Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 6 • Cricothyroidotomy |
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Incision
MC
A
Incision
B
Cricothyroid |
Thyroid cartilage |
muscle |
|
Cricoid cartilage
Finger placed on
Cricothyroid membrane
C
FIGURE 6–2
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S E C T I O N I • H E A D A N D N E C K A N D E N D O C R I N E P R O C E D U R E S |
The CT membrane is cut horizontally using a no. 15 scalpel blade (Figure 6-3).
A hemostat is placed in the CT membrane and the tissue is spread open (Figure 6-4).
Cricothyroid muscle
Incision
Cricoid cartilage
MC
FIGURE 6–3
Cricothyroid membrane
FIGURE 6–4
C H A P T E R 6 • Cricothyroidotomy |
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A small ETT is placed in the incision (Figure 6-5).
Placement is confirmed with the return of CO2 and the auscultation of bilateral breath sounds.
The tube is secured.
3. CLOSING
Not applicable.
STEP 4: POSTOPERATIVE CARE
The cricothyroidotomy is converted to a formal tracheotomy as soon as possible.
See tracheotomy procedure (Chapter 5).
If the previously described process is delayed, the ETT is replaced with a small tracheotomy tube.
Endotracheal tube
FIGURE 6–5
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STEP 5: PEARLS AND PITFALLS
Complications:
Subglottic stenosis
Chondritis
Bleeding
Cricoid fracture
If the landmarks are nonpalpable or there is a hematoma present, a vertical midline incision is made to gain wider exposure (see Figure 6-2, C). This incision can be extended if necessary.
SELECTED REFERENCES
1. Myers EN: Tracheostomy. In Myers EN (ed): Operative Otolaryngology: Head and Neck Surgery. Philadelphia, WB Saunders, 1997, pp 575-585.
2. Morris WM: Cricothyroidotomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed. Philadelphia, Elsevier, 2005, pp 82-83.
3. Tracheostomy. In Lore JM, Medina J (eds): An Atlas of Head and Neck Surgery, 4th ed. Philadelphia, Elsevier, 2005, pp 1015-1023.
4. McWhorter AJ: Tracheotomy: Timing and techniques. Curr Opin Otolaryngol Head Neck Surg 2003;11:473-479.
C H A P T E R 7
THYROGLOSSAL DUCT CYST
Dai H. Chung
STEP 1: SURGICAL ANATOMY
The thyroglossal duct is a persistent remnant of the thyroid gland’s embryologic descending tract from the floor of the pharynx to its final position in the neck. Thyroglossal duct cysts occur most commonly in the midline, just inferior to the level of the hyoid bone.
STEP 2: PREOPERATIVE CONSIDERATIONS
The exact location of the thyroid gland should be determined clinically, because aberrant ectopic thyroid tissue may be mistaken for a thyroglossal cyst.
When a thyroglossal cyst is infected, it should be first treated with antibiotics and/or surgical drainage before complete excision.
Imaging studies are not necessary (unless clinical examination findings are suspicious for aberrant ectopic thyroid).
STEP 3: OPERATIVE STEPS
1.INCISION
This operation (Sistrunk procedure) is performed with the patient under general anesthesia.
The patient is positioned supine and the neck is hyperextended by placing a shoulder roll.
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A transverse skin incision is made over the cyst; however, caution should be used to avoid making a skin incision over the main prominence of the cyst, well away from the hyoid bone (Figure 7-1).
The subcutaneous dissection through the platysma is carried out using scissors and cautery. Deep cervical fascia is cut in the midline to expose the cyst (Figure 7-2).
Incision
MC
Cyst bulging under skin
FIGURE 7–1
Infrahyoid muscle fascia
FIGURE 7–2
C H A P T E R 7 • Thyroglossal Duct Cyst |
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2. DISSECTION
The cyst is dissected away from surrounding superficial attachments and followed between the sternohyoid muscles to the hyoid bone (Figures 7-3 and 7-4). The central portion
of the hyoid bone is freed from strap muscle attachments (sternohyoid muscle inferiorly and mylohyoid, geniohyoid muscles superiorly). After freeing up the posterior plane of the hyoid bone from the thyrohyoid membrane, the surgeon resects the central portion (1 to 1.5 cm) of the hyoid bone along with the thyroglossal duct attachment (Figure 7-5).
Incision
Sternohyoid
muscle
Cyst
FIGURE 7–3
Thyrohyoid membrane
Hyoid bone
FIGURE 7–4
FIGURE 7–5
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The dissection is continued caudally toward the base of the tongue (Figure 7-6) and the remaining duct is ligated with absorbable sutures (Figure 7-7).
Duct of cyst
FIGURE 7–6
Suturing tract
FIGURE 7–7
C H A P T E R 7 • Thyroglossal Duct Cyst |
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3. CLOSING
After meticulous hemostasis, including at the cut ends of the hyoid bone, fascia is approximated in the midline using 3-0 polyglycolic acid sutures. After approximation of platysma using 4-0 polyglycolic acid sutures, subcuticular skin closure is performed. No drain is used.
STEP 4: POSTOPERATIVE CARE
This procedure is routinely performed as an outpatient procedure.
STEP 5: PEARLS AND PITFALLS
Resection of the central portion of hyoid bone with the thyroglossal duct specimen is essential.
Meticulous hemostasis must be achieved before wound closure to avoid postoperative hematoma.
Rule out presence of aberrant ectopic midline thyroid gland.
SELECTED REFERENCES
1. Foley DS, Fallat ME: Thyroglossal duct and other congenital midline cervical anomalies. Semin Pediatr Surg 2006;15:70-75.
2. Bratu I, Laberge JM: Day surgery for thyroglossal duct cyst excision: A safe alternative. Pediatr Surg Int 2004;20:675-678.
3. Ostlie DJ, Burjonrappa SC, Snyder CL, et al: Thyroglossal duct infections and surgical outcomes. J Pediatr Surg 2004;39:396-399.
4. Sistrunk WE: The surgical management of cysts of the thyroglossal tract. Ann Surg 1920;71:121-123.
C H A P T E R 8
ADRENALS—ANTERIOR, POSTERIOR (OPEN AND LAPAROSCOPIC)
Michael D. Trahan
STEP 1: SURGICAL ANATOMY
Successful adrenalectomy requires a precise knowledge of the anatomy of the retroperitoneal space, the anatomic relationships of the adrenals to the surrounding structures, and the differences in the blood supply to the two glands (Figure 8-1).
The arterial supply to the adrenal glands enters the perimeter of the gland originating from multiple sources including the inferior phrenic and renal arteries and directly from the aorta. These are named the superior, inferior, and middle adrenal arteries, respectively.
The right adrenal vein is very short and enters the vena cava on its posterior lateral aspect. This vein does not necessarily get longer as an adrenal mass gets bigger. A large mass can make identification of the vein very difficult and potentially hazardous. Great care should be used to get control of this structure early in the dissection to avoid catastrophic hemorrhage on the posterior aspect of the vena cava.
The left adrenal vein is longer than the right. It is joined by the left inferior phrenic vein before it drains into the left renal vein.
STEP 2: PREOPERATIVE CONSIDERATIONS
The indications for adrenalectomy include:
Select adrenal cancers
All biologically active adrenal masses
Adrenal metastases
Incidentally found masses more than 4 to 5 cm
Primary adrenal hyperplasia
The choice of surgical approach (open vs. laparoscopic, anterior vs. posterior) depends on a number of factors including surgical training/experience, pathology, and presence of contraindications to laparoscopic surgery.
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