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Thyroid Operative Notes Modified

last modified on: Thu, 02/29/2024 - 18:24

return to: Modified Operative Notes by Organ Site

The sample dictations below are not intended to be used as templates. They are variations on procedures and should not substitute for the surgeon's own dictation. They are provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences. Click on the large blue title of the procedure to move to the actual protocol.

Thyroidectomy and Thyroid Lobectomy

SAMPLE DICTATION

The sample dictations below are not intended to be used as a template. They reflect only two of a multitude a variations on this procedure and should not substitute for the surgeon's own dictation. They are provided to help visualize the procedure from beginning to end and to illustrate key points and staff preferences.

  1. Informed consent was reviewed with the patient in the preoperative evaluation area. The patient was brought to the operating room and placed on the operating table in the supine position. The patient was then transorally intubated and an incision planned in a skin crease at 1 fingerbreadth above the clavicles. A shoulder roll was then placed. The neck was prepped with chlorhexidine and draped in sterile fashion. Lidocaine 1% and epinephrine 1:100,000 was injected in the incision line. A 15-blade knife was used to make the skin incision, which was carried down through the platysma to the level of the strap muscles. Subplatysmal flaps were not elevated to prevent hematoma. The strap muscles were split in the midline raphae. The thyroid isthmus was identified and split over the trachea. The left hemithyroidectomy was performed by dissecting strap muscles off of the nodule, and the superior pole of the thyroid gland was identified. In dissecting around the superior pole of thyroid, the superior parathyroid gland was identified and was dissected away from the thyroid lobe. The gland was then retract superiorly and laterally and the inferior pole was released. The thyroid lobe was retracted out of the surgical bed and the remaining attachments of the thyroid were released from the trachea. The thyroid was carefully examined, and there was no evidence of parathyroid tissue on it after removal. The left recurrent laryngeal nerve was identified and its identity verified with a nerve stimulator which resulting in contraction of the posterior cricoarytenoid muscle. Next, the right side was dissected free in a similar fashion. During dissection of the right lobe, the superior parathyroid gland and recurrent laryngeal nerve were also identified and spared. The right recurrent laryngeal nerve was able to be stimulated at the end of the procedure resulting in contraction of the posterior cricoarytenoid muscle. After both thyroid lobes were removed, all bleeding was stopped with bipolar cautery, and the wound was copiously irrigated with sterile saline. No evidence of any lymphadenopathy in level 6 was noted. A 15-French Jackson-Pratt drain was inserted and secured to the skin with 3-0 nylon suture. The wound was then closed by reapproximating the strap muscles and platysma with deep 3-0 Vicryl stitches. The skin was closed with a running 4-0 Monocryl subcuticular stitch and Benzoin and Steri-Strips placed over the incision. The patient tolerated the procedure well, was extubated in the operating room and transferred uneventfully to the post anesthesia care unit.

  2. Total Thyroidectomy (Dr. Sperry):

Variation including using a laryngeal nerve monitoring endotracheal tube:

Informed consent was reviewed with the patient in the preoperative evaluation area. The patient was brought to the operating room and placed on the operating table in the supine position. The patient was then transorally intubated with a laryngeal nerve monitoring endotracheal tube, with visualization to confirm correct placement of the electrodes at the level of the glottis. An incision was planned in a transverse skin crease below the cricoid, with the neck extended. The neck was prepped and draped in sterile fashion. An incision was made which was carried straight down through the platysma to the level of the middle layer of the deep cervical fascia investing the strap muscles. The anterior jugular veins were identified and suture ligated. The fascia over the strap muscles was elevated superiorly and inferiorly, deep to the veins, up to the level of the thyroid notch and down to the clavicular heads. The sternohyoid and sternothyroid strap muscles were deinvested of fascia along the midline raphae, entering the visceral compartment. The thyroid tissue extending along the pyramidal lobe and remnant thyroglossal duct tract was dissected first, removing this from the level of the hyoid back down to the isthmus, including any lymph nodes.

The left hemithyroidectomy was performed by dissecting the sternothyroid strap muscle off of the lobe, and the superior pole of the thyroid gland was identified. To aid exposure of the superior pole, the sternothyroid strap muscle was cut at its superior attachment to the thyroid cartilage and reflected laterally, preserving the neurovascular bundle to the muscle. Dissection and ligation of vessels entering the thyroid gland was facilitated with the Ligasure hemostatic device. In dissecting around the superior pole of thyroid, the superior parathyroid gland was identified and was released away from the thyroid lobe. The gland was then retracted and the lateral and inferior fascia and vessels were released. The thyroid lobe was retracted out of the bed by rolling medially and the inferior thyroid vessels entering the thyroid at the tubercle of Zuckerkandl were carefully dissected and ligated. An inferior parathyroid gland was also separated from the thyroid gland and preserved with a lateral blood supply. Once the vessels were released from the gland, the recurrent laryngeal nerve was clearly visible medial and deep to this. The nerve was followed to where it entered deep to the laryngeal muscles, and it was gently retracted laterally away from the posterior-medial thyroid attachments, and the remaining attachments of the thyroid at Berry’s ligament were completely released from the trachea by sharp dissection. The thyroid was carefully examined, and there was no evidence of parathyroid tissue on it after removal. The left recurrent laryngeal nerve function was verified with a nerve stimulator which resulted in palpable contraction of the posterior cricoarytenoid muscle.

Next, the right lobe was dissected free, in a similar fashion as described for the left lobe. During dissection of the right lobe, the superior and inferior parathyroid gland and recurrent laryngeal nerve were also identified and preserved. The right recurrent laryngeal nerve was able to be stimulated at the end of the procedure resulting in contraction of the posterior cricoarytenoid muscle.  The specimen including both thyroid lobes and the pyramidal lobe were oriented for pathology. All bleeding was stopped with bipolar cautery, and the wound was copiously irrigated with sterile saline. No evidence of any palpable or abnormal appearing lymphadenopathy in level 6 was noted. A Jackson-Pratt drain was inserted and secured to the skin with 3-0 nylon suture. The wound was then closed by loosely reapproximating the strap muscles in the midline to cover the cricoid cartilage. The deep cervical fascia was reapproximated with 3-0 monocryl suture. The skin was closed in layers with 4-0 monocryl dermal sutures with good eversion and superficial skin approximation, followed by a running 5-0 monocryl knotless subcuticular stitch. The skin was cleaned and dried, and benzoin was applied to the peri-incisional skin and steri-strips placed lengthwise over the incision. The patient tolerated the procedure well, and was extubated in the operating room and transferred uneventfully to the post anesthesia care unit, without any noted stridor or breathing impairment.

 

Case Example of Thyroglossal duct cyst excision standard approach

After written informed consent was obtained with a history and physical reviewed along with a brief 'time out', the patient was placed under general anesthesia with endotracheal intubation with a 6.0 MLT tube.  The patient was positioned with the back-elevated, neck extended position with the head toward anesthesia. Benzoin was placed across the chin and a 1010 drape placed with adherent (sticky) portion applied to benzoined region with remained draped over mouth to permit later access to oral cavity.

The patient was then prepped (including 1010 drape) and positioned for a central neck dissection thyroglossal duct cyst removal. Just to the left of midline, a large mass was palpated. A 15 blade was used to incise the skin with a horizontal marked incision and down onto the mass. Subplatysmal flaps were raised superiorly and inferiorly down to the area of the thyroid. We divided the straps midline. Of note just to the left of midline, the strap muscles were adherent to the cyst. Inferiorly the cricoid cartilage was identified as well as the thyroid. The mass was dissected around and it appeared to be in continuity with the pyraminal lobe and isthmus. The thyroid was divided to the right and then to the left and tied off with a 3-0 silk running stitch to permit resection of the isthmus in-continuity with the mass extending above.

We dissected the cyst and mass from an inferior to superior direction as it was removed from the cricothyroid muscles and thyroid cartilage up to the hyoid bone with care to avoid the superior laryngeal nerves. A small amount of strap musculateure was removed with the specimen where it was densely adherent on the left side.

The hyoid bone was identified with preservation of soft tissue about the central portion and isolation of the bone laterally. On the right side, just medial to the lesser cornua and used a Freer underneath to protect while we released the hyoid with the mighty bite. The left side was addressed in identical fashion, except that we were lateral to the lesser cornua. The dissection was carried superiorly with a cuff of muscle.

From above, surgeon reached into the mouth and palpated the foramen cecum with the left hand and arm protected with a sterile sleeve and second glove - placed to permit later removal from the contaminated oral cavity to permit continued sterile dissection in a sterile field. With anatomic control directed by palpation intra-orally with concurrent dissection of the open neck, clips were placed to mark the region of the undersurface of the base of tongue where the TGD cyst was to be severed. Final cuts with the bovie were similarly directed both by intra-oral palpation and extra-oral inspection.

Frozen section was taken from the superior most part of the tract - revealing no evidence of a tract. Had there been a tract identified, further dissection (potentially communicating intraorally) would have been done where the hemoclips had been placed above the hyoid (see also: Case example thyroglossal duct cyst with tract through to oropharynx.)

The defect was closed by approximation of tongue base musculature (with care to remain extra-oral) buried 3-0 Vicryl stitches. The strap muscles were reapproximated with 3-0 Vicryl stitches and the wound was copiously irrigated with multiple bulbs of irrigation with normal saline. The platysma was then closed with buried 3-0 Vicryl stitches. This was after a fully perforated Jackson-Pratt drain was placed in the wound and brought out centrally and secured with 3-0 nylon. The platysmal layer was closed with buried 3-0 Vicryl. The dermis was approximated with interrupted 4-0 Monocryl and then a subcuticular closure was performed with a running 4-0 Monocryl. Skin closure was supplemented with several interrupted 5-0 nylon stitches.