covers both theoretical and operative aspects with pictorial presentation

1. Thyroidectomy
Welcome to seminar presentation
Presented by: Dr. M. RIZWAN
Dept. of Surgery
NIUM. Bangalore

2. Learning outcomes
Anatomy of the thyroid gland
Relations of the Thyroid gland
Thyroidectomy & its types
Preoperative investigation
Details of Procedure
Post-operative management
Possible complications

3. S. Anatomy of
thyroid gland

4. S. Anatomy of the gland
Butterfly shaped
Brownish & red
Ant.Traingle of neck
Measure-5x3x1.5
cm
Weight- 20-25 g
2 lobes, central
connecting isthmus
and pyramidal
lobe.
Isthmus extends:
2nd - 4th tracheal
cartilage.
Extension (behind)
C5-T1 vertebra
U.extent- oblique
ridge.
L.extent of- 6th T.
cartilage

5. Capsules of the thyroid gland
• True Fibrous capsule
• Condensed connective tissue
• Encloses the gland
• False fascial capsule
• Derived from the pretrachial fascia.
• Thickend laterally forming the lat.
Ligament of berry which fixes the gland
to the cricoid cartilage.
• Surgical importance……????
It has 2 Capsules:

6. Arterial supply to the gland
The thyroid
is supplied
with arterial
blood from
Superior
thyroid
artery, a
branch of the
external
carotid artery.
Inferior
thyroid
artery; a
branch of the
thyrocervical
trunk.
Thyroid ima
artery:
subclavian
artery/ arch
of aorta.
Accessssory
thyroid artery

7. Venous Drainage
• Superior thyroid veins,
emerges from the apex of each
lateral lobe, draining in the
internal jugular vein.
• Middle thyroid veins,
emerges from the lower part of
each lat. Lobe.
• Inferior thyroid veins,
emerges from the isthmus &
lower part of the lat. Lobe.
draining via the plexus
thyreoidea impar in the left
brachiocephalic vein.
Venous
blood
drained
via:

8. Surgical anatomy – cont’d
• External laryngeal nerve:
• Branch of SLN runs close to superior thyroid
artery.
• Related to upper pole, supply to CTM
• Injury produces voice weakness
• Recurrent laryngeal nerve:
• Branch of vagus nerve
• Related to lower pole of gland
• It runs upwards in the tracheo esophageal
groove, on posteromedial surface of thyroid
• Hooks- AOA -on L side. SCA-on R. side
• Injury produces vocal cord paralysis.
Important
nerves in
relation
to thyroid

10. Lymphatic drainage
The
lymphatic
of the gland
drain into:
Prelaryngeal
L.Ns, infront of
cricothyroid
memb.
Pretracheal
L.Ns, infront of
trachea.
Paratracheal
L.Ns, alongside
the trachea.
Upper & lower
deep cervical
L.Ns, along the
I.J.V .
Brachiocephalic
L.Ns.

11. Relations of the gland
Relations
of the
isthmus.
•Relations of
the lateral
lobes.

12. 1. Relations of the isthmus.
The isthmus has 2 surfaces (Ant. & Post.) & 2 borders (Upper & lower)
Anterior Posterior Upper Lower
1. Skin& superficial
fascia.
2. Ant. Jugularveins.
3. Deep fascia.
4. Sternohyoid &
sternothyroid
muscles.
1. Trachea(2nd, 3rd &4th
rings)
1. Related to the sup.
Anastomotic a.
(between rt & lft sup.
Thyroid aa)
2. Thepyramidal lobe
may project upwards
from the isthmus.
1. Giverise to the Rt &Lt
Inf. Thyroid veins.
2. Thethyroid ima a.
enters the lower
border.
3. An Inf. Anasomotic a.
runs along the lower
border of theisthmus.

13. Anterior
1. Skin& superficial
fascia.
2. Ant. Jugularveins.
3. Deepfascia.
4. Sternohyoid &
sternothyroid
muscles.

14. Lower
1. Giverise to the Rt &Lt
Inf. Thyroid veins.
2. Thethyroid imaa.
enters the lower
border.
3. An Inf. Anasomotic a.
runs along the lower
border of theisthmus.
Upper
1. Related to the sup.
Anastomotic a.
(between rt & lft sup.
Thyroid aa)
2. Thepyramidal lobe
may project upwards
from the isthmus.

15. 2. Relations of the lateral lobes.
each lobe has 3surfaces:
Posterior Medial Anterolateral
1. 2 Parathyroidglands
( sup. & inf. )embedded
in the post.Surface.
1. 2arteries:
A- Common Carotid a.(
inside the carotidsheath)
B-Inf. Thyroid a. before
it enters the gland.
1. Its upper part relatedto:
A- Layrnx(thyroid & cricoid
cartilages & cricothyroidm.)
B- Pharynx (Inf.
Constrictor m.)
C-External laryngealn.
2. Its lower part is relatedto:
A- trachea
B-oesophagus
C-Recurrent laryngeal n. in
between
1. Skin,superficial fascia & deep
fascia.
2. Its upper part is crossedbysup.
Belly of omohyoid.
3. Its middle part is covered by
sternohyoid & sternothyroidm.
4. Its lower part is overlappedby
the ant. Border of
sternomastoid.

16. Posterior
1. 2 Parathyroid glands
( sup. & inf. )embedded
in the post.Surface.
1. 2arteries:
A- Common Carotid a.(
inside the carotidsheath)
B-Inf. Thyroid a. before it
enters the gland.

17. Medial
1. Its upper part relatedto:
A- Layrnx(thyroid & cricoid
cartilages & cricothyroidm.)
B- Pharynx(Inf.Constrictor m.)
C-External laryngeal n.
2. Its lower part is related
to:
A- trachea
B-oesophagus
C-Recurrent laryngeal n. in
between

18. Anterolateral
1. Skin,superficial fascia & deep
fascia.
2. Its upper part is crossedbysup.
Belly of omohyoid.
3. Its middle part is coveredby
sternohyoid & sternothyroid
m.
4. Its lower part is overlappedby
the ant. Border of
sternomastoid.

19. Diffused simple goitre
Diffused colloidal goitre
Simple nodular goitre
Solitary or discreet thyroid nodules
Chronic thyroiditis
Primary toxic goitre
Toxic nodular goitre
Thyroidectomy – Indications
Carcinoma
Follicular
carcinoma
Papillary
carcinoma

20. Lobectomy
Hemi-
thyroidectomy
Total
thyroidectomy
Subtotal
thyroidectomy
Near-total
thyroidectomy
Thyroidectomy –Types

21. Lobectomy
Removal of
either right or
left lobe of
thyroid gland
Indication-
growth
limited to one
lobe and size
less than 2
cm.
solitary goitre
Well
differentiated
carcinoma

22. Hemi-thyroidectomy
1 lobe + Entire
isthmus is removed
benign diseases of
1 lobe
S. nodule
Toxic/ nontoxic
(adenoma/ colloid
goitre)
Histological report=
malignancy-
Completion
thyroidectomynancy
H . Report within 1
wk= immediate
H .report after 1 wk=
after 3 wk
Re-exploration in
2nd & 3rd wk
Not advisable

23. Subtotal thyroidectomy
Done in- multi-nodular
goitre & Toxic goitre
OOC- Toxic goitre
Majority of both lobes are
Removed .
In Toxic goitre-
Better to leave only a
strips of the tissue on post.
Surface of both lower pole
In non toxic goitre
Advisable- to leave 1/3rd of
NTG i.e. 4-5 grams of
normal thyroid tissue

24. Near-total thyroidectomy
on the site p. lesion.
Complete lobectomy
on contra lateral side. Posterior
capsules +a slice of thyroid
tissue are left to preserve
parathyroid gland
Indication
Large, diffusely infiltrating and
well differentiated CA involving
isthmus + contralateral lobe
Medullary carcinoma
Poorly differentiated lesion

25. Total thyroidectomy:
whole
thyroid gland-
Removed
Done in -
Thyroid Gland
malignancy
Papillary or
follicular
carcinoma
medullary
carcinoma
most
common
operation for
multi-nodular
goitre.

26. Hartley dunhill operation
Removal of 1
entire lateral
lobe+ isthmus
+partial
/subtotal of
opposite
lobe.
Done in non-
toxic MNG.

27. Pre-operative investigations
Full blood count (CBC)
Serum Urea, Electrolytes, Creatinine
Thyroid Profile: T3, T4, TSH
FNAC

28. Pre-operative preparation & imaging
Bring Euthyroid /near euthyroid condition.
Ultrasound thyroid gland
Radio-iodine (99mTc / 131I) scan
X-ray neck
X-ray chest– (Both AP / lateral)
Indirect laryngoscopy

29. INFORMED
CONSENT
FOR THE SURGERY
IS ESSENTIAL

30. procedure

31. Endo tracheal intubation
General anaesthesia + ET
Intubation

32. Thyroidectomy Steps 1–The preliminaries
• Position of patient:
– Supine position
– Neck elevated (15 to 30 degree)
– Neck slightly hyperextended
– Sand bag under shoulder
– Foot end slightly down

33. Thyroidectomy Steps 1 – The preliminaries
Preparing the part:
–The entire front of neck, from jaw line to nipples, is
cleaned with Cholorhexidine, surgical spirit and
Betadine.

34. Thyroidectomy Steps 1 – The preliminaries
• Draping:
– Sterile sheets are draped above, below and
on either sides of neck, keeping only neck
portion visible.
– Protection of the eyes
– Some surgeons prefer to cover this area
with self-adhesive sheet to enhance
sterility.

35. Principle of thyroidectomy
Prevent injury to RLN &
ELN
Preservation of
parathyroid gland & its
vascularities
Ligation of vessels in order
of MTV> ITA >STA > STV >
ITV
Meticulous technique
Absolute haemostasis
Avoidance of mass ligation
Cosmoses

36. Fast revision- structure dissected/ splited
• Skin
• Subcutaneous tissues
• superficial fascia
• Platysma (a muscle in superficial fascia
of neck)
• Investing layer of deep cervical fascia
• Pre-tracheal layer of deep cervical fascia
• Strap muscles of neck (thin flat muscles)
From
superficial
to deep

37. Thyroidectomy Steps 2– Incision and raising flaps
• Incision:
Kocher’s low collar skin incision, 2-3 cm above
supra-sternal notch along neck crease is made.
Extent - from posterior border of one sterno-
mastoid muscle to other.
Skin incision is deepened through subcutaneous
tissue, superficial fascia and platysma
In female incision is made at slightly higher side in
comparisons to male

38. Thyroidectomy Steps 2– raising flaps
 Skin flaps elevation:
– Two skin flaps are raised; one above and other below
– Upper flap: raised cranially up to the notch of thyroid cartilage.
– Lower flap: raised caudally up to suprasternal notch
– Flaps are held in place with Joll’s retractor
– Upper Flaps consists of – skin, sup Fascia & platysma
 Technique
 Infiltrate the superficial fascia with 60 ml of 1:400000 dilution of adrenaline
 Start the dissection for raising the flaps from lateral to medial side
 Always remain in subplatysmal plane.
 Prevent undue raising lower flap

39. Thyroidectomy steps 3 – Exposing the gland by spliting the straps muscle
• Anterior jugular vein are preserve the ( chance of air embolism)
• Investing fascia / deep cervical fascia is incised vertically in midline.
• { 2 layer of strap muscles Sterno hyoid-(outer one) sterno thyroid muscle}
• After the incision to DCF, Sterno hyoid muscles comes in to view, splited in midline
Technique of splitting the straps muscle
 Midline land mark - thyroid notch/ supra-sternal notch/ 2 ant. jugular vein
 Tissue in Para median line lifted up dissected vertically in midline with
monopolar cautary/ knife- to get in to midline raphe.
 Split the sternohyoid muscle & retracted laterally
 Sternothyroid is splited in midline simmliarly to expose thyroid gland.

40.  Insinuate the 2 index fingers in between pre tracheal fascia (false
capsules) & true capsules, stretch the two fingers laterally in b/w the
two capsules, medial traction is applied to deliver the gland.
 While insinuating the fingers care should be taken to Identify the MTV, if
identified ligate it / coagulate it.
 Thyroid gland is held with babcock’s forceps and retracted medially to
expose Para carotid tunnel.
 Carotid sheath opened, C. C. Artery & IJV come in to view.
 ITA is an important land mark ,it runs up, behind and deep to CCA,
take a horizontel turn to supply thyroid and Para thyroid gland.
Thyroidectomy steps 3 – Exposing the gland & ITA in P. carotid tunnel

41. Identifying The RLN & ELN
The recurrent laryngeal nerve is located b/w:
Beahrs triangle/ loreyes triangle
The common carotid artery- laterally
The oesophagus/ trachea - medially
The inferior thyroid artery- superiorly.
RLN Lies deeper, dissection should be started from inferior to ITA
The external laryngeal nerve lies
Jols triangle
Superior thyroid vessel & upper pole of thyroid- laterally
Midline of neck- medially
Attachment of Strap muscles & IDLCF to hyoid- superiorly

42. Identifying Superior & inferior Parathyroid Gland
Superior Parathyroid Gland
The SPT gland located on posterior aspect at the level of the upper 2/3rd of
thyroid
Approximately 1 cm above the crossing point of the RLN and ITA but posterior to
RLN
It is orange yellow in colour
The inferior parathyroid glands
 located between the lower pole of the thyroid and the isthmus
most commonly on the posterolateral surface of the lower pole of
the thyroid.
1- 2 cm below & medial to crossing point of the RLN and the ITA and anterior to
RLN

43. Thyroidectomy steps 4 – Dealing with vessels
ligation of ITA
 The branch of ITA supplying to thyroid gland is ligated just
medial to branching of ITA but away from the lower pole of the
gland & and than divided.
 If trunk of the ITA is ligated-compromise the blood supply to
parathyroid gland.
Ligation of STA
 It is ligated near to superior pole of thyroid as near as possible
and divided.
STV & ITV /TIA- ligated and divided subsequently

44. Separation from ant. Tracheal aspects by dividing The berry’s ligament & Isthmus
In lobectomy/hemithyroidectomy- the berrey’s ligament dissected
from trachea with electrocautray.
for dividing the isthmus, it is held with kochers or tonsil clamp. Divided
and sutured with interlocking continuous suture with 3.0 vicryl.
In Sub total thyroidectomy- a rim of thyroid tissue overlying the
parathyroid gland is preserved by apply a number of artery forceps at the
site of resection.
In total thyroidectomy operation is continued similar fashion on other
lobe.
Preserve the excised specimen in Formalin solution for biopsy

45. Thyroidectomy Steps 6 – Winding up process
• Redivac (suction) drain is inserted in the cavity left by
the excised thyroid gland,
• Brought out through a separate stab incision at the
side of the neck,
• Sutured to the skin with 2-0 Silk sutures.

46.  Strap muscles are approximated and sutured with 2-0 Vicryl.
 Cut edges of deep cervical fascia are also sutured with 2-0
Vicryl.
 Again, haemostasis is minutely checked.
 Joll’s retractor, which was holding the skin-platysma flaps
open, is removed.
Thyroidectomy steps 7 – Closure

47. Thyroidectomy steps 7 – Closure
• Platysma and subcutaneous tissues
are closed with 2-0 Vicryl interrupted
sutures.
• Skin closed with 3-0 Nylon, horizontal
mattress sutures or subcuticular sutures.
• The latter gives a finer scar, but it requires
more technical expertise, finesse and time.

48. Post-operative management
Patient is kept NPO/NBM (Nil Per Oral / Nil By Mouth) on
the day of surgery.
Supplemental IV fluid usually given on day of surgery; usually
between 2.5 to 3 litres.
Compatible blood transfusion if there had been excessive
blood loss during surgery.

49. Post-operative management
Oral intake initiated from next day, starting with ‘clear fluids’,
going on to ‘free fluids’, then to soft diet and finally to normal
diet
Analgesics essential in post-operative period; there is
invariably severe pain during first night.
Antibiotics avoided in clean elective surgeries

50. Post-operative management
• Daily vital (PTR, BP) chart is maintained.
• Rise of temperature after 3rd post- operative day indicates
infection.
– This may require inspection of suture line.
• Careful note is made of daily output from Redivac drain.
• Drain removed after 48 hours or when drainage falls to few ml during
last 24-hour period, whichever is earlier.

51. Post-operative management
• Initial dressing changed after 48-72 hours (to inspect for infection of
suture line),
• Unless there is soakage, when it should be removed earlier.
• Dry dressings sufficient every alternate day, if suture line is clean
and dry.
• Sutures usually removed on 5th post- operative day.
– This gives minimum scarring.

52. Thyroidectomy –Possible complications
Anaesthesia retaliated complications
Haemorrhage /Hematoma
 manifest after 48 hours of surgery
This may compress the airway, becoming life-threatening
Hypothyroidism in up to 50% of patients after ten years.
Laryngeal nerve injury in about 1% of patients
Recurrent laryngeal nerve
Unilateral damage results in a hoarse voice.
Bilateral damage presents as laryngeal obstruction
(surgical emergency: an emergency for tracheostomy)
 Total vocal cord paralysis – aphonia

53. Thyroidectomy –Possible complications cont….
Infection - 2% rate.possibly an increased risk with chronic pre-operative steroid
use.
Stitch granuloma
Devascularisation of the parathyroid
Hypoparathyroidism
temporary (transient) in many patients
permanent in about 1-4% of patient
Hypocalcemic tetany (due to accidental removal of parathyroid glands