Ppt on incision of neck, thyroidectomy, parathyroidectomy

1. Contoso
Pharmaceuticals
Incisionsintheneck,Thyroidectomy,
Parathyroidectomy,
Cricothyroidotomy
Mahima Shrivastava
Group 55
2nd course
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2. Incisionintheneck
The surgeon selects the proper incision and its
placement in relation to the underlying pathology.
The orientation of the connective tissues of the
dermis creates lines of tension in the skin, known
as the lines of Langer, which are associated with
skin creases of the body. Generally speaking, the
transverse incision is cosmetically superior to the
vertical, since crossing the normal skin lines will
produce a more prominent scar. However, the
vertical lines produce excellent exposure for
surgery of the arteries. Combinations of vertical
and transverse incisions can be used, if necessary.
Remember, a superiorly-based apron flap should
be used for neck dissection. Close the edges of the
divided platysma muscle carefully and
reapproximate the margins of the skin incision
meticulously to lessen the likelihood of unsightly
scarring from tension upon the skin.

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A) Gluck incision for
unilateral and bilateral
neck dissection
B) Double-Y incision of
Martin
C) Single-Y incision D) Schobinger incision.
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Incisionsinthe
neck

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Pharmaceuticals
Generalinstrumentsusedinfunctionalandselectiveneckdissection.(A)1,scissors;2,knives;3,needleholders.(B)1,
atraumaticandtoothedtissueforceps;2,suctiontips;3,monopolarforceps.(C)1,Volkmannretractors;2,Howarthraspatory;
3,Desmarresvascularretractor;4,Deschampsligatureneedle;5,skinhooks;6,Farabeufretractors;7,Langenbeckretractors.
(D)1,straightPe´an’s
forceps;2,large and smallDuval forceps;3,large and smallAllisforceps.(E) 1,right-angle forceps;2,largeand
smallcurvedPe´an’sforceps;3,Dandyhemostaticforceps;4,mosquitoforceps.
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Thyroidectomy&Parathyroidectomy
A thyroidectomy is an operation that involves
the surgical removal of all or part of the
thyroid gland. In general surgery, endocrine or
head and neck surgeons often perform
a thyroidectomy when a patient has thyroid
cancer or some other condition of the thyroid
gland (such as hyperthyroidism) or goiter.
Parathyroidectomy is the surgical removal of
one or more parathyroid glands.
The parathyroid glands are four rice-sized
glands located on back of the thyroid gland in
the neck.

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Procedure:
 1. Position: put the patient in semiFowler position;
patient’s neck should be hyperextended; place small
pillow at the area of the upper thoracic spine, beneath
the shoulders; place a doughnut support under the head.
 2. Approach. After the local anesthesia mark the
location of the incision, two finger breadths above the
jugular notch. Use a knife to mark very superficially the
middle and edges of the previously marked location of
the incision.
 3. Incise the low collar symmetrical mark of the skin,
carrying out the incision through the superficial fascia
(subcutaneous fat and platysma). Establish good
hemostasis by electrocoagulation or ligation using silk.
 4. Formation of flaps. By blunt dissection, elevate the
upper flap to the notch of the thyroid cartilage and the
lower flap to the jugular notch using the retractors.

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 5. Opening of the investing fascia.The opening is accomplished by
a longitudinal midline incision along the raphe of the strap muscles,
which is actually the medium layer of the investing fascia.
 6. Elevation of the strap muscles.The sternohyoid muscles are
easily elevated, but the thyrohyoid and sternothyroid muscles are
attached to the false thyroid capsule and should be separated
carefully to avoid injuring the gland and causing bleeding. In
extremely rare cases, when the thyroid gland is huge, section of the
strap muscles becomes necessary. Divide them at the proximal one-
third to avoid paralysis due to injury of the ansa hypoglossi.The
sternohyoid muscles are the most superficial and the sternothyroid
and thyrohyoid are beneath. For practical purposes, the thyrohyoid
is an upward continuation of the sternothyroid.
 7. Exposure and mobilization of the gland.With all strap muscles
elevated and retracted, the index finger of the surgeon is gently
inserted between the thyroid and the muscles.A lateral elevation is
also taking place, occasionally using all the fingers except the
thumb. Occasionally the strap muscles should be divided.The
surgeon now decides whether to perform a total or a partial
(subtotal) lobectomy.The anatomy of the normal and the abnormal
must be studied carefully regarding size, extension, consistency and
fixation of the gland. Frozen section should follow.

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 8.Total lobectomy
 a. Retract the lobe medially and anteriorly by
special clamps or deep sutures outside the
lesion.
 b. Ligate the middle thyroid vein.
 c. Identify the recurrent laryngeal nerve by blunt
dissection into the tracheoesophageal groove.
 d. Identify and protect the parathyroids.
 e. Ligate the inferior thyroid artery.
 f. Ligate the lower pole vessels.
 g. Carefully ligate the upper pole. Perform en
masse ligation, thereby ligating the superior
thyroid artery, or, if possible, prepare the artery
above the pole and ligate.
 h. Dissect the lobe from the trachea by dividing
the gland between straight mosquitoes. Suture
ligate the tissue that is clamped over the
trachea with 3-0 silk.
 i. If the pyramidal lobe is present, ligate its most
distal part and remove it together with the lobe.
 j . Ligate the isthmus, if present.
 k. Obtain careful hemostasis.

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 9. Partial (subtotal) thyroidectomy. Apply multiple hemostats at
the thyroid parenchyma and partially transect the gland. Use 4-0
silk suture ligature for suture ligation of the thyroid parenchyma
and surface veins. If possible, approximate the segment to the
trachea. Both upper pole remnants or the tracheoesophageal
remnant should weigh approximately 5-6 g.
 10.In a patient with hyperplasia, remove 1/3 glands.The
remaining 1/2 gland can be left in situ or implanted into the
sternocleidomastoid muscle.When a patient is explored for a
suspected adenoma, the healthy glands will be smaller than
normal.Try to identify all the glands and do not stop after having
removed the adenoma, because in a small percentage of cases
multiple adenomas are found. Always send adenomas for frozen
section. If the gland is determined to be malignant, the
surrounding tissue should be removed.
 11. Reconstruction. Insert an elastic drain. Close the midline and
the superficial fascia, approximating the marked points and
avoiding dog-ears. Closure of the skin is up to the surgeon.
Remember to check the vocal cords as soon as the endotracheal
tube has been removed.

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Post-OperativeCare
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 • During the first post-operative week, patients may experience a sore throat and discomfort when
swallowing.This is quite normal and may fluctuate, and pain may get worse (two – three days after surgery)
before it gets better. Progressive recovery can be expected in 7 - 10 days.You may use over-the-counter throat
lozenges if necessary.
 • Although there are no dietary restrictions after surgery, a soft diet may feel better for the first day. Drink
plenty of fluids to prevent dehydration.You may experience nausea after anesthesia but you can advance to a
regular diet as tolerated.
 •Take pain medication as prescribed by your surgeon. DO NOTTAKEASPIRINOR NSAIDS (i.e. Ibuprofen,
Advil, Motrin, Aleve, Naprosyn), ASTHESE INCREASETHE RISKOF BLEEDINGAND BRUISING.Codeine (or
other opiates) may cause nausea, vomiting, and constipation. If so, many patients will use regular
acetaminophen (Tylenol) for relief.You may use an over-the-counter stool softener if necessary.
 • Allow sufficient time to recuperate and increase activities as tolerated during the first post-operative week.
Patients are encouraged to get out of bed and walk around the night of their surgery.Avoid any heavy lifting
or strenuous activity for one week after surgery. It is not unusual to miss a week of work, and, if you have a
physically demanding job, you may not return to work for two weeks.

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• Consider sleeping with your head elevated for the first
two to three days after surgery.This can help to
decrease the swelling around the incision and make you
feel more comfortable.
• Keep your incision dry for two days after surgery.You
can hold a dry towel over the incision while showering,
and if the wound gets wet, it should be patted dry. Do
not put any creams or medications on the wound until
instructed to by your surgeon.
•Your post-operative visit should be scheduled
approximately one week after surgery.This should be
scheduled as part of your surgical booking with our
office.This is important so that we may evaluate your
progress, review your pathology results, and remove
your sutures.
•Your surgeon may instruct you to take a calcium
supplement and will inform you of the amount to take.
Your calcium supplement should be readily available to
you at all times.You may also be instructed to take
prescription strengthVitamin D (Rocaltrol) by your
surgeon.

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Cricothyroidotomy
A cricothyrotomy is an incision made through
the skin and cricothyroid membrane to
establish a patent airway during certain life-
threatening situations, such as airway
obstruction by a foreign body, angioedema,
or massive facial trauma.
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Needle cricothyroidotomy
In a needle cricothyroidotomy, the doctor uses a 12- or 14-gauge catheter
and needle assembly.The needle is advanced through the cricothyroid
cartilage at a 45-degree angle until the trachea is reached. When the
doctor is able to withdraw air through the syringe, he or she knows that
the catheter is in the correct spot.The catheter is then pushed forward
over the needle, which is then removed. An endotracheal tube connector is
then fitted onto the end of the catheter and connected to a bag-valve unit
with an oxygen reservoir.
A needle cricothyroidotomy will supply the patient with enough oxygen for
about 40–45 minutes; it is a time-limited technique because it does not
allow the efficient escape of carbon dioxide from the bloodstream. It will,
however, help to ventilate the patient until he or she can be taken to a
hospital or trauma center.
Needle cricothyroidotomy is the only form of this procedure that can be
done in children under 12 years of age.The reason for this restriction is
that the upper part of the trachea is not fully developed in children, and a
surgical incision through the cricothyroid membrane increases the risk of
the child's developing subglottic stenosis, which is a condition in which the
trachea is abnormally narrow below the level of the vocal cords due to an
overgrowth of soft tissue. It is often seen in children who were intubated as
infants.

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Indications: acute laryngeal or upper
airway obstruction.
The patient’s neck is extended and
stabilized. Palpate for the cricoid
cartilage approximately 2-3 cm below
the thyroid notch. A 1-cm horizontal
incision is made just above the superior
border of the cricoid (this avoids the
vessels that run under the inferior
border, in the same manner as the
intercostal neurovascular bundles) to
expose the cricothyroid membrane,
which is then punctured in the midline.
The blade must be directed inferiorly to
avoid trauma to the true vocal cords.
Care is taken not to extend this
puncture through the back wall of the
larynx and into the esophagus. Insert a
blunt instrument into the incision and
rotate it perpendicularly to widen the
incision to accommodate a small
cannula.

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Surgical cricothyroidotomy
In a surgical cricothyroidotomy, the doctor steadies the patient's
thyroid cartilage with one hand and makes a horizontal
(transverse) incision across the cricothyroid membrane.The
incision is deepened until the airway is reached.The doctor then
rotates the edge of the scalpel 90° in order to open the incision
to receive an endotracheal or tracheotomy tube. A hemostat or
surgical clamp may be used to hold the incision open while the
doctor prepares to insert the tube through the opening into the
trachea. After checking the tube to make certain that it is in the
proper location, the doctor tapes it in place. If necessary, the
doctor may use suction to clear the patient's airway.
In some emergency situations, the doctor or other medical
professional may not have an antiseptic available to cleanse the
skin over the patient's throat, and may have to use any sharp-
edged implement that is handy to make the incision. Emergency
cricothyroidotomies have been performed with scissors, hunting
or pocketknives, razor blades, broken glass, and the jagged
edges of a lid from a tin can.The airway has been held open with
such objects as paper clips, nail clippers, the plastic barrel from a
ballpoint pen, and a piece of plastic straw from a sports water
bottle.

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Risks:-
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Needle cricothyroidotomy
The risks of a needle cricothyroidotomy include:
 external scar from needle puncture
 Bleeding
 accidental perforation of the esophagus
 hypercarbia (overly high levels of carbon dioxide
in the blood)
Surgical cricothyroidotomy
The risks of surgical cricothyroidotomy include:
 large visible external scar from the incision
 subglottic stenosis
 bleeding
 accidental perforation of the esophagus
 fracture of the larynx
 pneumothorax, which is a condition in which air
has entered the space around the lungs
 damage to the vocal cords resulting in
hoarseness or a changed voice

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Post-OperativeCare
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Needle cricothyroidotomy
A needle cricothyroidotomy must be replaced by a formal surgical tracheotomy or other means of ventilating the
patient within 45 minutes.
Surgical cricothyroidotomy
A surgical cricothyroidotomy can be left in place for about 24 hours, but should be replaced within that time
period by a formal tracheotomy performed in a hospital operating room .
Other aspects of aftercare depend on the cause of the airway blockage and the nature of the patient's injuries.
The head and neck contain major blood vessels, a large portion of the central nervous system, the organs of
sight, smell, hearing, and taste, and the central airway—all within a relatively small area. Injuries to the face and
neck often require treatment by specialists in neurology, trauma surgery, otolaryngology, ophthalmology, and
plastic surgery as well as by specialists in emergency medicine.

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