Right total & left subtotal thyroidectomy
OEPRATIVE TECHNIQUE:
The patient was brought into the operating room, placed on the operating table in a supine position with the arms extended at the side. The patient underwent smooth induction of general endotracheal anesthesia, and both arms were tucked at the side. The patient's neck had previously been clipped of any hair using surgical clippers and the area was then prepped with a chlorhexidine solution and then draped in a normal fashion, after the patient had been placed in a modified Fowler position with a shoulder roll. A NIM monitor endotracheal tube had been placed, however, later in the case this NIM monitor was not functioning and, therefore, the NIM monitor was not used for the case.
A curvilinear incision was made approximately 2-1/2 fingerbreadths above the sternal notch along a skin crease, after the skin was anesthetized using 0.25% bupivacaine with epinephrine. After the skin incision is made with a #15 blade scalpel, several anterior jugular veins were encountered and were ligated and clamped on either side using hemostats, divided with a Metzenbaum scissors, and tied off using 3-0 silk suture. The platysma muscle was identified and was divided and superior and inferior skin flaps were developed using the Bovie electrocautery device. A thyroid retractor was then placed within the wound, and the median raphe of the strap muscles were then identified and incised. The strap muscles were then retracted laterally, exposing the parenchyma of the thyroid.
The right side was approached first, and the ligament of Berry on the right side was taken down by first exposing it with hemostats and dividing it with a handheld Harmonic scalpel. The superior pole vessels were seen and were divided close to the thyroid capsule as possible, and the right superior parathyroid gland was identified and was preserved. The gland was slightly rotated in a lateral to medial fashion and the right middle thyroid vein was identified and divided. As the gland was rotated medially, the recurrent laryngeal nerve on the right side was clearly identified and dissection continued far away from this recurrent laryngeal nerve at all times during the dissection. The lower pole vessels were also encountered and the right inferior parathyroid gland was encountered and was preserved. The inferior pole vessels were encountered and divided using the handheld Harmonic scalpel, and the gland was rotated again from a lateral to medial aspect and was divided at the isthmus. This specimen was then labeled with 1 stitch on the isthmus, 2 stitches on the superior pole and 3 stitches anteriorly and was sent to frozen section to confirm that no cancer was present within the specimen.
Frozen section revealed that this is consistent with a multinodular goiter and no cancer was seen on frozen section.
During removal, the right side did have a violation of a cyst and some of this cyst fluid had drained out into the neck cavity during dissection.
Attention then turned to the left side where, in a similar fashion, the dissection continued bluntly on the anterior surface of the thyroid gland until the gland could be rotated medially with the aid of a finger with a peanut dissector. The ligament of Berry on the superior aspect was taken down using the handheld Harmonic scalpel, and the left superior parathyroid gland was identified and preserved. The middle thyroid vein was preserved, it was divided using a handheld Harmonic scalpel. Again, that was divided using a handheld Harmonic scalpel and the gland was rotated medially. A subtotal thyroidectomy was performed on the left side by preserving approximately 1 g of thyroid tissue on the left lower pole. The left inferior parathyroid gland was identified and was left connected to the inferior pole vessels.
The wound was then irrigated copiously with 0.9% normal saline and no bleeding had occurred. A 4 x 8 piece of Surgicel was then placed underneath the strap muscles and the median raphe. The strap muscles was reapproximated using a running 3-0 Polysorb suture. A running 3-0 Polysorb suture was also used to reapproximate the platysma muscle and a running 4-0 Caprosyn suture was used to close the skin, with the aid of Indermil and skin adhesive
It should be noted that on the left thyroid, several nodules were also present but no nodular thyroid tissue was left behind, and a small amount of thyroid tissue left on the left side.
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