thyroidectomy

1. THYROIDECTOMY
DR BASHIR YUNUS
SURGERY RESIDENT
AKTH
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2. OUTLINE
• DEFINITION
• INDICATIONS
• TYPES
• PRE-OP PREPARATION
• ANAESTHESIA
• POSITION
• PROCEDURE
• CLOSURE
• POSTOP MGT
• COMPLICATIONS
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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
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4. Contraindications
• Recurrent thyrotoxicosis after subtotal thyroidectomy
• Thyrotoxicosis without a palpable thyroid
• Drug goiter
• Thyrocardia
• Children
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5. TYPES OF THYROIDECTOMY
• Hemithyroidectomy
• Subtotal thyroidectomy
• Total thyroidectomy
• Near total thyroidectomy
• Isthmusectomy
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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
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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)
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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
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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
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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.
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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.
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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
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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
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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
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18. QUESTIONS
1. What is the blood supply to the thyroid gland
2. What are the preoperative measures prior to thyroidectomy for
thyrotoxicosis
3. What are the types of thyroidectomy
4. Outline the steps of thyroidectomy
5. What are the complications of thyroidectomy
6. What does the recurrent laryngeal nerve supply and what is the
consequence of it division
7. What does external laryngeal nerve supplies and what is the
consequences of it division
8. What is the Simon’s triangle
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19. REFERENCES
• Graeme J. Poston; Principles of operative surgery. 2nd edition 1996
• Vijay P Khatri, Juan A Asensio; Operative surgery Manual. 1st edition
2003
• Farquharson’s textbook of operative general surgery. 8th edition 1995
• Operative surgery Viva for MRCS
• Mahmud Sakr. www.slideshare.net
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