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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_808_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Preface
- •Contents
- •1.1 Introduction
- •1.2 Hypothyroidism
- •1.8 Thyroid Cancer
- •1.9 Non-thyroidal Illness (NTI)
- •1.10.1 Congenital Hypothyroidism
- •1.10.2 Consumptive Hypothyroidism
- •1.10.3 Juvenile Autoimmune Hypothyroidism
- •1.12 Post Thyroidectomy Considerations
- •References
- •2: Solitary Thyroid Nodule
- •2.1 Introduction
- •2.2 Clinical Evaluation
- •2.3 History
- •2.4 Physical Examination
- •1.3 Iodine Deficiency
- •1.4 Hyperthyroidism
- •1.5 Subclinical Thyroid Disease
- •1.6 Thyroiditis
- •1.7 Goitre
- •2.6 Serum Thyroglobulin
- •2.7 Serum Calcitonin
- •2.8 Radiological Evaluation
- •2.8.1 Thyroid Ultrasonography
- •2.8.2 Radioisotope Imaging
- •2.11 Cytological Evaluation
- •2.12 Molecular Assessment
- •2.14.1 Preparation
- •2.17 Summary
- •References
- •References
- •4.2 Ectopic Thyroid
- •4.3 Thyro-thymic Rests
- •4.5 The Nerves at Risk During Thyroidectomy
- •4.6 The Recurrent Laryngeal Nerve
- •4.9 Blood Supply
- •4.11 Parathyroid Glands
- •4.12 Lymphatic Drainage
- •4.13.2 Regulation
- •4.13.3 Actions
- •4.16 Actions
- •References
- •5: Pre-operative Counselling
- •6.1 Introduction
- •6.3 Immediate Post-operative Period
- •6.6 General Instructions
- •References
- •7: Central Compartment Lymph Node Dissection
- •Reference
- •8.1 Introduction
- •8.3 Postoperative Care
- •Reference
- •9: Trans-oral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA)
- •9.1 Introduction
- •9.3 Preoperative Evaluation
- •9.5 Postoperative Care
- •9.6 Outcome
- •9.7 Operative Safety
- •9.8 Conclusion
- •References
- •10: Robotic Thyroidectomy
- •10.1 Introduction
- •10.3 Indications
- •10.4 Contraindications
- •10.4.1 Relative
- •10.4.2 Absolute
- •10.5.1 Retro-auricular approach—Robotic thyroidectomy
- •10.5.1.1 Surgical Equipment
- •10.5.2 Trans-axillary/Breast Approach
- •10.5.2.1 Surgical Equipment
- •10.5.3 Robotic trans-oral thyroidectomy
- •10.6.1 Postoperative Pain
- •10.6.2 Recurrent Laryngeal Nerve Injury
- •10.6.3 Brachial Plexus Injury
- •10.6.4 Hypoparathyroidism
- •10.6.5 Bleeding and Hematoma
- •10.6.6 Voice and Swallowing Function
- •10.6.7 Paraesthesia
- •10.6.8 Cosmetic Satisfaction
- •10.6.9 Complications Specific to Trans-Oral Approaches
- •10.7 Economic Parameters
- •10.7.1 Peri-Operative Time
- •10.7.2 Hospital Stay
- •10.7.3 Cost
- •10.8 Oncological Outcomes
- •10.8.1 Completeness of Resection
- •10.8.2 Lymph Node Retrieval
- •10.8.3 Survival and Recurrence
- •10.9.1 Visualisation
- •10.9.2 Dexterity
- •10.9.3 Retraction
- •References
- •11.1 Introduction
- •11.2 Hypocalcaemia
- •11.4 Wound Infection
- •11.4.2 Laryngotracheal Oedema
- •11.5 Oesophageal Injury
- •11.5.1 Thoracic Duct Injury
- •11.5.2 Thyroid Storm
- •11.6 Tracheomalacia
- •10.9.4 Precision
- •10.9.5 Surgeon Ergonomics
- •10.10.1 Cost
- •10.10.2 Learning curve
- •10.10.3 Lack of haptic feedback
- •10.10.4 Operative time
- •10.12 Conclusions
- •References
- •12.1 Introduction
- •12.2 Recurrent Laryngeal Nerve (RLN)
- •12.4 Unilateral Vocal Fold Paralysis
- •12.5 Bialteral Vocal Fold Palsy
- •12.8 Clinical Features
- •12.9 Treatment
- •References
- •13.1 Introduction
- •13.2 Post-operative Care
- •13.2.1 Immediate Post-operative Management
- •13.2.2 Post-operative Management
- •13.2.3 Antibiotics
- •13.2.4 Pain Relief
- •13.2.5 Ice Pack Dressing
- •13.2.6 Head End Elevation
- •13.2.7 Drain
- •13.2.8 Hypocalcaemia
- •13.2.9 Levothyroxine Dose
- •13.2.11 Discharge Advice
- •13.2.12 Follow-Up
- •References
- •14.1 Historical Perspective
- •14.2 The Poorly Differentiated Thyroid Carcinoma (PDTC)
- •14.3 Undifferentiated Thyroid Cancer (UTC)
- •14.3.1 Risk Stratification
- •14.6 Tracheal Infiltration
- •14.6.2 Recurrent Laryngeal Nerve (RLN)
- •14.6.4 Locoregional Recurrence
- •14.7 Conclusion
- •References
- •15.1 Introduction
- •15.2 Aetiology
- •15.3 MEN 2B
- •15.3.1 RET Proto-Oncogene
- •15.4.1 Tumour Markers
- •15.4.2 Rearranged During Transfection (RET) Testing
- •15.4.4 Surgical Management
- •15.4.5 Postoperative Management
- •15.5 Conclusion
- •References
- •16.1.1 Radiopharmaceuticals [1]
- •16.1.3.3 18F Fluorodeoxyglucose, FDG
- •16.2 Thyroid Scintigraphy
- •16.2.2 Camera Method
- •16.2.2.2 Procedure
- •16.2.2.3 Interpretation
- •16.2.3 Amiodarone Induced Thyrotoxicosis (AIT)
- •16.2.6 Congenital organification Defect Evaluation—Perchlorate Discharge Test
- •16.3 Thyroid Nodule Evaluation
- •16.3.2 FDG PETCT Imaging
- •16.4.1 Indications
- •16.4.4 Complications
- •16.5.2 Patient Preparation
- •16.5.3 Scan Procedure
- •16.5.3.1 Interpretation
- •16.5.5 Radiation Safety Precautions
- •16.5.9.2 Carcinogenicity
- •16.5.9.3 Iodine Refractory Thyroid Cancer [18]
- •16.5.9.4 Martinique Principles
- •16.6.1 Introduction
- •16.6.3.1 Imaging Protocols
- •16.6.3.2 Patient Preparation
- •16.6.3.3 Procedure
- •16.6.3.4 Interpretation
- •16.6.7 Gamma Probe Guided Parathyroidectomy [22]
- •16.7 Conclusion
- •References
- •17.1 Introduction
- •17.2.1 Variations
- •17.3 Calcium Metabolism
- •17.4.1 Adenoma
- •17.4.2 Hyperplasia
- •17.4.3 Carcinoma
- •17.5 Hyperparathyroidism
- •17.5.1 Primary Hyperparathyroidism
- •17.5.2 Secondary Hyperparathyroidism
- •17.5.3 Tertiary Hyperparathyroidism
- •17.5.3.1 Primary Hyperparathyroidism
- •17.5.3.2 Neonatal Hyperparathyroidism
- •17.5.3.3 Familial Hypocalciuric Hypercalcemia
- •17.5.4 Familial Hyperparathyroidism
- •17.5.6 Hypoparathyroidism
- •17.5.7 Pseudohypoparathyroidism
- •17.6 Primary Hyperparathyroidism (PHPT)
- •17.6.1 Clinical Manifestations
- •17.6.1.2 Arterial Hypertension
- •17.6.1.3 Cardiovascular Disease
- •17.6.2.1 Biochemical
- •17.8 Localization Studies
- •17.8.1 Non-Invasive Localization
- •17.8.2 Scintigraphy
- •17.8.2.1 Technetium99 Sestamibi Scan
- •17.8.2.2 Positron Emission Tomography
- •17.8.3 Computed Tomography
- •17.8.4 Magnetic Resonance Imaging
- •17.8.5 Invasive Localization
- •17.8.6 Intraoperative Localization
- •17.8.6.1 Radio Guided Surgery
- •17.8.6.2 Intraoperative Ultrasound
- •17.8.6.3 Methylene Blue
- •References
- •18.1 Introduction
- •18.2 MEN 1
- •18.3 MEN 2
- •18.4 Conclusion
- •References
- •19.1 Secondary Hyperparathyroidism (SHPT)
- •19.3.1 Bricker’s Trade-off Hypothesis
- •19.3.3 Medical Treatment
- •19.4 Tertiary Hyperparathyroidism
- •19.5 Refractory Hyperparathyroidism
- •19.6.2 Preoperative Management
- •19.6.3 Post-operative Management
- •19.6.4 Hungry Bone Syndrome
- •19.7 Post-transplant Hyperparathyroidism
- •References
- •20.1 Introduction
- •20.2.1 Parathyroid Hormone Assay
- •20.2.2 Intra-Operative PTH Assay
- •20.2.3 Localization Studies
- •20.2.3.1 Radio-Guided Parathyroidectomy
- •References
- •21: Parathyroidectomy: Surgical Techniques
- •21.1.1 Preoperative Counselling
- •21.1.2 Desirable Additional Supports
- •21.4 Tertiary Hyperparathyroidism
- •21.4.1 Parathyroid Auto-transplantation
- •21.4.2 Intraoperative PTH Assay
- •21.4.3 Intraoperative Localization
- •21.4.4 Radio-guided Parathyroidectomy
- •21.4.5 Mini-parathyroidectomy
- •21.4.6 Postoperative Management
- •21.4.7 Hungry Bone Syndrome
- •21.5 Complications
- •References

Surgical
Management of
Thyroid and
Parathyroid Diseases
C. Gopalakrishnan Nair
Santhosh John Abraham
Editors
123

Surgical Management of Thyroid
and Parathyroid Diseases

C. Gopalakrishnan Nair
Santhosh John Abraham
Editors
Surgical Management
of Thyroid and Parathyroid
Diseases

Editors
C. Gopalakrishnan Nair
Professor of Surgery
Endocrine Surgery Division
Amrita Institute of Medical Sciences
and Research Centre
Kochi, Kerala, India
Santhosh John Abraham
Department of Surgery
Lourdes Hospital
Kochi, Kerala, India
ISBN 978-981-97-3773-4 ISBN 978-981-97-3774-1 (eBook)
https://doi.org/10.1007/978-981-97-3774-1
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore
Pte Ltd. 2024
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If disposing of this product, please recycle the paper.

Preface
Ayurveda, the traditional medicine in India has a long history, and Sushruta, the
renounced master surgery in Ancient India, elaborates reconstruction of nasal deformities and the removal of urinary bladder stones in his chronicle. However, there are
no authentic references to thyroidectomy in traditional Indian medicine.
Modern medicine was introduced to India in the nineteenth century and the
major centres were mostly in urban areas. There was a high prevalence of iodine
deciency diseases in many areas of India and large volume-goitres were usual.
However, complicated operations like thyroidectomy were performed only in a few
major urban hospitals. The practice of thyroidectomy was not standardised and partial or subtotal thyroidectomy was practised.
Professor (Dr) Sivapatham Vittal initiated the attempts to streamline the surgical
management of thyroid disease in India.
S. Vittal, MS, FRCS(Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAES,
DSc (Hon) (Fig.1).
Professor Vittal received undergraduate and post-graduate training at the prestigious Madras Medical College. He was impressed by the complexities of the endocrine system and developed a keen interest during his post-graduate days. He moved
to the UK after his post-graduation and was deeply inuenced by Mr. Selwyn Taylor
Fig. 1 Prof Sivapatham Vittal
v

vi
Preface
and Professor R. B. Welbourn, acclaimed Endocrine Surgeons at Hammersmith
Hospital, London, UK. He received the fellowship in Surgery from the Royal
College of Surgeons of Edinburgh. He was awarded a Travelling Fellowship with
Prof Ivan Johnston, a distinguished Endocrine Surgeon at Royal Victoria Inrmary
at Newcastle-Upon-Tyne, UK.
Upon returning to India, he joined his alma mater as a faculty in the Department
of Surgery. He was instrumental in creating the division of Endocrine Surgery in the
Department of General Surgery at Madras Medical College and Government General
Hospital, Chennai, in 1980, which culminated in a full-edged Department of
Endocrine Surgery in 1987, the rst Department of Endocrine Surgery in India and
South Asia (Fig.2). He invited many Overseas Surgeons like Professor John Farndon,
Professor Pady Boulter, and Mr Andrew Gunn to visit his department and organised
many academic programmes to popularise Endocrine Surgery nationwide (Fig.3).
He was instrumental in forming the Indian Association of Endocrine Surgeons in
1993, of which he was the Founder President. The organisation continues to be a
prestigious platform for spreading knowledge in all aspects of endocrine surgery.
Professor Vittal is a widely appreciated teacher and was effective in spreading
the message of safe thyroidectomy to budding surgeons. Because of its increasing
prevalence, the knowledge and skill in managing thyroid diseases have to be disseminated to all practising surgeons and Professor Vittal plays a crucial role in
this aspect.
Fig. 2 Inauguration of Division of Endocrine Surgery in Madras Medical College & Government
General Hospital, Chennai in 1980 which culminated in to the Department of Endocrine Surgery
in 1987 - First in India and South Asia

Preface
Fig. 3 Prof John Farndon with Prof S Vittal during his visit to Department of Endocrine Surgery
in Madras Medical College & Government General Hospital, Chennai
vii
He has been an eminent teacher for over 55 years, editing and publishing a
Surgical Endocrinology book. He has been on the Editorial Board of several prestigious journals: the British Journal of Surgery, the World Journal of Endocrine
Surgery, and the Indian Journal of Surgery.
Professor S Vittal is a recipient of the prestigious “Dr B C Roy National Award”
for the year 1995 for developing the speciality of Surgical Endocrinology in India.
This is the highest award given to a doctor by the Medical Council of India. In 2011,
the Government of India awarded him the prestigious Padma Shri award, one of the
highest civilian awards, for his yeoman service in Medicine.
For all his great contributions, he is popularly known as the “Father of Endocrine
Surgery” in India.
Kochi, Kerala, India C.GopalakrishnanNair
Kochi, Kerala, India SanthoshJohnAbraham

Contents
1 Introduction to Thyroidology with Special Reference to
Conditions Requiring Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . 1
A. G. Unnikrishnan and Suganthi Kumaran
2 Solitary Thyroid Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Loreno E. Enny, Kul Ranjan Singh, and Anand Mishra
3 Overview of Surgical Management of Hyperthyroidism . . . . . . . . . . . 31
C. Gopalakrishnan Nair and Misha J. C. Babu
4 Anatomy of Thyroid and Parathyroid Glands . . . . . . . . . . . . . . . . . . . . 37
C. Gopalakrishnan Nair
5 Pre-operative Counselling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
C. Gopalakrishnan Nair, Riju Ramachandran, and Pradeep Jacob
6 Thyroidectomy: Steps of Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
C. Gopalakrishnan Nair, Riju Ramachandran, and Pradeep Jacob
7 Central Compartment Lymph Node Dissection . . . . . . . . . . . . . . . . . . . 95
Riju Ramachandran, C. Gopalakrishnan Nair, and Pradeep Jacob
8 Modified Segment Oriented Cervical Lymph Node
Dissection for Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
C. Gopalakrishnan Nair and Misha J. C. Babu
9 Trans-oral Endoscopic Thyroidectomy via Vestibular
Approach (TOETVA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Gyan Chand
10 Robotic Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Krishnakumar Thankappan, Nisha Rajrattansingh Akali,
Nageswara Rao Noothanapati, Snigdha Elaprolu, and
Lakshmi Ravunniarth Menon
11 Complications of Thyroid Surgery (Except Vocal Cord Palsy) . . . . . . 151
P. V. Pradeep
ix

x
Contents
12 Management of Vocal Fold Palsy in Thyroid Surgery . . . . . . . . . . . . . . 159
Jayakumar R Menon and Manju E. Issac
13 Post-operative Care and Post-operative Management of Benign
Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Sabaretnam Mayilvaganan, Sai Krishna Vittal,
Sai Vishnupriya Vittal, and Sarrah Idrees
14 Introduction to Surgical Treatments of Thyroid Cancers: Surgical
Management of Advanced and Metastatic Thyroid Cancers . . . . . . . . 181
Riju Ramachandran and C. Gopalakrishnan Nair
15 An Update on Medullary Thyroid Carcinoma . . . . . . . . . . . . . . . . . . . . 197
Supriya Sen and Deepak Thomas Abraham
16 The Role of Nuclear Medicine in Thyroid and Parathyroid
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
P. Shanmuga Sundaram, Padma Subramanyam, and
G. Dinesh Kumar
17 Surgery of the Parathyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Aravindan Nair and P. Balaji Viswanath
18 Management of PHPT in MEN 1 and MEN 2 Syndrome . . . . . . . . . . . 265
Sabaretnam Mayilvaganan and P. R. K. Bhargav
19 Hyperparathyroidism of Renal Origin . . . . . . . . . . . . . . . . . . . . . . . . . . 271
A. Vimala, Ranjani Ravi, and Jinsi N Babu
20 Surgical Treatment of Hyperparathyroidism: An Overview . . . . . . . . 281
C. Gopalakrishnan Nair
21 Parathyroidectomy: Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . 291
C. Gopalakrishnan Nair and Riju Ramachandran

Introduction toThyroidology
withSpecial Reference toConditions
Requiring Surgical Treatment
A.G.Unnikrishnan andSuganthiKumaran
1.1 Introduction
Diseases of the thyroid gland have high global prevalence, and India is not an exception. Based on projections from studies on thyroid disease, about 42 million people in
India suffer from diseases of the thyroid gland [1] and it is now being recognised as the
most common non-communicable disease of women. Diseases of the thyroid gland are
more frequently diagnosed in women than men [2]. Common diseases of the thyroid
can be categorised into hypothyroidism, hyperthyroidism, thyroiditis, goitre either diffuse or nodular, and thyroid cancer. Other rare problems include recurrent thyroid cysts.
1.2 Hypothyroidism
1
Hypothyroidism is the most common thyroid hormonal dysfunction and is characterised by weight gain, lethargy, menstrual irregularities in the form of menorrhagia,
excess hair fall and cold intolerance. It is more common in elderly women aged from
46 to 54years [3]. The characteristic laboratory ndings are high serum TSH and low
T3 and T4 levels (Table 1.1). The treatment is essentially medical by levothyroxine
supplementation with an aim to regulate the serum levels of TSH and F T4 within
normal levels. The dosage schedule is titrated based on TSH levels (0.4–4.2uIU/mL).
Table 1.1 Hypothyroidism
A. G. Unnikrishnan (*) · S. Kumaran
Chellaram Diabetes Institute, Pune, Maharashtra, India
e-mail: skn@cdi.org.in
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2024
C. G. Nair, S. J. Abraham (eds.), Surgical Management of Thyroid and
Parathyroid Diseases, https://doi.org/10.1007/978-981-97-3774-1_1
Parameters
TSH High 0.4–4.2uIu/mL
Total T3 Low 75–195ng/dL
Total T4 Low 4.6–11.2 mcg/dL
Levels
Normal range
1
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