THYROIDECTOMY

DR.B.Selvaraj MS; Mch; FICS;

Professor of Surgery

Melaka Manipal Medical College

Melaka 75150 Malaysia

OPERATIVE SURGERY

THYROIDECTOMY

• INDICATIONS:

- Thyroid malignancies

- Multinodular goiter

- Graves’ disease

• ANESTHESIA:

- GA-(ET)

• POSITION:

- Semi-fowler’s position with neck hyperextension

• Pre-op preparation for surgery:

- Investigations like TFT, FNAC, USG thyroid, Thyroid scintigraphy and bone scan

- Never use iodine containing contrasts

- If patient is hyperthyroid bring to euthyroid state with anti-thyroid drugs and propranolol

- Give Lugol’s iodine from 10 days prior to surgery to diminish vascularity

- Exclude MEN sydromes

THYROIDECTOMY

• POSITIONING

- Semi-fowler’s position

- Pillow in between scapulae to hyperextend neck on a headrest

- Protect eyes

• DRAPPING- Double towel for head

-Expose cranially mandible,

caudally suprasternal notch, laterally

sternomastoid muscles

-Silk thread to imprint incision

THYROIDECTOMY

• Skin incision & division of platysma

- Kocher’s low collar incision

- Subdermal platysma muscle incision

• Mobilisation of upper & lower flaps- Skin with platysma flaps mobilised

cranially upto thyroid cartilage- upper flap

- Lower flap mobilised caudally upto

suprasternal notch

THYROIDECTOMY

• Ligation of anterior jugular veins

- The superficial anterior jugular veins are suture ligated and divided

• Division of strap muscles &

pretracheal fascia- Divide the strap muscles in the middle

- Incise the pre tracheal fascia

- Dissect laterally in between the

pretracheal fascia(false capsule) and true

capsule of thyroid gland

THYROIDECTOMY

• Mobilisation of lateral lobe and ligation of middle thyroid vein

- Mobilise the lateral part of a lobe

- Ligate and divide middle thyroid vein

• Exposure of superior pedicle & it’s

division- Clamp, divide and transfix the superior

pedicle as close to the gland as possible

- Nowadays Harmonic scalpel has been

used

THYROIDECTOMY

• Division of inferior thyroid pedicle

- Inferior thyroid pedicle is exposed, clamped, divided and transfixed

• Division of inferior thyroid artery- Retract the lateral part of the lobe

medially

- Ligate and divide inferior thyroid artery

branches individually at the surface of the

gland

THYROIDECTOMY• Separation from anterior

tracheal aspect

- Division of Berry’s ligament allows the thyroid to be mobilized medially

- Dissection of the thyroid from the trachea can then be performed with the electrocautery

• For Hemithyroidectomy- If lobectomy is indicated, then the

isthmus is clamped using a Kocher or

tonsil clamp, divided, and oversewn with

an interlocking continuous 3-0 Vicryl

suture

THYROIDECTOMY• For Total Thyroidectomy

- If total thyroidectomy is indicated, the operation is continued in a similar fashion on the other side to remove the thyroid gland in toto

- Preserve parathyroids and recurrent laryngeal nerves

• For Subtotal Thyroidectomy- Perform a subtotal resection if operating

for benign disease, thus preserving the

parathyroid glands and not dissecting in

the area of the recurrent laryngeal nerves.

-The line of resection on the thyroid lobe to

preserve this rim of thyroid tissue overlying

the parathyroid glands is shown in Fig

THYROIDECTOMY

- Once resection is completed and hemostasis is ensured, closure is performed by first reapproximatingthe strap muscles at the midline using interrupted 3-0 Vicrylsutures

CLOSURE OF INCISION

-The platysma muscle is

likewise reapproximated

using interrupted 3-0

Vicryl sutures

-Finally, the skin is

reapproximated with a

subcuticular stitch of

4-0 Monocryl suture

- Keeping a suction

drain is surgeon’s

option

THYROIDECTOMY

• COMPLICATIONS

- Tension hematoma

- Recurrent laryngeal nerve injury

- Superior laryngeal nerve injury

- Hypoparathyroidism

- Hypothyroidism

- Wound infection

- Hypertrophied scar or keloid

• Recent Advances- Endoscopic Thyroidectomy: Bilateral

Axillo-Breast Approach (BABA)

- Axillary port insertion and sharp

dissection with Harmonic. A 12-mm port is

made on the right axilla (marked by star )