1. Basic Format Thyroidectomy
Procedures
Basic Format
Thyroidectomy
Partial Thyroidectomy, Thyroidectomy, Total Thyroidectomy
Nearly half of all Americans are likely to have a thyroid nodule — solid or fluid-filled lump — sometime in their lives. One or more of these nodules may develop in the thyroid gland. Most of them are non-cancerous (benign). However, about 5% to 10% of thyroid nodules are cancerous (malignant), and require prompt and appropriate treatment.
The thyroid is a gland located at the base of the neck, just below the Adam's apple. Although very small, it makes a big difference in our health. An endocrine gland, it is a part of the human body that secretes hormones. The thyroid produces hormones that regulate many of the body's basic functions, such as how fast the heart beats and how quickly calories are burned.
Thyroid nodules, whether benign or malignant, rarely cause any symptoms. Most of the time, they are discovered by self-examination, by a physician or incidentally during some x-ray test of the neck being performed for unrelated reasons. A very large nodule can sometimes cause some difficulty swallowing and occasionally shortness of breath.
If a patient with a thyroid nodule develops a hoarse, weak voice, then thyroid cancer is a concern. Other risk factors for malignancy in a thyroid nodule are prior history of radiation exposure and family history of thyroid cancer.

2. Objectives
Assess the anatomy, physiology, and pathophysiology of the Thyroidectomy.
Analyze the diagnostic and surgical interventions for a patient undergoing a _______________.
Plan the intraoperative course for a patient undergoing_____________.
Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for_____________.
Describe the care of the specimen
Discuss the postoperative considerations for a patient undergoing _______________ .

4. Terms and Definitions Langer’s lines
Langer’s lines: named after Carl Langer, an Austrian anatomist,
The structural orientation of the fibrous tissue of the skin, forming the natural cleavage lines that, though present in all body areas, are visible only to certain sites such as the creases of the palm. These lines are of particular importance to surgery. Incisions parallel to them make a much smaller scar upon healing than those made at right angles to the lines. (from Taber’s)

5. Definition/Purpose of Procedure
Total Thyroidectomy
removal of thyroid gland for malignancy or to relieve compression on the trachea or esophagus
Subtotal or Partial Thyroidectomy
removal of about 5/6’s of thyroid gland to treat hyperthyroidism
Purpose:
Total: to treat various diseases of the thyroid; usually cancer by removal of gland (ablative)
Subtotal: enlarged glands affecting breathing or swallowing problems; tracheal or esophageal obstruction
Thyroid gland removal is surgery to remove all (total thyroidectomy) or part (subtotal or partial thyroidectomy) of the thyroid gland.
Subtotal: removal of about 5/6’s of thyroid gland to treat hyperthyroidismm
Thyroid Lobectomy: excision of an entire lobe for benign tumor or toxic diffuse goiter
Thyroidectomy: removal of thyroid gland for malignancy or to relieve compression on the trachea or esophagus
Why? Patients who are diagnosed with hyperthyroidism have such enlarged thyroid glands that it causes breathing problems as a result of pressure on the esophagus or trachea. Therefore, removal of all or part of the gland is indicated. Usually, a subtotal thyroidectomy is performed. The key is that enough of the thyroid gland is left to produce enough TH
(thyroid hormone).

6. Relevant A & P
The thyroid gland is part of the endocrine system and is essential in regulating the body's metabolism.
The primary function of the thyroid is iodine metabolism.
It is located in the anterior neck with right and left lobes located on either side of the trachea; it is connected by the isthmus, which lies over the trachea at the base of the neck. The lobes lie below the larynx and beside the trachea. The blood supply is rich. It has 4 major blood supplies: superior thyroid arteries branch off the external carotids, and the inferior thyroid arteries ascend from the subclavians;The recurrent laryngeal nerve that supplies the vocal cord is in close association with the inferior thyroid artery and this should be of primary importance during dissection.

7. Relevant A & P
Notice the parathyroid glands –which the surgeon wants to be very careful not to excise! They are 4 small glands embedded in the posterior thyroid (2 on each side); may be as many as ten located along the neck
Function: regulation of calcium and phosphorus metabolism
Primary hyperparathyroidism is associated with hypercalcemia (secondary to kidney, skeletal, or GI disease).

8. Pathophysiology Hyperthyroidism Goiter Cancer
Thyroid disorders are more common in older children and adolescents
(especially in girls) than in infants. Most thyroid disorders can be treated with medication, but surgery is sometimes required.
Some diseases affect the gland by reducing its output of hormones (hypothyroidism), while others cause overproduction of hormones (hyperthyroidism).
Thyroidectomy may be recommended for the following:
Increased thyroid function (hyperthyroidism or thyrotoxicosis)
Lemone and Burke: The most common causes of of hyperthyroidism (85%) are Grave’s Disease and toxi multnodular goiter. The patient typically has an increased appetite, but loses weight and may have very active bowels or diarrhea. Additional manifestations related to hypermetabolism are heat intolerance and increased sweating. The patient’s hair is very fine, skin smooth and warm. My have some emotional lability.
Hyperactivity is treated with surgical removal, medication, or administration of radioactive iodine to decrease function.

9. Pathophysiology
Enlargement of the thyroid (nontoxic goiter) -- Decreased thyroid function (hypothyroidism) with enlargement (hypertrophy) of the gland – this can result from excess TSH stimulation (when the amount of circulating TH is deficient), growth-stimulating immunoglobins, or substances that inhibit TH synthesis. The key manifestations are myxedema in adults, and cretinism in children. What is myxedema? Infiltration of the skin by mucopolysaccharides, giving it a waxy or coarsened appearance-seen particularly with patients with hypothyroidism. Other S & S are sluggishness. Intolerance of the cold, apathy, fatigue, and constipation. Nonpitting edema of the skin, hair dry and brittle—if left untreated, hypothermia, coma and death may occur.
Cretinism: congential condition caused by lack of thyroid hormones, characterized by arrested physical and mental development, myxedema
Another fact about goiter is that the thyroid gland may be enlarged due to deficiency of iodine, a mineral essential to the production of thyroxin.
Treatment of this deficiency is administration of thyroid hormones.
Primary cancer of the thyroid
Patients unwilling to be treated with radioactive iodine whose hyperthyroidism cannot be treated with antithyroid drugs.
Hashimoto's thyroiditis (a type of hypothyroidism, an autoimmune disease, with nontender enlargement of the gland)

10. Pathophysiology
Thyroid cancer is the most common endocrine cancer. It occurs in all age groups, mainly adults, affecting about three times as many women as men. Its incidence has increased in recent years — by about 3% per 100,000 people per year. It is, in fact, now ranked first among all cancers in terms of its "incidence growth" in women and ranked third in men.
An estimated 23,600 people will be diagnosed with thyroid cancer in 2004 in the United States, according to the American Cancer Society. And about 1,460 people will die of this cancer this year.
For most individuals with thyroid cancer, the prognosis is excellent. The most common types of it can often be completely removed with surgery. What's more, five-year survival rates are among the highest of any kind of cancer-more than 80%.
At this time, Show the Videotape: Thyroid Disorders

11. Diagnostics Exams: H & P, Visual/ Palpation Preoperative Testing
TA test
TSH test (sensitive assay)
T4 test
T3 test
T3 uptake test
RAI uptake test
Thyroid suppression test
Hyperthyroidism is diagnosed according to manifestations of the specific disorders causing excessive TH, and by diagnostic test results. Elevated levels of TH (both T3 and T4) and increased radioactive iodine (RAI) uptake are diagnostic criteria of hyperthyroidism.
TA is serum thyroid antibodies—measured to find out if an autoimmune disorder is involved—elevated w/Graves disease
TSH: best indicator of primary hyperthyroidism is suppression of TSH below 0.1 micrograms/mL.
T4 test: serum thyroxine levels—measured to determine TH concentration and to test thyroid gland function.—elevated in hyperthyroidism & acute thyroiditis
T3 test: serum triiodothyronine measured by radioimmunoassay—measures bound and free forms of this hormone. It is an effective test for DX of hyperthyroidism (and thyroiditis).
T3 uptake test: (T3RU) measured by in vitro test in which client’s blood is mixed w/radioactive T3—results are elevated in hyperthyroidism
RAI uptake: measures absorption of 131 I or 123 I by the thyroid gland. A calculated dose of radioactive iodine is given orally or IV, & the thyroid is then scanned. Diagnosis of Graves disease is made by evaluating distribution of radioactivity in the gland and is positive if elevated.
Thyroid suppression—TAI and T4 levels are measured first. The patient takes TH for 7-10 days, then then tests are repeated. Failure of hormone therapy to suppress RAI and T4 indicates hyperthyroidism.

12. Surgical Intervention: Special Considerations
Patient Factors
Maintain a calm, quite atmosphere
Room Set-up
Etc
These pts need a calm and quiet environment to 1.reduce the risk of overstimulation, which could result in thyroid crisis and 2. To make the experience more tolerable

13. Surgical Intervention: Anesthesia
Method: General
Equipment and considerations:
Lubricate and protect pt’s eyes

14. Surgical Intervention: Positioning
Position during procedure
Supine with shoulder roll, head hyperextended
Possibly some reverse Trendelenburg
Supplies and equipment
Sheet roll or thyroid rest/pillow for extending the neck
Special considerations: high risk areas

15. Surgical Intervention: Skin Prep
Method of hair removal
Men need shave
Anatomic perimeters
Begins w/anterior neck and extends to point of chin or cheekbones (surg pref), to nipples, to bedline
Solution options: Betadine or hibiclens or Duraprep

16. Surgical Intervention: Draping/Incision
Types of drapes
Absorptive hand towels
OR Basic Pack and Thyroid Sheet
Sheet
Order of draping
Crushed/wadded absorptive towels
on either side of neck, head drape, and split sheet
Special considerations
State/Describe incision
Transverse/Collar
Note: before procedure, surgeon may mark proposed incision line by grasping line of suture and pressing against neck—guideline for nearly unnoticeable scar
Incision: Transverse “collar” incision is make in the crease of the neck 1 inch above the suprasternal notch (silk suture may be pressed against the neck to mark the line of incision); bleeding is controlled with curved hemostats or the ESU

17. Thyroid Sheet

18. Surgical Intervention: Supplies
General: suction, ESU, prep set, basin set, gloves & gowns, marking pen, dissector sponges
Specific
Suture: 3-0 & 4-0 for silk suture for ligation; 2-0 or 3-0 silk mounted on a fine needle (Ferguson or French-eye) for occlusion of large arteries; interrupted silk suture on a fine needle on muscle and fascial layers. Subcutaneous tissue is closed w/fine interrupted absorbable sutures
Blades # 10, # 15
Medications on field (name & purpose)
Catheters & Drains
¼ “ Penrose

19. Surgical Intervention: Instruments
General: Minor set or Thyroid set; Pull a tracheotomy tray for post-op standby
Include (2) Rt angle clamps w/fine points
Specific: Specialty
Mastin muscle clamp Lahey thyroid tenaculum, Green thyroid (loop) retractor, Lahey thyroid retractor, Beckman self-retaining retractor,
Ligating clip appliers
Bipolar forceps w/cord

20. Thyroid Instruments Mastin muscle clamp Lahey Thyroid tenaculum
Green thyroid tenaculum
Beckman retractor

21. Surgical Intervention: Equipment
General: standard room set-up
Specific: N/A

22. Surgical Intervention: Procedure Steps
Platysma muscle is incised symmetrically using a collar/transverse incision & # 10 blade and retracted
* Hemostatis will be provided via ESU pencil or bipolar forceps
* Surgeon may prefer to clamp & tie some vessels, or may use ligating clips
Incision is extended through the subcutaneous tissues & Platysma muscle divided. Superior and inferor flaps are mobilized and retractors are placed
* Prepare self-retaining retractor of choice
Strap muscles are separated w/blunt and sharp dissection
Thyroid lobe is elevated & exposed with a Lahey tenaculum and the sternocleimastoid muscle is retracted with a Green retractor

23. Surgical Intervention: Procedure Steps
* Because the knife (# 10 blade) is used so much during mobilization, it may be left on the field where he/she can pick it up freqently. STSR that if asked to leave on field, it is placed on a folded towel (or other platform) to prevent accidental injury

24. Surgical Intervention: Procedure Steps
The middle & inferior thyroid vein is exposed, divided, ligated.
The superior and inferior thyroid arteries are identified, clamped, divided & ligated
* Slow and methodical is the rule of thumb. Keep fresh, dry raytex available
* Many (12) Mosquito hemostats or straight Kelly clamps may be used
Care is taken to identify the parathyroid glands and preserve the recurrent laryngeal nerve. The parathyroid glands are mobilized & vascular supply is preserved.
Above steps may require use of small right angle clamps and ligature on passer.
Many steps are repeated. Keep two clamps, scissors, and ties ready

25. Surgical Intervention: Procedure Steps
ID of parathyroids & recurrent laryngeal nerve
Ligation of superior thyroid vessels

26. Surgical Intervention: Procedure Steps
Hemostasis is achieved w/ESU.
* May alternate between sharp dissection, blunt dissection, & ESU.
Thyroid gland is freed from trachea and delivered as a specimen
* If only one lobe is taken, the isthmus is divided so that it is removed w/resected lobe is the pryamidal lobe.

27. Surgical Intervention: Procedure Steps
Hemostasis is achieved after lobe or lobes removed.
* Sequence is irrigation, placement of wound drain, closure, initiate count.
Strap muscles are approximated with an interrupted suture
Penrose drain may be inserted in thyroid bed and brought to the outside
Platysma is approximated
Skin is closed w/staples, or nonabsorbable suture and collar-type dressing is applied

28. Counts Initial: sponges and sharps (instruments) First closing
Final closing
Sponges
Sharps
Instruments

29. Dressing, Casting, Immobilizers, Etc.
Types & sizes
Surgical wound may be left without a dressing to allow for observation of swelling
Thyroid collar (also “Queen Anne”) may be applied using a gauze strip around the pt’s neck OR after the wound is dressed, a collar is made with cloth towel folded in thirds lengthwise. The towel is wrapped around the neck and criss-crossed in front—secured w/tape
Type of tape or method of securing
Thyroid collar dressing may consist of a strip of adhesive tape with a folded gauze covering its center portion. The dressing is brought from the back of the neck to the front, and the free ends of the collar are crossed and secured over the chest (Info p. 56 MAVCC Fig 5)

30. Specimen & Care Identified as thyroid or lobe of thyroid (rt vs lt)
Handled: Frozen section could be ordered if tissue looks suspicious; routine

31. Postoperative Care Destination
PACU: position in Fowler’s
CAUTION:
STSR will maintain integrity of sterile field until pt leaves OR proper
Ensure tracheotomy tray is transported postop w/pt and stays at bedside for at least 24 hrs
Expected prognosis (Good, Depends on Dx)
Surgeon will be assessing for voice capability asap
Short recovery—normal activities asap
Medications usually required for life
The results of thyroid surgery are usually excellent. Monitoring of thyroid hormone production may need to continue for some months after the operation. Thyroid hormone replacement maybe necessary
In general, recovery from thyroid surgery is very rapid, and you should be able to resume all normal activities, including going back to school or work, within a few weeks

32. Postoperative Care Potential complications
Hemorrhage from major arteries in the neck
Infection
Tracheal edema w/resultant obstructed airway
Other: Damage to…
Accidental removal of parathyroid glands with resulting tetany
Damage to one or both recurrent laryngeal nerves w/paralyzed vocal cords and completely obstructed airway
Thyroid storm from excessive manipulation of toxic gland.
Surgical wound classification: I
Thyroid Gland Removal: Risks
Risks for any anesthesia include the following:
Reactions to medications
Problems breathing
Risks for any surgery include the following:
Bleeding
Infection
Additional risks for thyroidectomy include the following:
Bleeding and possible airway obstruction
Temporary or permanent loss of ability to speak due to paralysis of the vocal chords
Inadequate thyroid function (hypothyroidism)
Injury to the adjacent parathyroid glands --
Inadequate level of calcium in the blood (hypocalcemia)
What is a thyroid storm? Another name is thyroid crisis—and extreme state of hyperthyroidism that is rare today because of improved diagnosis and Tx methods. It is life-threatening due to excessive TH. It would typically occur w/untreated hyperthyroidism (most often Grave’s disease) and people w/hyperthyroidism who have experienced another stressor (eg infection, trauma, untreated diabetic ketoacidosis, or manipulation of thyroid gland during surgery. Manifestations: hyperthermia, tachycardia, systolic hypertension, GI symptoms (like diarrhea).

33. Resources www.allrefer.com STST pp. 461-466 Procedure 14-13
Alexander’s pp
Berry & Kohn p. 858
Fuller’s p. 171, 108,
MAVCC Unit 3 OBJ 12, 13, 14, 15
Complete Review of ST: Boegli. Rogers, McGiness

34. Related H & N Procedures
Parathyroidectomy
Removal of one or more parathyroid glands for adenoma or hypersecretions of parathormone
In a parathyroidectomy procedure a small horizontal incision is created just under the Adam's apple to get access to the parathyroid glands. Parathyroidectomy is recommended when the parathyroid glands produce excessive amounts of parathyroid hormone (hyperparathyroidism). After surgery, complete healing without complications usually occurs within 4 weeks. The long term outlook is excellent.

35. Related H & N Procedures
Thyroglossal Duct Cystectomy
Removal of pretracheal cystic pouch attached to the hyoid bone, and when present, the sinus tract, an embryological remnant from the descent of the thyroid gland into the anterior neck. It is removed to prevent recurrent cystic formation and prevent infections
Scalene Node Biopsy
Incision made just above clavicle & biopsy taken to determine the spread of TB or CA of lungs

36. The incision used for a Thyroidectomy is:
Postaural
Eyebrow
Y-type incision on either side of the ear
collar
d. The collar incision made 1 inch above the suprasternal notch for removal of the thyroid or parathyroid tissue provides the best cosmetic results

37. Patients having neck surgery are more likely to encounter respiratory problems from edema. The equipment to accompany these patients from surgery is:
Suction
Tracheotomy set
Oxygen
Packing
b. A Tracheotomy set should accompany patients leaving the OR following procedures on the neck because of the serious complications of respiratory embarrassment, which may occur in the event of severe cervical edema.

38. Damage to one or both recurrent laryngeal nerves
Surgical hazards associated with a Thyroidectomy include all of the following except:
Damage to one or both recurrent laryngeal nerves
Damage to the facial nerve
Accidental removal of the parathyroid glands
Hemorrhage from major arteries in the neck
b. Surgical hazards include thytoxicosis (thyroid storm), accidental removal of the parathyroids, accidental injury to major arteries in the neck, and damage to recurrent laryngeal nerves. The Facial nerve (VII) does not extend to the neck.

39. The subcutaneous neck muscle that covers the anterior portion of the neck region from the jaw to the clavicle is called the __________________ muscle.
Platysma
Deltoid
Sternocleidomastoid
buccinator
a. Platysma

40. The tissue that may be accidentally resected during a Thyroid Lobectomy is:
A scalene node
The larynx
Parathyroid gland (s)
A cervical lymph node
c. Parathyroid glands

41. A sampling of lymph nodes in the neck region is referred to as a:
Modified Neck Dissection
Scalene Node Biopsy
Carotid Node Biopsy
Lingual Tonsillectomy
b. Scalene Node Biopsy