Thyroidectomy Asma Dahir - Surgical Tech

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Relevant Anatomy❖ Thyroid Gland: 2 lobs that are anterior to

the larynx➢ Lobs are connecting by the thyroid

isthmus at the level of the second tracheal ring

➢ A fibrous capsule invests the thyroid➢ Thyroid crosses the trachea and

esophagus➢ Consists of two groups of cells:

■ Follicular cells: produce, store, and release triiodothyronine

■ Parafollicular cells: secrete calcitonin

Relevant Anatomy❖ Arterial blood supply: Superior and

inferior thyroid arteries➢ Branch of the external carotid

artery; it courses downward and toward the apex of the lateral lobe

➢ Inferior thyroid artery is the largest branch of the thyrocervical trunk of the subclavian artery

❖ Venous drainage: Superior thyroid, middle thyroid and continues downward to the inferior pool

❖ Nerve Supply: via the cardiac, superior laryngeal and inferior laryngeal nerves.

Physiology❖ The thyroid is part of the endocrine

system, which is made up of glands that produce, store, and release hormones into the bloodstream so the hormones can reach the body's cells. The thyroid gland uses iodine from the foods you eat to make two main hormones: Triiodothyronine (T3) Thyroxine (T4)

Pathophysiology ❖ Hyperthyroidism:

➢ Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormone by the thyroid gland.

❖ Thyroid Carcinoma:➢ A cancer of the thyroid, the

butterfly-shaped gland at the base of the neck.

Diagnostic Exams ❖ History and Physical❖ Physical examination❖ Serum levels of TSH❖ Ultrasound❖ Laryngoscopy❖ Scans❖ Biopsy

Surgical Intervention ❖ A thyroidectomy is an operation

that involves the surgical removal of all or part of the thyroid gland.

Special Consideration ❖ A Queen Anns dressing or a thyroid collar may

be used at the end of the procedure❖ Surgeon my ask for a silk tie to mark the line of

the incision of the neck❖ Often straight mosquito and crile hemostats are

used rather a curved❖ The Surgical Technologist should keep the back

table and mayo stand sterile until the patient has been transported from the OR in case of an emergency tracheotomy

❖ A tracheotomy tray should be transported with the patient to PACU and the ward.

Anesthesia | Positioning ❖ General Anesthesia

❖ Supine position with roll towel or padded sandbag placed between the scapula to extend the neck

❖ Reverse Trendelenburg may be requested:➢ Padded footboard

Skin Prep❖ Begin at the anterior neck - extend

the prep from just below the level of the infra-auricular border and the lower lip to a level just below the niples and sown to the table at the sides of the neck and around the shoulders. Fold a towels are placed at the sides of the neck to prevent prep solutions from pooling under the patient.

Draping ❖ Folded towels and a sheet with a small

fenestration (with a clear plastic adhesive insert) are used; individually drape sheet complete the draping. A sterile sponge may be placed on either side of the neck to prevent blood from pooling under the neck.

❖ Upper towel - placed along chin to follow jawline

❖ Lower towel - placed at level of clavicles

❖ Lateral towel - placed along side of neck using sternal end of clavicles as a landmark

Supplies❖ Knife blades:

➢ #10 x 2➢ #15 x 2➢ Bulb syringe ➢ ¼” Penrose drain

Instruments ❖ Harmonic Scalpel❖ Thyroidectomy set

➢ Includes several sizes of rake retractors, ➢ Green loop retractors, ➢ self-retaining retractors such as a

Weitlaner➢ Straight mosquito ➢ Kelley Hemostat➢ Right angle clamps➢ lahey thyroid clamp

❖ Bipolar forcep electrocautery❖ Hemoclip appliers and ligating clip❖ Head lamp

Incision ❖ Symmetrical, transverse incision

following the Langer lines is mad over the thyroid.➢ Two fingers above the

clavicular head.■ May vary

Procedural Steps ❖ Incision is made through the

skin, and cervical fascia and the platysma muscle is derived➢ Electrocautery or bipolar

electrocautery, hemoclip and ties will be used to control bleeding.

Procedural Steps ❖ Superior and inferior flaps are mobilized

and retractors are placed. The upper skin flap is created to the level of the thyroid notch; two double skin hoools are placed to retract the flap superiorly. The lower skin flap is created down to the sternoclavicular joint. Bleeding continues to be controlled primarily with clamps and ties.

➢ A self-retaining retractor such as a Weitlaner may be placed.

Procedural Steps ❖ The fascia between the strap muscles is

incised and the muscles are separated and the thyroid lobe is exposed. The sternocleidomastoid muscle is retracted with a Green Loop retractor. The middle and inferior thyroid veins are identified, clamped, divided and ligated.

Procedural Steps ❖ The superior poles are retracted caudally

with Lahey thyroid clamps and the tissue between the trachea and superior poles is dissected with the Metzenbaum scissors. The recurrent and superior laryngeal nerves must be identified and preserved.

Procedural Steps ❖ The parathyroid glands and inferior

thyroid artery are identified. The parathyroid glands are mobilized and the vascular supply is preserved.

Procedural Steps ❖ Branches of the inferior thyroid artery

that do not supply the parathyroid glands are clamped, divided, and ligated. The superior connective tissue is divided. Hemostasis is achieved with the ESU.

➢ Recurrent nerved must be preserved

➢ May alternate between sharp, blunt and electrocautery.

Procedural Steps ❖ The thyroid is elevated with Aliss or Lahey

clamps and it is dissected from the trachea.➢ If only one lobe is taken, the

isthmus is divided so that it is removed with the resected lobe.

Procedural Steps ❖ Hemostasis is achieved after lobe(s) are

removed. ➢ If strap muscles have been incised,

they are reapproximated with suture of the surgeon's choice. A Penrose drain may be placed and exteriorized at the midline.

➢ The Platysma muscle is reapproximated and a subcuticular closure is used to bring the skin edges together. Skin closure taped may be applied to the wound and the dressing is applied.

https://youtu.be/HK2xe3BcP6w

Counts | Dressing Material❖ 3 counts

➢ Inicial ➢ platysma muscle ➢ cervical fascia ➢ Final

❖ Queen Anns dressing or a thyroid collar

Specimen Care❖ During the procedure, multiple biopsies

of the thyroid gland and surrounding tissues are taken as frozen sections.

❖ Important that the circulator identifies and documents the specimen and the location in which it was obtained.

Prognosis No Complications:

❖ Return to normal activities in 2 - 4 weeks ❖ Medications usually required for life

Complications:

❖ SSI❖ Hemorrhage ❖ Tetany - Muscle Spasms caused by lack of

Calcium due to the malfunction of the parathyroid glands

❖ Damage to nearby structures - nerves

Wound Class Management ❖ Class 1: Clean

Work Cited ❖ Goldman, Maxine A. Pocket guide to the operating room. Philadelphia: F.A. Davis Co,

2008. Print. (page 771)❖ Frey, Kevin B., and Tracey Ross. Surgical technology for the surgical technologist: a

positive care approach. Boston, MA: Cengage Learning, 2016. Print. (page 501)