of lungs

The incision used for a Thyroidectomy is:

a. Postaural

b. Eyebrow

c. Y-type incision on either side of the ear

d. collar

Patients having neck surgery are more likely to encounter respiratory problems from edema. The equipment to accompany these patients from surgery is:

a. Suction

b. Tracheotomy set

c. Oxygen

d. Packing

Surgical hazards associated with a Thyroidectomy include all of the following except:

a. Damage to one or both recurrent laryngeal nerves

b. Damage to the facial nerve

c. Accidental removal of the parathyroid glands

d. Hemorrhage from major arteries in the neck

The subcutaneous neck muscle that covers the anterior portion of the neck region from the jaw to the clavicle is called the __________________ muscle.

a. Platysma

b. Deltoid

c. Sternocleidomastoid

d. buccinator

The tissue that may be accidentally resected during a Thyroid Lobectomy is:

a. A scalene node

b. The larynx

c. Parathyroid gland (s)

d. A cervical lymph node

A sampling of lymph nodes in the neck region is referred to as a:

a. Modified Neck Dissection

b. Scalene Node Biopsy

c. Carotid Node Biopsy

d. Lingual Tonsillectomy