1. Subtotal thyroidectomy 2

2. Types of Thyroidectomy
Hemithyroidectomy - entire isthmus is removed along with 1 lobe- benign diseases of only 1 lobe.
Subtotal thyroidectomy - MNG
Near total thyroidectomy - both lobes are removed except for a small amount of thyroid tissue in the vicinity of the recurrent laryngeal nerve entry point and the superior parathyroid gland.
Total thyroidectomy- entire gland is removed – thyroid carcinoma.
Hartley Danhill op. - removal of 1 entire lateral lobe with isthmus and partial/subtotal removal of opposite lateral lobe. It is done in non toxic MNG.

3. Main steps of Thyroidectomy
Horizontal anterior neck incision if possible, within a skin crease.
Create upper and lower flaps between the platysma and strap muscles
Divide vertically between the strap muscles and anterior jugular veins.
Separate the strap muscles from the thyroid gland

4. Main steps of Thyroidectomy
Divide the middle thyroid vein
Mobilize the superior pole of the thyroid lobe.
Divide the superior thyroid artery and vein close to the thyroid gland -avoid injury to the external branch of the superior laryngeal nerve and the superior parathyroid gland.

5. Main steps of Thyroidectomy
Identify the recurrent laryngeal nerve whenever possible using the nerve monitoring device
Identify the inferior parathyroid gland
Divide the inferior thyroid artery and vein
Separate the thyroid lobe and isthmus from the trachea

6. Main steps of Thyroidectomy
Repeat this process for the other thyroid lobe.
Remove the thyroid gland
Reapproximate the strap muscles
Reapproximate the platysma muscle
Close the skin with a subcuticular stitch

7. Complications Hypothyroidism in up to 50% of patients after ten years
Laryngeal nerve injury in about 1% of patients, in particular the recurrent laryngeal nerve:
Unilateral damage results in a hoarse voice.
Bilateral damage presents as laryngeal obstruction after surgery and can be a surgical emergency: an emergency tracheostomy may be needed. Recurrent Laryngeal nerve injury may occur during the ligature of the inferior thyroid artery.
Hypoparathyroidism: temporary (transient) in many patients, but permanent in about 1-4% of patients

8. Complications Infection Stitch granuloma Chyle leak
Hemorrhage/Hematoma (This may compress the airway, becoming life-threatening.)
Surgical keloid scar
Thyroid storm in operations performed for hyperthyroidism

9. Subtotal Thyroidectomy Incision
The patient is placed supine on the operating room table.
The top part of the table is elevated so the patient is in a slightly reclining position.
The extended head must be perfectly aligned with the body so a symmetrical incision is made by the surgeon.

10. Incision
The incision is made transversely about two fingers breadth above the sternal notch.
It should be placed in a skin crease if possible for best cosmetic result.
Most commonly, a slight indentation is made in the skin by using a heavy silk suture to compress the skin.

11. Incision
The incision should extend well beyond the borders of the sternocleidomastoid muscles.
For large goiters, the incision is made a little more cephalad (toward the head).
By usual convention the surgeon stands on the right as the right side of the thyroid is removed first.
The incision is made using one sweep of the belly of the blade across the skin and through the subcutaneous tissue.

12. Surgical Details of the Procedure
Bleeding vessels in the skin and subcutaneous tissue are controlled by applying hemostats and ligated using 3-0 absorbable sutures.
Incision is carried through the rather superficial platysma muscle to the avascular plane below this muscle.
Care must be taken to avoid severing the anterior jugular veins
Tissue flaps are raised both superiorly and inferiorly using a combination of blunt and cautery dissection.

13. Surgical Details of the Procedure
The superior dissection is taken up to the level of the thyroid cartilage and the inferior dissection is taken to the level of the sternal notch.
At the lower flap margin care must be taken to avoid the communicating arch between the right and left anterior jugular veins to avoid the possibility of air embolus.
The left and right anterior jugular veins are usually ligated with double silk ties and cut with a scissors.

14. Surgical Details of the Procedure
A self-retaining retractor is then placed to hold the two edges of the skin flaps apart to allow adequate exposure of the underlying strap muscles.
Sternohyoid muscle can be incised transversely and retracted inferiorly and superiorly.

15. Surgical Details of the Procedure
Blunt dissection is used to develop the plane underneath the sternohyoid muscle. This will expose the sternothyroid muscle.
The sternothyroid muscle is incised after the loose areolar tissue is grasped and retracted toward the ceiling. It is important to enter the correct plane between this muscle and the thyroid.

16. Surgical Details of the Procedure
This exposes the capsule of the thyroid and the anterior capsular veins of the thyroid.
The thyroid gland is then partially delivered up into the wound by placing two fingers and the lateral edge of the gland and slightly separating them.

17. Surgical Details of the Procedure
Many surgeons ligate and divide the right middle thyroid vein at this time.
The dissection of the thyroid gland is usually done by freeing the right upper pole first.
Dissection is done either by gentle blunt force by inserting a finger or hemostat under the right superior thyroid vessels.
The vessels are ligated with silk ties or very commonly with a Harmonic scalpel.

18. Surgical Details of the Procedure
It is important that all vessels be carefully ligated as it is difficult to control cut vessels that have not been ligated as they tend to retract to a position very near the superior laryngeal nerve.
The superior thyroid artery should be ligated outside of and away from the gland.
After the right superior thyroid vessels and the right middle thyroid vein have been controlled, attention is turned to the right lower pole of the thyroid.

19. Surgical Details of the Procedure
The inferior pole arteries and veins are carefully ligated with care taken not to disrupt the adjacent parathyroid gland or to injure the underlying trachea.
If a thyroidea ima is present, it is carefully separated from the trachea and ligated and divided,

20. Surgical Details of the Procedure
The inferior thyroid artery is then located on the inferior lateral part of the gland by retracting the thryoid medially and superiorly. Great care must be taken to completely separate it from the right recurrent laryngeal nerve that is always found adjacent to the artery (it may even run between the bifurcation (branches) of the artery).

21. Surgical Details of the Procedure
It must be remembered in resecting large thyroid glands that the right recurrent laryngeal nerve may be more superficial than expected.
The right side of the gland is then dissected off of the trachea using fine tipped forceps to guide the Bovie cautery and a small sponge to push the thryoid medially.
When the midline of the trachea has been reached (the isthmus), clamps are placed on each side to compress the thyroid tissue.

22. Surgical Details of the Procedure
The isthmus is then divided between the two rows of clamps using Bovie cautery.
The surgeon moves to the patient’s left side and removes the left side of the thyroid gland using the same steps as described above.
After the gland has been removed, the folded sheet behind the patient’s neck is removed and the hyperextension of the neck is released.

23. Surgical Details of the Procedure
The wound is irrigated and the field is repeatedly check for any bleeding points. Meticuluos hemostasis is critical in thyroid surgery to prevent a clot from forming and compressing the trachea.
Many surgeons will leave a small suction-type drain in the thyroid cavity, even in the presence of a dry field. This is brought out through a stab wound the skin laterally on the neck.

24. Surgical Details of the Procedure
The strap muscles (prethyroid muscles) are then reapproximated and if transected are closed using 2-0 or 3-0 absorbable interrupted suture.
The platysma muscle is reapproximated using a 4-0 or 3-0 interrupted absorbable suture.
The subcutaneous tissue is reapproximated using a 4-0 interrupted absorbable suture.
The skin is closed using a subcuticular (just below the skin surface) aborbable stitch (e.g., Monocryl) or interrupted 4-0 or 5-0 nylon sutures