Performing surgeon/coauthor: Brendan C. Stack, Jr., M.D., FACS, FACE
Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
-The patient is rotated so that the patients head is pointed away from the anesthesia team, and elevated 30 degrees upward. A shoulder roll is placed underneath the patients shoulders in order to extend the neck. The patient is intubated with an endotracheal NIMS
-A 3cm midline incision is made halfway between the inferior border of the cricoid cartilage and the sternal notch
-dissection is continued down to the strap muscles, and a plastic self-retaining Alexis retractor is placed to maintain exposure
-Strap muscles are divided vertically in the midline and retracted laterally off of the thyroid capsule
-Superior vasculature is identified and ligated with hemoclips and/or a harmonic scalpel
-Thyroid lobe is further dissected down to the level of the tracheoesophageal groove, with continuous interrogation from the electronic handheld probe connected to the NIMS to protect against any accidental nerve trauma. All additional vasculature found is ligated with hemoclips and/or a harmonic scalpel.
-The recurrent laryngeal nerve is identified with the handheld electronic probe connected to the NIMS to confirm its integrity.
-A kittner dissector is held over the recurrent laryngeal nerve for protection while electrocautery is used to incise the enveloping fascia connecting the thyroid lobe to the trachea.
-Isthmusectomy is performed with a harmonic scalpel
-A 10-15 french lumenless drain is placed transcutaneously in selective cases
-Strap muscles are reapproximated using a single interrupted 3-0 vicryl suture in the midline
-The deep dermal layer is closed with interrupted 3-0 vicrly sutures followed by a running subcuticular monocryl suture and a sterile adhesive placed over the closed wound.
-Benign multinodular thyroid goiter +/- compressive symptoms
-Isolated thyroid malignancies less that 4cm
-Isolated thyroid nodules of indeterminate malignant potential (Bethesda III, IV cytology)
-Isolated thyroid nodules greater than 4cm
-Hyper-functional thyroid nodules
-The thyroid should be thoroughly visualized with an ultrasound. MRI/CT can be used if ultrasound shows insufficient visualization or for lesions/enhancements greater than 4cm. Biopsies should be obtained on any unidentified nodules to access for malignancy. Thyroid function levels should be obtained to access for hyper functionality.
-Bilateral nerve damage leading to the need for tracheostomy
-Hypothyroidism (10-20% of patients will need postoperative thyroid hormone replacement)
1.Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1–133. doi:10.1089/thy.2015.0020