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Right Hemithyroidectomy
Table of Contents
Positioning
- Patient Positioning
- The patient is placed supine with the arms tucked or wrapped with a sheet in a “burrito” fashion
- All bony prominences should be padded
- Thyroid bag is inflated to create appropriate neck extension
- Patient is then placed in modified beach chair position
- Ultrasound Examination
- Identify landmarks
- Trachea
- Thyroid isthmus
- Common carotid artery
- Internal jugular vein
- Thyroid cartilage
- Cricoid cartilage
- Assess thyroid lobe of interest for target nodule
- Assess superior and inferior extent of thyroid poles
- Assess lateral cervical lymph nodes
- Draping
- Prep surgical field widely
- Drape patient such that a wide field is visible including inferior to sternal notch, superior to thyroid cartilage, and laterally beyond lateral border of sternocleidomastoid muscles bilaterally
Exposure
- Make 5 cm Transverse Incision on Anterior Lower Neck
- Identify sternal notch, cricoid cartilage
- Place 5 cm incision in natural skin crease that will allow adequate exposure to both superior and inferior thyroid poles
- Use scalpel to incise epidermis and dermis
- Use electrocautery to incise subcutaneous fat and platysma
- Elevate Subplatysmal Flaps Superiorly to the Top of Thyroid Cartilage and Inferiorly to Sternal Notch
- Have assistant retract flap using skin hooks or small retractor
- Maintain plane just posterior to platysma
- Ensure appropriate retraction to prevent through-and-through injury into flap
- Insert Self-retaining Retractor over Microfoam Tape and Incise Investing Layer of the Deep Cervical Fascia
- Incise the fascia in the midline, using trachea as your guide
- Retract Sternohyoid and Sternothyroid Muscles from Thyroid
- Use blunt retractor to retract muscles laterally and fully expose thyroid lobe
Examination
- Isolate/Retract Right Superior Pole Vessels Away from the Larynx
- Preserve the external branch of the superior laryngeal nerve by creating a space medial to the vessels
- Bluntly dissect lateral to the upper pole vessels to create a space
- Retract upper pole caudad and place medium clips on stay side of superior pole vessels
- Cauterize/energy device to divide caudad to clips
- Check Right Vagus Nerve Signal
- To ensure the circuit is intact and nerve monitor appropriately functioning
- Divide and Ligate Middle and Lower Pole Veins
- Continue lateral mobilization of thyroid lobe
- Divide and ligate middle thyroid vein and lower pole vessels if seen
- Rotate thyroid lobe medially and anteriorly
Preservation
- Identify/Preserve Right Superior and Inferior Parathyroid Glands
- Identify both parathyroids and dissect them posteriorly, away from thyroid lobe, using blunt and electrocautery dissection
- Be cognizant of recurrent nerve and inferior thyroid artery location in relation to superior parathyroid
- Develop Plane Beneath Thyroid, Identify Right Recurrent Laryngeal Nerve Using Nerve Monitor
- Continue to rotate thyroid medially and anteriorly
- Using blunt dissection, identify the recurrent nerve near the inferior thyroid artery and superior parathyroid
- Confirm location with nerve monitor
- Trace and expose the course of the nerve superiorly to cricothyroid insertion and inferiorly towards the thyroid lower pole
- Develop a plane posterior to the thyroid and anterior to the nerve, down to the trachea
- Ligate small terminal inferior thyroid artery branches with suture or clips
- Continue to dissect the nerve away posteriorly
- Release thyroid from trachea using appropriate techniques based on proximity to nerve
- Divide the Ligament of Berry
- Once the nerve is safely out of harms way, Ligament of Berry can be divided
- Continue to release thyroid from trachea, retracting lobe anteriorly and medially; can use electrocautery or scalpel depending on proximity to nerve
- Isthmusectomy
- Once thyroid lobe released from trachea and only attached via isthmus, place sequential clamps on isthmus
- Divide thyroid at isthmus to right of clamps
- Tie clamps
- Remove Specimen, Mark for Pathology
Stabilization
- Hemostasis of the Right Thyroid Bed
- Assess resection bed for any bleeding
- Cauterize areas of oozing as long as they are away from nerve
- Place clips, stick tie, or simply hold pressure if oozing near nerve
- Ensure previously placed clips and ties are secure
- Positive Pressure Ventilation in Trendelenburg, Hemostasis
- Assess for additional bleeding by placing patient in Trendelenburg and asking anesthesia to give patient Valsalva
- Find any bleeding sources
- Irrigate resection bed, consider hemostatic agent if indicated
- Check Right Vagus Nerve and Recurrent Laryngeal Nerve Signals
Closure
- 4-0 Vicryl to Reapproximate Sternohyoid and Sternothyroid
- Interrupted Vicryl to cover trachea and reapproximate strap muscles to midline
- Reapproximate Platysma and Fascial Layers
- Interrupted Vicryl to reapproximate platysma
- Consider interrupted Vicryl to reapproximate subcutaneous fat to minimize tension on skin
- 5-0 Prolene Subcuticular to Close Skin
- Place in knotless, running, subcuticular fashion
- Apply Dermabond and Remove Prolene
- Once Dermabond has dried, gently pull on one end of Prolene to remove in entirety