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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4451_Библиотеки_им_академика_М_И_Перельмана
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N. M. Nagarkar et al.
2.4 Balloon Test Occlusion
Angiography with balloon occlusion studies may
be required in patients with extensive extrathyroidal disease involving the great vessels in order
to further clarify the surgical planning.
2.5 Serum Thyrotropin
A serum TSH level should be obtained if the
nodule is >1cm. If the serum TSH is subnormal,
a radionuclide thyroid scan should be obtained
to document whether the nodule is hyperfunctioning, isofunctioning or nonfunctioning [42].
Since hyperfunctioning nodules rarely harbour
malignancy, if one is found that corresponds to
the nodule in question, no cytologic evaluation
is necessary. If overt or subclinical hyperthyroidism is present, additional evaluation is
required. A higher serum TSH level, even within
the upper part of the reference range, is associated with the increased risk of malignancy in a
thyroid nodule, as well as more advanced stage
thyroid cancer [43, 44].
3 General Principles ofThyroid
Gland Surgery
• Successful thyroid surgery implies meticulous
technical skill and attention to detail.
• As per widely accepted the Lahey’s concept, routine visual identication of the
RLN during thyroid surgery is now considered the gold standard for prevention of
RLN injury.
• During positioning, 20° of reverse
Trendelenburg position is maintained to avoid
venous engorgement in the neck.
• There is little evidence that the timing of postoperative RAI is so crucial that iodinecontaining preps cannot be used.
• Careful placement of the incision and protection of skin edges promote optimal cosmetic
results.
• The division of the laryngeal head of the sternothyroid muscle is occasionally helpful to
improve exposure of the superior pole of the
thyroid gland. Dividing near the laryngeal
attachment preserves its neurovascular supply.
• While dissecting below the isthmus, the surgeon must watch for the right and left inferior
thyroid veins, which can blend in to form an
inferior venous plexus, termed the plexus thyroideus impar, below the isthmus. The surgeon must also watch for a high-riding
innominate artery or a thyroid ima artery. This
artery arises as an unpaired inferior vessel
from the innominate, carotid or aortic arch
and occurs in 1.5–12% of cases.
• A constant midline tracheal reference point
must be maintained as it helps as a landmark
while dissection is continued and can be helpful if the neck base anatomy is distorted by
malignant or benign goitrous.
• Identication and continued observation of
the recurrent laryngeal nerve are the best ways
to avoid injury to the nerve.
• Skeletonize the superior pedicle and ligate
close to the thyroid gland to avoid injury to the
superior laryngeal nerve and parathyroids.
• Identify and lateralize the parathyroid glands
with their blood supply.
• Trachea may be deviated from it from its central position very often.
• Inferior thyroid artery should be ligated as
proximal to the thyroid gland to preserve the
blood supply to the parathyroid gland.
• In cases of large goiters, placing a nasogastric
tube preoperatively can help in intraoperative
localization of the oesophagus.
4 Hemithyroidectomy
4.1 Case
A 45-year-old female presented with a 6-month
history of anterior neck swelling. Ultrasonography
was suggestive of 4.8 cm hyperechoic nodule,
solid nodule. FNAC was Bethesda II.
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4.2 Operative Technique: Caveats
• Mark a 3–5 cm horizontal incision line
between the cricoid cartilage and suprasternal
notch (Fig.1).
• Use an existing neck crease or line of relaxed
skin tension.
• Mark the incision higher in younger patients,
because the scar will migrate lower over time
and a scar below the clavicle is often
unsightly.
• Incise through the platysma to the subcutaneous tissue with electrocautery to the investing
fascia. Platysma is decient in the midline.
• Avoid injuring the communicating anterior
jugular veins.
• Subplatysmal aps are elevated with blunt
dissection and electrocautery in the plane just
above the investing fascia and anterior jugular
veins up to the thyroid notch and down to the
sternal notch (Fig.2).
• The skin edges are protected with running,
locking silk sutures after raising subplatysmal
aps.
• Identify the median raphe of the strap
muscles.
• Divide the strap muscles in the midline up to
the thyroid notch and down to the sternal
notch with electrocautery.
• Elevate bluntly with a freer elevator, peanut
sponge or electrocautery.
• The strap muscles should be sacriced with a
healthy margin if there is any tumour inltration of the muscles.
Fig. 1 Horizontal collar incision is provided
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Fig. 2 Following skin ap elevation, the straps are cut
and reected. The enlarged thyroid lobe is delivered into
the wound meticulously. Care must be taken not to injure
any vessels
• Retract the strap muscles superolaterally to
expose the superior pole.
• The sternothyroid and/or thyrohyoid muscles
may have to be divided to provide better exposure of the superior pole in large goiters.
• Once the superior vascular bundle has been
identied, skeletonize the vessels circumferentially using a right-angle clamp.
• Ligating the superior pole close to the thyroid
helps decrease the risk of SLN injury.
• Dissect the thyroid carefully inferiorly and
medially using a peanut sponge.
• The middle thyroid veins are encountered and
ligated with the ultrasound scalpel/suture
ligation.
• Once the RLN is identied, dissecting parallel
and to the nerve sheath prevents damaging the
nerve and its branches; very often we can
encounter the branching of RLN at its point of
entry to the larynx.
• Carefully dissect and lateralize the parathyroid glands with their blood supply when dissecting the thyroid capsule.
• The parathyroids usually receive their blood
supply from the inferior thyroid arteries.
• Once the RLN and the inferior parathyroid
gland have been safely identied, ligate the
inferior vascular pedicle while the thyroid is
mobilized medially.
• Make sure to identify early branching of the
RLN near the inferior pedicle before ligating
the pedicle (Fig.3).
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Fig. 3 Dissection is performed in the thyroid bed to identify and preserve the recurrent laryngeal nerve
Fig. 4 Intact specimen must be oriented prior to sending
for histopathological examination
• Ligate the inferior pedicle close to the thyroid
to avoid devascularizing the inferior
parathyroid.
• Transect the thyroid at the junction of the isthmus and the contralateral lobe.
• Remove the pyramidal lobe if present, up to
the thyroid notch.
• Irrigate the wound thoroughly, and evaluate
bleeding during Valsalva by anaesthesia with
bipolar cautery haemostasis.
• The strap muscles are approximated with
absorbable sutures. Leave a space inferiorly to
allow drainage of potential hematomas.
• Approximate the platysma layer carefully.
Close the skin with absorbable subcuticular
stitches (4-0 Monocryl).
• The specimen in toto is shown in Fig.4.
N. M. Nagarkar et al.
5 Total Thyroidectomy
forThyroiditis
5.1 Case
A 39-year-old female presented with a 2-year
history of anterior neck swelling. Diagnosed case
of Hashimoto thyroiditis was not responding to
medical therapy. Ultrasonography was suggestive of 2.5cm hyperechoic nodule, solid nodule.
FNAC was Bethesda II.
5.2 Operative Technique: Caveats
All operative steps are depicted in Figs.5, 6, 7, 8,
9, 10, 11 and 12.
• At high risk for associated thyroid cancers
[45].
• The parathyroid glands in patients with
Hashimoto’s thyroiditis are possibly more
susceptible to injury, either due to the inammation or due to the additional retraction
required to mobilize the rmer than normal
thyroid glands [42].
• The blood vessels are usually dilated and fragile, and they tend to rupture with aggressive
manipulation. The bleeding may be difcult to
control.
Fig. 5 A symmetrical cervical collar incision is marked.
A taut suture thread can be used to mark the skin
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Fig. 6 Subplatysmal aps are elevated, superiorly up to
the hyoid and inferiorly up to the sternal notch. Care must
be taken not to injure the anterior jugular vein in the midline and laterally the external jugular vein
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Fig. 9 Right RLN can be seen entering the larynx. We
must also note the tubercle of Zuckerkandl just overlying
the RLN
Fig. 7 Notice the dilated veins over the enlarged thyroid
gland
Fig. 8 The left recurrent laryngeal nerve is seen at the
tracheoesophageal groove. One can appreciate the RLN
being parallel to the trachea and entering the larynx at the
cricothyroid joint
Fig. 10 Thyroid bed after completing the thyroidectomy
Fig. 11 Excised thyroidectomy specimen
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Fig. 12 Postoperative follow-up after 6 months with
almost no visible scar
• There may be a presence of multiple nodes in
the paratracheal, prelaryngeal and pretracheal
lymph nodes due to thyroiditis.
• The rate of temporary and permanent RLN
palsy is described to be higher compared to
thyroidectomy for benign disease [43].
6 Total Thyroidectomy forLarge
Multinodular Goiter
N. M. Nagarkar et al.
Fig. 13 Symmetrical Kocher’s incision is marked
Fig. 14 Skin aps are raised superiorly and inferiorly;
one must note the engorged anterior jugular venous
system
6.1 Case
A 56-year-old female presented with an 8-year
history of anterior neck swelling. Ultrasonography
was suggestive of multiple nodules with the largest nodule measuring 8 cm TIRADS 3 nodule.
FNAC was Bethesda II.
6.2 Operative Technique: Caveats
All operative steps are depicted in Figs.13, 14,
15, 16 and 17.
Fig. 15 A large thyroid gland’s veins usually dilate. In
cases with large thyroid glands, strap muscles can be
divided to provide adequate exposure
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Fig. 16 Complete exposure of the thyroid gland
Fig. 17 Total thyroidectomy specimen
• Difculty of intubation may be caused by an
enlarged thyroid gland producing tracheal
deviation or compression.
• The transient RLN palsy rates in total thyroidectomy have a higher rate than other operative
methods for MNG.It is mainly due to traction
on the RLN due to retraction and gland
mobilization.
• The patients with MNG who had papillary
carcinoma had an increased risk of multifocal
cancers compared with the patients with solitary nodule who developed papillary carcinoma [44].
• Patients with long-standing goiter, even when
benign, are more prone to develop tracheomalacia. A discussion with the anaesthetist is of
utmost importance.
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• Asymmetric nodules in the thyroid gland may
displace the trachea to one side leading to
gross tracheal deviation.
• Due to long-standing nature of the disease,
there may be a considerable number of dilated
vessels. Vessels must be carefully dissected
and ligated when necessary.
• The lateral dissection must be done meticulously as there may be considerable shape distortion of the gland shape with nodules
protruding out of the gland.
• Identication of parathyroid gland may be difcult due to enlarged thyroid gland.
• It is utmost important to ensure that all the
nodules are dissected out, as any remaining
nodules may lead to persistent or recurrent
disease.
6.3 Case
A 48-year-old female presented with a 12-year
history of anterior neck swelling. Ultrasonography
was suggestive of multiple nodules with the largest nodule in the right lobe measuring 12 cm
TIRADS 3 nodule. FNAC was Bethesda II.
All operative steps are depicted in Figs.18,
19, 20 and 21.
Fig. 18 Skin incision and identifying the subplatysmal
plane. The platysma is absent in the midline, and one must
be careful during the ap elevation
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Fig. 19 In certain large multinodular goiter, the glands
can insinuate under the sternocleidomastoid muscle. We
must dissect along the plane and capsule of the thyroid
gland to ensure the removal of entire thyroid gland
Fig. 20 Thyroid bed following total thyroidectomy and
scabbard trachea appearance due to the compression of
the trachea by the enlarged thyroid gland
N. M. Nagarkar et al.
7 Total Thyroidectomy
withSternotomy forLarge
Multinodular Goiter
7.1 Case
A 48-year-old female presented with a 7-year
history of anterior neck swelling, and the lower
pole of the swelling was not palpable despite
adequate neck extension. Ultrasonography was
suggestive of multiple nodules with the largest
nodule measuring 6cm TIRADS 3 nodule. FNAC
was Bethesda II.CECT was suggestive of mediastinal extension up to the subclavian artery.
7.2 Operative Technique: Caveats
All operative steps are depicted in Figs.22, 23,
24, 25, 26, 27, 28, 29 and 30.
• Crile initially dened mediastinal goiters as
those that extend to or are inferior to the aortic
arch [46].
• The need for sternotomy must be discussed
with the patient and relatives preoperatively. A
cardiothoracic team must be on standby for all
the substernal goiter cases.
Fig. 21 We can appreciate the multiple lobulations of the
thyroid gland
Fig. 22 In cases of large thyroid glands, the trachea may
be grossly deviated
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Fig. 23 Subplatysmal aps are raised, and sternocleidomastoid muscles are retracted laterally to expose the thyroid gland completely
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Fig. 26 The thyroid gland is freed from all sides, and the
dissection is continued laterally to identify and preserve
the RLN
Fig. 24 Lower pole of the thyroid gland is seen passing
below the sternum. * shows the pericardia
Fig. 25 A complete sternotomy is done
Fig. 27 The lower pole of the gland was reaching up to
the right innominate artery. * shows the innominate artery
Fig. 28 Total thyroidectomy specimen with cervical and
mediastinal parts. * shows the cervical part and ** shows
the mediastinal part
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Fig. 29 The sternotomy wound is closed with steel wires
to provide adequate strength
Fig. 30 Following layered skin closure
• The sternotomy is required in 5–29% of cases
of substernal goiters based on the pooled evidence [46].
• A history of goiter with retrosternal extension
beyond 160 months is a risk factor for sternotomy. Thyroid tissue density, posterior
mediastinal location and subcarinal extension,
as measured using CT imaging, are independent preoperatively obtained risk factors for
sternotomy [47].
• An initial transcervical collar incision is taken
to dissect the thyroid by the standard approach.
• The lower pole dissection is done cautiously
as long-standing goiters and some ectopic
nodules can derive additional blood supply
from the mediastinal vessels.
• Mercante in 2011 [48] proposed a classication system for the substernal goiters based on
the CECT imaging:
– Grade I—the lower border of the thyroid is
above the aortic arch.
– Grade II—the lower border of the thyroid
is between the convex and concave parts of
the aortic arch.
N. M. Nagarkar et al.
– Grade III—the lower border of the thyroid
is below the concave part of the aortic arch.
• Early retrosternal extension cases may be
completely approached by transcervical pullup technique.
• The evidence of an ectopic nodule, a dumbbellshaped goiter, a conical-shaped goiter constricted by an isthmic thoracic inlet or a
thoracic goiter component wider than the thoracic inlet, can also predict the need to undergo
sternotomy [47].
• Mediastinal goiters can remain asymptomatic
until compression of the structures located in
the thoracic inlet occurs. Life-threatening
mechanical compression can occur because of
the limited space below the thoracic inlet.
• The pooled incidence of malignancy in
retrosternal goiters has been reported between
3 and 21% [49, 50]. Rugiu and colleagues
consider malignancy as a high risk of sternotomy procedure due to the higher chances of
extrathyroidal extension and/or the need to
perform level VII lymph node clearance [51].
• In a recent Italian case series of sternotomy
for thyroidectomy showed that postoperative
bleeding (0.5%), permanent unilateral recurrent laryngeal nerve palsy (1.3%), bilateral
recurrent laryngeal nerve palsy (0.6%), transient hypoparathyroidism (14%) and permanent hypoparathyroidism (4.1%) [52]. The
mortality rate of substernal goiter surgery has
been reported as high as 2.3%, the surgery for
retrosternal goiters involves a higher risk for
complications than cervical goiters do and the
risk does not differ between patients with and
without symptoms [53].
8 Total Thyroidectomy
withMinisternotomy andNeck
Dissection
8.1 Case
A 63-year-old female presented with a 7-year
history of anterior neck swelling. Ultrasonography
was suggestive of multiple nodules with the largest nodule measuring 4 cm TIRADS 5 nodule.
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FNAC was Bethesda VI—papillary thyroid cancer. CECT was suggestive of retrosternal extension and a level VII lymph node.
8.2 Operative Technique: Caveats
• Ministernotomy involves a midline osteotomy
from the sternal notch down the manubrium to
the second intercostal space, where a second
horizontal osteotomy is performed (Fig.31).
• A thyroidectomy is attempted rst through a
cervical approach, before a powered saw is
used to make the osteotomies and a sternal
retractor used to access the mediastinum, and
a total thyroidectomy is then completed.
• Anterior mediastinal nodal clearance can be
performed after opening the sternum (Fig.32).
• The sternum is closed with wires (Fig.33) as
a drain is placed and the wound is closed in
layers. The advantages, compared with a
conventional sternotomy that continues from
sternal notch to xiphoid process, include a
smaller incision, decreased pain, faster
recovery, shorter hospital stay and fewer
complications.
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Fig. 32 The thyroid bed following thyroidectomy with
bilateral central compartment and bilateral neck dissection. We can appreciate the yellow-amber-coloured thymic tissue in the mediastinum
Fig. 31 Ministernotomy can be used as an alternative to
complete sternotomy, where osteotomy is done only for
the manubrium sterni
Fig. 33 Sternotomy wound closed with steel wires
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