thyroidectomy-surgical seminare, prepared by Dr. Siddharth JINDAL, third year resident in dept. of general surgery at P.D.U. Government Medical College and Civil Hospital, Rajkot, Gujarat.
THYROIDECTOMY- Operative Surgery
Dear viewers,
Greetings from “Surgical Educator”
Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. I have already uploaded two videos on open and Laparoscopic Appendicectomy. In this video today, I have discussed Thyroidectomy Surgery. However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the videos.
THYROIDECTOMY- Operative Surgery
Dear viewers,
Greetings from “Surgical Educator”
Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. I have already uploaded two videos on open and Laparoscopic Appendicectomy. In this video today, I have discussed Thyroidectomy Surgery. However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the videos.
Mediastinoscopy & mediastinotomy indications & techniquesAbdulsalam Taha
The mediastinum is the central compartment of the chest. Its boundaries and compartments are well known.Although, it contains the most vital organs of the body; it is often a forgotten compartment. Involvement of mediastinal nodes has a dramatic prognostic and therapeutic impact in patients with non-small cell lung cancer. Cervical mediastinoscopy remains the most important technique for staging of the mediastinum.
The technique of extended mediastinoscopy and redo mediastinoscopy are described as well. Indications, technique and complications are discussed.
Skull Metastasis From Papillary Thyroid Carcinoma : Case Report and Literatur...komalicarol
Although papillary thyroid carcinoma is a relatively common form of malignancy, metastatic spread to the skull
is exceptional. Here, we report a case of papillary thyroid carcinoma revealed by frontal skull metastasis.
Skull Metastasis from Papillary Thyroid Carcinoma: Case Report and Literature...semualkaira
Although papillary thyroid carcinoma is a relatively common form of malignancy, metastatic spread to the skull
is exceptional. Here, we report a case of papillary thyroid carcinoma revealed by frontal skull metastasis.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. ”
“The most important thing about
thyroidectomy is the meticulous
dissection needed for Preserving
The Two Nerves And Bilateral
Parathyroid Glands
Thus, rendition of a symphony
30-09-2021
2
3. CURTAIN RAISER
1. Surgical Anatomy What We Already Know.
2. Triangles In Thyroid Surgery Geometrical Nexus In The Neck!
3. Appreciation of the Historical Contributions
4. Types of Thyroidectomy
5. Patient Preparation for The Surgery
6. Operative Procedure
7. Complications
8. Recent Advances
9. Summary
10. Thyroid trivia
11. Q&A
30-09-2021
3
4. SURGICAL ANATOMY
OVERVIEW OF THE GLAND
VASCULAR SUPPLY
INNERVATION & LYMPHATIC SUPPLY
RELATIONS
MUSCLES TO KNOW
MISC. FACTS
30-09-2021
4
13. THYROID’S
INTIMACY
WITH VAGUS
1. Superior thyroid artery is
accompanied by ELN
2. RLN runs in the
tracheo-esophageal groove
near the posteromedial surface
close to the thyroid gland;
• nerve lies b/w the branches of
inferior thyroid artery ~ 50% on
right side;
• on left side nerve lies posterior to
the Inferior thyroid artery in ~50%
30-09-2021
13
16. MUSCLES
Anterior aspect of neck
Supra-hyoid muscles
1. Stylohyoid
2. Geniohyoid
3. Mylohyoid
Infrahyoid - STRAP MUSCLES
1. Sternohyoid- in front
2. Omohyoid- in front
3. Sternothyroid- deep to above m/s
4. Thyrohyoid- deep to above m/s
Mnemonic: TOSS
30-09-2021
16
18. TUBERCLE OF ZUCKERKANDL [Misc.]
TZ is postero-lateral projection from the thyroid lobe resulting at a point where lateral and the
medial components fuse.
Applied importance:
1. Grade 3 TZ: significant pressure symptoms, persistent after subtotal thyroidectomy
2. Intimately assoc. with RLN & Superior parathyroid. Enlargement occurs lateral to RLN—
The nerve appears to pass into a cleft medial to the enlarged tubercle.
3. Elevation of TZ: safe dissection; RLN passes medially through tunnel
4. The widened pre-vertebral space on X-ray of neck: (?) enlarged TZ [grade 2/3]
30-09-2021
18
19. Grading of TZ
Grade I <0.5cm
Grade II 0.5-1.0 cm
Grade III >1cm
30-09-2021
19
22. BEAHR’S TRIANGLE
[RIDDLE’S]
USED TO IDENTIFY RLN CLOSE TO TEG
BOUNDARIES:
RLN [LOWER ARM]
INFERIOR THYROID ARTERY [SUPERIOR]
COMMON CAROTID ARTERY [BASE]
30-09-2021
22
23. LORE’S
TRIANGLE
IDENTIFICATION OF RLN INFERIORLY
BOUNDARIES:
MEDIAL: Medial border is formed by
trachea and esophagus
LATERAL: CCA
SUPERIOR: Surface of inferior pole of
thyroid gland
30-09-2021
23
25. RLN TRIANGLE
Inverted Triangle--
Apex: inferiorly: thoracic inlet
Medially: trachea
Laterally: medial edge of retracted
strap muscle
Superiorly: lower edge of inferior pole
of the gland
RLN exits as single trunk here
@ thoracic inlet
30-09-2021
25
26. TRIANGLE OF
CONCERN
COMMONEST SITE FOR BLEEDING IN
THYROIDECTOMY
Boundaries
Medial: trachea
Lateral: RLN
Base: thyrothymic ligament and loose fat
above sternum/
SMALL BRACNHES OF INFERIOR THYROID
ARTERY
30-09-2021
26
31. Down the memory lane…
1912: KOCHER first thyroid surgery
Billroth, Kocher, Joll , Lahey and Galen: importance of laryngeal nerve preservation in thyroid
surgeries.
Illustration & description of nerves: Leonardo Di Vinci and Vesalius
20th century: Russian: Alexander Borbov: routine visual identification of nerves
George Crile: region of RLN , “no man’s land”
1935: Amelia Galli-Curci, famous opera singer [soprano], underwent a disastrous thyroid surgery,
EBSLN damaged.
Indian contribution: Sushruta [6th century B.C.] First to describe injury to neck at angle of jaw
voice hoarseness [? blood vessels]
Rufus and Ephesus: hoarseness was due to nerve injury and not vascular injury
30-09-2021
31
41. WORKUP
1. DL/IDL: VC check
2. CECT/MRI/intra-luminal imaging: potentially more advanced and regional disease
3. XRC [PA]- Retrosternal goiter
4. Decrease vascularity and risk of thyroid storm: anti-thyroid medications, beta blockers, lugol’s iodine [SSKI]
5. Rx of Beta-Blockers: continued for 7-10 days post-op because of longer t ½ of T4
6. MTC: r/o Phaeochromocytoma and MEN syndromes
7. Serum Calcium & PTH assay
8. In c/o thyroidectomy for solitary thyroid nodule, workup
TFT- serum TSH [higher TSH is an independent risk factor for malignancy]
USG, Radionuclide scintigraphy
FNAC
Thyroid suppression therapy 30-09-2021
41
42. 1. Adequately consented
2. North facing endotracheal tube, so that it doesn’t interfere with surgical field.
3. LA – to help hemostasis while raising flaps; aids in post-op analgesia.
4. Neuromonitoring
5. Surgical aids: loops, microscope, fine bipolar forceps, ligaclips
6. Mild hypotensive anesthesia should be used but reversed before the procedure is
completed.
30-09-2021
42
56. METICULOUS DISSECTION
Preserving Superior
Laryngeal nerve
Each branch of superior thyroid
vessels is isolated, ligated and
divided individually at the point
where it enters the thyroid gland.
Preserving and
identifying RLN
Knowing the course and
anatomic variants
Parathyroid
preservation
• Familiarity with anatomic
location
• Inferior: fat surrounding inferior
thyroid vessels
• Superior: poster lateral to RLN
• Preserve posterior thyroid
capsule
• Divide inferior thyroid, distal to
origin of blood supply to
parathyroid.
30-09-2021
56
57. POSITIONING
• Supine
• Semi-fowler’s position
• Neck extended
Shoulder roll
• Head supported by donut pillow
Allows anterior mobilization of the
visceral compartment.
r/o cervical spine ds.
Pre-op antibiotics- no need
Draping- double towel
30-09-2021
57
58. INCISION
KOCHER COLLAR INCISION
1. 1 fingerbreadth below cricoid anterior arch.
2. 2 fingerbreadths above suprasternal notch.
3. Incision in or parallel to normal crease: good post-op
cosmesis.
4. Stretching it to a silk ligature over the planned incision site
facilitates marking a balanced skin incision.
5. Incision should be in midline.
6. Incision too low, in women with larger breasts, descend
into sternum, high chance of keloid formation.
7. Length : adequate for mobilisation
8. Larger incisions: larger lesions/short or heavy necks/low
set larynx
30-09-2021
58
60. SURGICAL OUTLINE
o Ventral to Dorsal Approach
o Inferior Pole Dissection
o Berry’s Ligament Dissection
o Superior Pole Dissection
o Isthmusectomy
o Contralateral Surgery
o Closure
30-09-2021
60
63. STRAP MUSCLES & MIDLINE AIRWAY
1. Palpate thyroid cartilage prominence midline
2. Make an incision through cervical fascia in the midline and extend the incision to
expose the full length of the strap muscles. [sternothyroid & sternohyoid]
3. Elevate sternohyoid muscle in midline.
4. Elevate sternothyroid muscle and dissect the thyroid capsule away from it on both sides.
5. This permits adequate digital exploration of entire thyroid gland.
6. Most cases, retract strap m/s: laterally, retract thyroid lobe in opp. direction
7. If gland is unusually large: transect sternothyroid muscle [laryngeal part] in upper third
[Why?]
30-09-2021
63
65. STAP MUSCLES- DIVISION- YES OR NO?
If lateral retraction of the strap m/s doesn’t provide adequate exposure,
they should be divided without hesitation.
Maneuver can helpful not only when thyroid lesion is large but also, when
• Thyroid and larynx are low set
• Barrel chested males in c/o COPD
30-09-2021
65
67. True thyroid capsule has large capsular vessels, which cause significant
bleeding, if handled aggressively.
Pyramidal lobe: inferior most portion of the embryological remnant of the
thyroglossal duct tract. 30-40%
Look for Delphian lymph nodes in this area.
30-09-2021
67
69. 30-09-2021
69
Loose connective tissue after division/retraction of strap
muscles
Its between true capsule of thyroid and straps
It’s the false thyroid capsule/peri-thyroidal sheath
Represents: pre-tracheal portion of the middle or visceral
layer of the deep cervical fascia
Cauterize occasional vessels which are undersurface of
the straps, arising from the true capsule after individual
identification.
True thyroid capsule bluntly dissected digitally
71. Lateral thyroid region is opened up by division of middle thyroid vein
Ligate Middle Thyroid Vein, if +
Retract laterally:
Strap muscles
Carotid sheath to some extent
SCM
Medial retraction of the thyroid gland and Laryngotracheal complex
exposes the parathyroids and RLN
Tip: Gauze and digital retraction works best, avoid instruments that
penetrate the thyroid such as the Lahey’s clamp
30-09-2021
71
73. INFERIOR POLE DISSECTION
Dissection of inferior pole related veins
Inferior parathyroid identified
Inferior parathyroid swept away and preserved with dissection being medial to upper cranial
aspect of the inferior parathyroid gland
Ideally: inferior parathyroid marked with a small surgical clip, reflected inferiorly & laterally
before one searches for the RLN.
30-09-2021
73
77. RLN & Inferior Thyroid artery
• Several approaches
• Triangles [mentioned earlier]
• Thoracic inlet in the RLN Triangle: advantage single nerve trunk [prior to branching]
• Most extra-laryngeal nerves are superior, once its crossed the inferior thyroid artery.
• If found at inferior location, avoid tracing the entire course
• Identify inferior thyroid artery
• Inferior thyroid artery and RLN- intimate foreplay, relations described earlier
• Its typically deep to the artery
• Relationship varies from side to side
• Identification of ITA not only helps in identification of the RLN but also the parathyroid.
30-09-2021
77
82. DISSECTION AT LIG. OF BERRY
Challenging
Indiscriminate cautery and clamping- neural injury
RLN should be dissected and visualized up until it disappears from the surgical field by
entering the inferior most fibers of the inferior constrictor muscle lateral to the cricothyroid
m/s at the lower edge of the lateral cricoid cartilage k/a laryngeal entry point
RLN should be in constant view during retraction.
Lig. of Berry – if post component + to RLN, judicious thyroid lobe retraction conveyed to the
nerve upward bowing of the nerve; transient neuropraxia
30-09-2021
82
84. SUPERIOR POLE & SLN
1. Why now? Greater lobe mobilization
2. Superior pole vessels are dissected, downwards mobilization using mayo
clamp.
3. Superior pole parenchyma facilitating downward retraction.
4. Final segment of RLN identified with ease
5. Better accessibility: sternothyroid transection, and medial retraction of the
complex
6. Laryngeal head of the sternothyroid muscle as It inserts on the oblique line
of thyroid cartilage of the larynx, robust indicator of EBSLN, as it runs down
just posterior on the inferior constrictor muscle on the lateral edge.
30-09-2021
84
87. • Superior pole vessels should
be taken individually to
optimize their control
Avoids risk to EBSLN
• Posterior branches of superior
thyroid artery may contribute
to the blood supply of the
superior parathyroid , should
be reflected posteriorly &
maintained
30-09-2021
87
91. ISTHMUS
Can be divided easily
Any point of thyroidectomy
Generally, divided at the junction with the contralateral lobe opposite to tumor
30-09-2021
91
92. BEFORE CLOSURE
1. If appropriate, lobectomy specimen frozen section.
2. Examine neck for nodes [jugular III/IV]
3. Inspect for parathyroid glands
4. Lee found that 11% of 414 thyroidectomy specimens had parathyroid
5. Any presumptive parathyroid should be biopsied for confirmation and then autotransplanted.
30-09-2021
92
93. FINAL CLOSURE
1. Assess for hemostasis on thyroid bed, strap m/s and airway
2. Ask anesthetist to give cycles of PPV, assess for bleeders, if any
3. Proper wash
4. Drains are infrequently needed, individual choice
5. With large dead space, extensive dissection and strap muscle tansection; drainage may be
appropriate, 15 Fr JP drain.
6. 3-0 absorbable suture, re-approximate strap muscles
7. Close platysma with absorbable sutures
8. Skin: subcuticular stitches
9. Remove dressings after 2 weeks.
30-09-2021
93
94. THYROID BED UPTAKE AFTER TOTAL
LOBECTOMY
LIG OF BERRY
Most common
Close relationship with RLN
PYRAMIDAL LOBE
Must be sought and dissected
superiorly to the level of notch in
the thyroid cartilage
SUP. POLE
More tapered
More bullous
Clamps should be placed high to
encompass
Don’t mass ligate the superior pole
Ligate individually.
30-09-2021
94
95. POST-OP CARE
Tracheomalacia- on extubation
1. Position: 45 degrees head up for first hours post-op
2. Steroid therapy [i/v] in first 24 hours [analgesia + reduces trans neuropraxia]
3. Antibiotic prophylaxis + analgesia
4. Early mobilization
5. Resume oral intake: complete consciousness, within 4 hours
6. Drain removal <20ml/24h or <10ml/8h
7. Calcium management
8. Post-op VC check
9. Venous thromboembolism prophylaxis: within 24h till discharge
30-09-2021
95
97. HAEMORRHAGE [1%]
1. Slippage of ligatures
2. Ppt by vigorous coughing or retching in post op period
3. S/S: tachycardia, breathlessness, hypotension
4. Progressive tension hematoma under strap muscles
5. Bedside removal of skin & deeper sutures
6. Later shift to OT and assess
7. BT (sos)
30-09-2021
97
100. HYPOPARATHYROIDISM
• Clinical assessment for HYPOCALCEMIA [clinical signs]
• Asymptomatic: no Rx
• Symptomatic hypocalcemia: Treat with P/O- I/V [Calcium prepn]
• Need for supplementation > 6 months: permanent hypoparathyroidism
• After 2 months: try weaning off from oral calcium and re-assess.
30-09-2021
100
101. THYROID STORM/CRISIS
Unusual
In thyrotoxic patients, inadequately prepared
Happens due to stress or operations
Mortality ~ 50%
Tachycardia, hyperpyrexia, cardiac collapse, altered mental status, hypotension,
severe dehydration, tremors and nausea
30-09-2021
101
103. HUNGRY BONE SYNDROME
1. Pts with pre-op hyperthyroidism
2. Increased bone breakdown in their hyperthyroid state
3. After surgery bone breakdown over, “hungry” for calcium
4. Remove calcium from plasma rapidly, Sr. ALP rises
5. HypoCa, HypoPO4, HypoMg, HyperK ECG changes +
6. Hyperkalemia: urgent treatment
7. Magnesium infusion needed.
8. Rx: Vit D3 + Calcium supplentation for 6 months
30-09-2021
103
104. EBSLN INJURY
Mostly unnoticed, more common [as compared to RLN palsy]
Unless professionals [singers, teachers]
Diagnose with fiber-optic laryngoscope
Bowing of VC on paretic side
Videostroboscopy : Assymetric mucosal traveling wave
laryngeal EMG: denervation to cricothyroid muscle
Rx : speech therapy
30-09-2021
104
105. NERVE INJURIES IN THYROID SURGERY
I. EBSLN injury- not life threatening. Will just lead to
hoarseness
• Inability to sing a high pitch: cricothyroid
II. U/L RLN injury: hoarseness
I. B/L RLN injury- airway obstruction, stridor [emergency]
30-09-2021
105
106. OTHER COMPLICATIONS
1. Hypothyroidism: supplement levothyroxine
2. Infection antibiotics
3. Recurrent thyrotoxicosis: more common with subtotal thyroidectomy
4. Seroma formation
30-09-2021
106
110. INTRA-OPERATIVE NEUROMONITORING
IONM systems for RLN/X: electrical stimulation– EMG signal at VC
Detected by electrodes embedded in ET tube
All IONM: Intermittent direct stimulation, before & after thyroid surgery
Continous stimulation of vagus monitor, during dissection
Some developed countries, mandatory
30-09-2021
110
112. FLUROSCENT IMAGING AIDS FOR
PARATHYROID IDENTIFICATION
1. Critical for prevention of hypoparathyroidism
2. Detects fluorescence from parathyroid glands
3. Parathyroid tissue auto-fluoroscence in the near infra-red spectrum [285nm]
4. Detection: spectroscopy
5. Adv: non-invasive & avoidance of exogenously administered fluorophore
6. Disadv: limited penetration [few mm], software expertise, visible spectrum light to be turned off
7. Exogenous fluorophore: indocyanine green [i/v]
30-09-2021
112
115. BIBILIOGRAPHY
1. Surgery of the Thyroid and Parathyroid glands- 2nd edition: Gregory W. Randolph
2. Atlas of thyroid surgery: principles, practice and clinical cases: Ernest
Gemsenjaeger
3. Chassin’s operative stategy in General Surgery: An expositive atlas: 4th edition
4. SRB’s surgical operations: text and atlas
5. Kirk’s general surgical operations: sixth edition
6. Scott-Brown’s otorhinolaryngology head & neck surgery- volume I, 8TH edition
7. Sabiston textbook of surgery: 21st edition.
8. Schwart’z principles of surgery: 11th edition
30-09-2021
115
117. In what location,
relative to inferior
thyroid artery, is the RLN
found?
1. Medial or posterior to the ITA
2. Lateral or anterior to the ITA
3. Passing b/w the branches of ITA
4. All of the above
30-09-2021
117
119. An asymptomatic child with
normal physical
examination is found to
harbor a mutation in codon
918 of the RET tyrosine
kinase receptor,
compatible with MEN 2B.
USG of neck is
unremarkable & Sr.
Calcitonin levels are
normal. What course is
indicated ?
1. Repeat examination and
ultrasound yearly
2. Total thyroidectomy
3. Planned thyroidectomy in 3-5
years
4. Total thyroidectomy with bilateral
neck dissection
30-09-2021
119
120. 48/F with thyrotoxicos is
referred to the clinic,
she was poorly
controlled on
carbimazole and has
received orbital
radiotherapy for severe
proptosis. This has
improved matters but
she has relapsed on
stopping her
carbimazole.
1. Tru cut biopsy
2. Radioactive iodine
3. Thyroid lobectomy
4. Total thyroidectomy
30-09-2021
120
121. 55/M is in the HDU for
many months after
open aortic surgery.
He is maintained on
TPN. Clinically he is
euthyroid, but his TFT
reveal low TSH & low
T4. Diagnosis?
1. Sick euthyroid syndrome
2. Hypothyroidism
3. Hashimotos thyroiditis
4. Poor compliance with
thyroid metabolism
30-09-2021
121
122. Last dose of
carbimazole when
given in pre-op
preparation in a
thyrotoxicosis patient
for thyroid surgery is
given at?
1. 7 days prior to surgery
2. 5 days prior to surgery
3. 3 days prior to surgery
4. Evening before surgery
30-09-2021
122