T e k n i k O p e r a s i

TIROID

Roys Pangayoman

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SEJARAH

Goiter = Gutter (tenggorokan) Aulus Cornelius Celcus (30AD) : Strumectomy = membuang

struma Paul of Aegina (607-690): operasi struma harus hati-hati

mengenai A.carotis dan N.reccurentes Albucasis (Baghdad, 1000) : first successful thyroidectomy Ruggiero Frugardi “Roger of Salermo” (1170) : operasi Struma

(dalam Chirurgia Magistri Rogeri) Lorentz Heister (1683-1758), Jerman : tiroidektomi pertama di

dunia (1752) dalam “Chirurgie”. Theodor Kocher (1841-1917), Bern, Swiss: 5000 tiroidektomi

dgn preservasi kel.paratiroid dan n.laringeus rekurens. Menurunkan mortalitas dari 50% menjadi kurang dari 1%.

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Halsted, berguru pada Kocher : (1906: Menyembuhkan tetani pasca tiroidektomi dengan suplemen paratiroid sapi; 1908: tetani hubungan dengan kalsium; 1920: Buku “The operative story of goiter”)

Radical Neck Dissection Operasi tiroid per endoskopi

o Gassless techniqueo Supraclavicular approacho Mammary approach

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TERMINOLOGI

Tiroidektomi : pengangkatan kelenjar tiroid

Lobektomi : pengangkatan satu lobus kelenjar tiroid

Ismulobektomi : pengangkatan satu lobus kelenjar tiroid beserta isthmusnya

Subtotal tiroidektomi: mengangkat sebagian besar tiroid kedua lobus (kiri-kanan) dengan menyisakan jaringan tiroid masing-masing 2–4 gram.

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Near total tiroidektomi: ismolobektomi dekstra dan lobektomi subtotal sinistra dan sebaliknya, sisa jaringan tiroid masing-masing 1–2 gram.

Total tiroidektomi: pengangkatan “seluruh” kelenjar tiroid

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ANATOMI

Kelenjar, warna coklat terang, kenyal, terdiri dari 2 lobus (kiri dan kanan) dihubungkan melalui isthmus. (dan kadang2 lobus piramidalis)

Lokasi: anterior leher, vertebra C5-T1, berat 15-20 g, panjang 5 cm, lebar 2 cm, tebal 2-4 cm. Tebal isthmus 2-6 mm.

Dikelilingi 2 kapsul: true capsule dan false capsule (perithyroid sheath, surgical capsule)

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IMPORTANT STRUCTURES Ventral: platysma, false capsule,

m.sternothyroid, m.sternohyoid Superior: kartilago tiroid Posterolateral: carotid sheath dan

m.sternocleidomastoid Posterior: menempel dengan membrana

cricothyroid dan cartilago cricoid melalui Ligamentum of Berry.

Anterior: strap muscles (sternothyroid, omohyoid, sternohyoid, thyrohyoid)

Kelenjar parathyroid (4 buah) yg terletak di posterolateral superior dan inferior. Di superior terletak di antara true dan false capsule setinggi cartilago cricoid. Di inferior terletak anterior dari n.larygeus reccurens

Fascia superficialis dan deep fascia. VASKULARISASI

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Arterio A. thyroidea

sup – cabang a.carotis ext

o A. thyroidea inf – cabang truncus thyro cervical dari a.subclavia

o A. thyroidea ima – cabang arcus aorta/ a.innominata

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Vena

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o V. thyroidea sup – menuju v. jugularis internao V. thyroidea media – menuju v. jugularis internao V. thyroidea inf – menuju v. brachiocephalica

Limfatiko Terutama menuju nodus jugularis internao Pole superior dan medial isthmus menuju ke nodus grup

superioro Pole inferior menuju nodus grup inferior dan nodus pretracheal

Persyarafano Simpatis: berasal dari ganglia simpatis cervicalis sup dan

medial, berfungsi sbg vasomotoro Parasimpatis: berasal dari n. vagus, menuju ke kel.tiroid melalui

cabang2 n.laringeus rekurens yg mempersarafi otot2 intrinsik laring & cab.externa n.laringeus superior (m.cricotiroid)

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INDIKASI TIROIDEKTOMI (Chassin, Lore, Zollingers, Clark’s CURRENT)

1. Goiter besar/ multinodular goiter 2. Kecurigaan keganasan3. Penekanan ke organ sekitar4. Tirotoksikosis residif setelah penghentian obat / nonresponsif 5. Severe opthalmopathy (exopthalmus)6. Hyperthyroidism in pregnancy (…controversy) or children7. Woman who wish to became pregnant within 1 year of treatment8. Kosmetik

Schwartz: Surgical treatment of the thyroid is performed:1. to establish the diagnosis in a patient with a mass within the thyroid

gland2. to remove benign and malignant tumors3. as therapy for thyrotoxicosis4. to alleviate pressure symptoms attributable to the thyroid

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KONTRA INDIKASI 1. Inoperable tumor (sudah ekstensi ke struktur organ lain:

trachea, esofagus, dll)2. Hipertiroid (relatif)

KOMPLIKASI Early:

o Perdarahano Serak, afonia, paralisis pita suarao Krisis tiroid (thyroid Storm)o Pneumothorax – possible but rare (Lore)

Late:o Hipokalsemia (hipoparatiroid)o Hipotiroido Nekrosis flap

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Komplikasi Lain

Non metabolik: o Nerve injury (n.laryngeus recurrens serak / cabang

external dari n.laryngeus superior tidak bisa bersuara high pitch)

o Perdarahano Obstruksi jalan nafaso Nekrosis flap

Metabolik: (hipoparatiroidisme)o Terjadi sekitar 0,6-2,8%o Klinis: baal-baal, baal ujung jari, gelisah, spasme

carpopedal (tetani)o Th/: 10 cc Calcium Gluconas IV dilanjutkan pemberian

kalsium oral 1,5-2 g per hari atau Calcitriol (Rocatrol) 0,25 15

– 10 microgram, 2 kali sehariKRISIS TIROID (THYROID STORM)

= hyperthyroid crises precipitated by surgical stress or trauma (Current)= Mortalitas ±10% jika tidak ditangani dgn baik.Gejala:

1. Febris2. Delirium3. Kejang4. Diare

5. Muntah6. Takikardia7. Congestive heart failure8. Berkeringat

Th/: 1. Hentikan operasi 2. Oksigen3. Bolus D 40% 20-25cc4. Beta bloker (propranolol) 40 –

60mg p.o. tiap 4 jam atau 2 mg iv selama 4 jam

5. PTU 1200 – 1500 mg/ hari (200-250 mg/ 4 jam peroral)

6. Methimazole 120 mg/ hari (20 mg/ 4 jam peroral) atau carbimazole 14-40 mg peroral

7. Lugolisasi (KI 5 gtt/ 6 jam)8. Dexamethason 2 mg / 6 jam iv

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9. Antipiretik10. Koreksi elektrolit11. Cegah hipotermi

Bechara Y. Ghorayeb, MD, PAOtolaryngology - Head & Neck Surgery

8830 Long Point, Suite 806Houston, Texas 77055

Thyroidectomy  Informed Consent

Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed. The most common indications for thyroidectomy include a large mass in the thyroid gland, difficulties with breathing related to a thyroid mass, difficulties with swallowing, suspected or proven cancer of the thyroid gland and hyperthyroidism (overproduction of the thyroid hormone). Your physician will discuss the need for thyroidectomy based on your history, the results of a physical examination and tests. The most common tests to determine whether a thyroidectomy is necessary include a fine needle aspiration biopsy, thyroid scan, ultrasound, x-rays and/or CT scan, and assessment of thyroid hormone levels. The procedure is usually done under general

anesthesia. The extent of surgery (removal of one or both lobes) may sometimes be determined in the course of surgery after microscopic examination of tissue removed during the surgery.

After surgery it is very common to have difficulty in swallowing. Occasionally, swallowing may even be a little painful.  This pain usually resolves within 24 to 72 hours.

Bleeding or infection are also possible short term complications. Although rare in thyroid surgery, some patients may develop a thick scar or keloid.

Two complications specific to thyroid surgery are hypocalcemia and vocal cord weakness or paralysis.

Hypocalcemia, or low blood levels of calcium, may occur after complete removal of both thyroid lobes. This condition is caused by injury or interference with the blood supply of four tiny glands called parathyroid glands, which are located within or very close to the thyroid gland. Hypocalcemia is usually temporary, but sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcemia is fortunately rare.  This is why, serum calcium, magnesium and phosphorus levels are

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carefully monitored in the first 24 hours after the surgery. 

Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the thyroid gland. Temporary hoarseness may result. Again, this is an uncommon, usually temporary complication. Permanent vocal cord paralysis is rare.

Frozen section and final diagnosis:   During surgery, the specimen removed is examined by the pathologist who performs frozen sections.  In the majority of cases, the pathologist is able to distinguish between benign and malignant lesions.  In a very small percentage of patients,however, the frozen section may not identify a small cancer which is picked up on permanent sections, a few days later. When this happens, the patient may have to return to surgery for removal of the remaining thyroid tissue and sometimes lymph node dissection. 

Depending on the final histologic (microscopic examination) diagnosis of the gland removed, and on the blood tests, continuous follow-up by the

endocrinologist and / or surgeon may be indicated for replacement of the thyroid hormone. Following total thyroidectomy, patients have to take replacement thyroid hormone for the rest of their life.

I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, and I/We have sufficient information to give this informed consent.  I/We certify this form has been fully explained to me/us, and I/We understand its contents.  I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

_________________________________________________________________________________________Patient / Legal Guardian

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___________________________________________Date: __________________________Time__________

Witness

TEKNIK OPERASI

1. Posisi pasien dalam SUPINE atau SEMI FOWLER2. Bahu diganjal dgn bantal sehingga LEHER HIPEREKSTENSI

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3. Kepala diletakkan di atas donut balloon, yakinkan posisi dagu sejajar dgn long axis tubuh pada garis median

4. Aseptik dan antiseptik di leher dan sekitarnya5. Dibuat MARKER UNTUK INSISI dengan

menggunakan silk 2-0 pada lipatan kulit leher ± 2 jari di atas sternal notch (atau 1 cm di bawah cartilago cricoid), memanjang sampai ke otot sternocleidomastoid

6. Jika benjolan hanya pada satu sisi/ lobus, insisi tetap sama agar dapat mengekspos sisi lain

7. Insisi kulit, subkutis dan platysma sekaligus menjadi satu flap – mobilized as one layer (untuk mencegah perdarahan, edema dan perlengketan postoperasi)

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8. DISEKSI tumpul dengan jari atau kassa pada batas platysma dengan loose areolar tissue di bawahnya, tepat superficial dari vena jugularis anterior – no blood technique. Diseksi dilakukan ke arah CAUDAL (sampai sternal notch) dan CRANIAL (sampai terlihat cartilago thyroidea) dan dibuat flap yang difiksasi ke kain drapping.

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9. INSISI FASCIA colli superficialis secara vertikal pada GARIS TENGAH strap muscle hingga batas bawah sampai level sternal notch, batas atasnya sampai cartilago thyroid. (Pada tumor yang besar dapat dilakukan pemotongan otot strap muscle secara horizontal di 1/3 proximalnya setelah sblmnya v.jugularis anterior diligasi)

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10. Diseksi tumpul pertengahan strap muscles sampai fascia colli profunda. Fascia ini diincisi.

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11. Dilakukan pemisahan kelenjar tiroid pada cleavage plane (antara kelenjar tiroid dgn m.sternocleidomastoideus) *

12. Strap muscle (m.sternohyoid dan m. sternothyroid) diretraksi ke kiri dan ke kanan.

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13. Dilakukan diseksi tumpul dan tajam mulai dari tiroid di bagian tengan dengan mengidentifikasi v.thyroid media. Vena ini diligasi dan dipotong.

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14. Diseksi dilakukan ke pool bawah dengan mengidentifikasi arteri dan v.thyroidea inferior dan diligasi. Juga harus diidentifikasi dan dipreservasi n. laryngeus reccurens yang terletak di daerah tracheoesofageal groove, umumnya berjalan di antara bifurcatio arteri thyroidalis inferior. Harus diingat variasi anatomis n. laryngeus recurrens

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15. Dilakukan diseksi sedekat mungkin dengan massa tumor dan selalu lakukan 2 buah ligasi ke arah pembuluh darah serta 1 ligasi ke arah tumor.

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16. Diseksi dilakukan hingga ke pool atas. Pembuluh darah dari daerah atas (superior) harus dapat diidentifikasi dengan baik (a/v thyroidalis superior dan a/v thyroidalis inferior) kemudian diligasi dan dipotong.

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17. Dilakukan diseksi tumpul untuk memisahkan kel. Paratiroid dengan kel. Tiroid. Kelenjar paratiroid dapat diidentifikasi berupa jaringan yang terletak di posterior tiroid, berbentuk seperti lemak dan berwarna kekuningan.

18. Kelenjar paratiroid dilepaskan dari kel.tiroid, sambil dipreservasi arteri yang memperdarahinya

19. Kmdn didiseksi dan dilanjutkan ke arah isthmus (pada cleavage plane), ligamentum Berry dan isthmus diklem dan dipotong.

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20. Perdarahan diligasi, sambil dilihat apakah ada robekan pada trachea, kemudian cuci dengan NaCl fisiologis.

21. Posisi pasien dikembalikan ke keadaan semula (ganjal dibuka) sehingga leher kembali berelaksasi. Kemudian dipasang drain ke dasar luka operasi (penrose, vaccum). Strap muscle direkatkan sedekat mingkin. Kemudian fascia colli ditutup dengan jahitan interupted chromic 2-0. Platysma didekatkan dan dijahit interrupted dengan chromic 3-0. Kulit ditutup secara subkutikular dengan benang sintetis 4-0. Luka operasi ditutup dengan kassa steril.

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PASCA OPERASI

1. Posisi head up 30o

2. Periksa pita suara pasca extubasi3. Balutan diperiksa adakah hematoma/ bleeding4. Periksa fonasi suara5. Drain dilepas jika produksi minimal 6. Buka jahitan setelah 10 hari – 2 minggu

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