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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


Langers 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 5/6s 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

Relevant A & P

Pathophysiology
Hyperthyroidism Goiter Cancer

Pathophysiology

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 pts 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 Sheet Sheet

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 neckguideline 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 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

Surgical Intervention: Procedure Steps


* 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

Surgical Intervention: Procedure Steps


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

Surgical Intervention: Procedure Steps

Ligation of superior thyroid vessels

ID of parathyroids & recurrent laryngeal nerve

Surgical Intervention: Procedure Steps


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.

Surgical Intervention: Procedure Steps


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 pts 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 frontsecured 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 Fowlers 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 recoverynormal 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 Alexanders pp. 629-631 Berry & Kohn p. 858 Fullers p. 171, 108, 322-324 MAVCC Unit 3 OBJ 12, 13, 14, 15 Complete Review of ST: Boegli. Rogers, McGiness

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

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