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Right Hemithyroidectomy

TK Pandian; Roy Phitayakorn, MD
Massachusetts General Hospital

Transcription

CHAPTER 1

Hi, my name is Dr. Roy Phitayakorn and today you are going to see a diagnostic right hemithyroidectomy and isthmusectomy with recurrent laryngeal nerve monitoring. First, we're going to position the patient, and then you're going to see me use an ultrasound machine to look at the thyroid and mark out its pertinent landmarks. You’ll then see us make a 5-centimeter incision above the sternal notch and dissect down to the thyroid gland. We will then carefully ligate the upper, middle, and inferior pole of the thyroid gland and then carefully separate the right superior and inferior parathyroid glands from its undersurface. You’ll then see us find the recurrent laryngeal nerve, protect it, and proceed to remove the thyroid gland off of the trachea.

CHAPTER 2

Okay so just to review here - so we’ve padded all bony prominences. Okay, and we put O-B sponges underneath all the IVs. We've cut off the plastic piece over here so it doesn’t pinch his skin, and then we wrap him up kind of like a burrito - you have the cloth tape? Alright, we wrap it around from elbow to elbow. Josh, how’s your IV? It’s running great - great. Alright, then we put the patient into a- what's called a modified Fowler position or semi-Fowler position - otherwise known as beach chair. Okay and then at Mass General, we use what’s called a thyroid bag to provide some extension. As you can see, I inflate it slowly and Josh is watching the head of the patient - to make sure that the patient doesn't have any neck injury as we inflate. So he's kind of like up like this - almost like in a sniffing position as they call it - which brings his thyroid out from behind the - the sternal notch. Okay then we hook up the nerve monitor if you want to come over here and take a look at this. We use the Nerveana nerve monitor. So basically this is used to monitor the recurrent laryngeal nerve. And we use what’s called an intermittent stimulation system as opposed to continuous nerve monitoring. So you can see here as a result of his position, you can see this the right thyroid nodule, actually quite nicely. It’s basically bulging out of his neck here. You can see if I push, you can see it. So I put the gel on the probe, and then I touch the side to make sure that if I’m touching the left side of the probe, the left side moves. Okay, so we know the probe is oriented correctly and then I place it here over the patient. The thyroid sits on the thyroid cartilage like the saddle sits on a horse. Okay, so the cartilage of the trachea here is basically the horse, and then the thyroid is the saddle. As you can see here's the little bridge of the saddle. If we go over to the right side, you can see there’s a very large nodule that’s basically occupying the whole screen here. Okay, that's it right here. Over here is his carotid artery, and that's his jugular vein right here. Okay, so carotid artery, jugular vein, and then giant thyroid nodule. And if you go down, you can see it is not substernal - it seems to end above his sternal notch - and as you scroll up, you can see the thyroid pole ends- right there. So we have to go up at least this high, so it looks like the best incision will be the middle incision then. So that we have - so we’re basically looking at a distance from here to here, so we choose the middle incision so that we can get up to the upper pole. Next, I make what's called a Gaz pouch. It's a pouch made of two towels that we hold in place to use for our instruments. Okay, I'll take two DeBakes, Metz, and straight Mayos. And I'll take a lap pad. Thank you. Ruler and marking pen.

CHAPTER 3

So I mark his sternal notch. Mark his chin. Thyroid cartilage is there, so the middle of the incision will be somewhere around here. We’re gonna try and do this through a 5-centimeter incision, which is basically the same size as the nodule, so I may have to enlarge that a little bit. Okay, so this is a 5-centimeter incision with a little bit extra in case we need it. Ready for time out. Just pull over to your side. And you hold up the skin hooks for a second. Okay, move on down. Okay, and grab the deeper stuff. Pull straight up. So you can see in a man, the platysma is actually quite thick - right here - but it still doesn't seem to connect in the middle. Right. Okay? As we talked about last time, it’s an example of how Netter’s wrong. He’s not wrong often, but he is wrong here. Almost - you got to grab that other edge - yep - perfect. Pull straight up. Very muscular guy. And, put the hooks underneath the edge of the platysma. We’ll raise our superior skin flap to the top of the thyroid cartilage, and then you'll do the inferior side. And as you can see, here - this is the anterior jugular veins - here and here - so we're trying to leave those down while raising the skin flap. So what I do is I pull down with my sponge here. I’m basically trying to bluntly dissect the plane here. Until we get to the top of the thyroid cartilage. This is the deep cervical fascia here, and this is his platysma, which is elevated as a skin flap, and you can see the anterior jugular veins - one is here, one is here. This just might be a branch of one - it’s kind of hard to tell at this point. We’ll now do our inferior skin flaps down to the sternal notch. And what Dana's doing is, she's using her finger to kind of gently, bluntly dissect along this plane to create it - our flap. Alright, we're next going to raise our lateral flaps, which go to the end of the sternocleido - excuse me - to the beginning of the sternocleidomastoid muscle. On the left side, we won't do as much dissection since it's only a right thyroid lobectomy, and we're not doing a total. If we are doing a total, we would also elevate flaps all the way out onto the left side. So as you - keep those. So as you can see, this is the sternocleidomastoid muscle here. Alright, we’ll do this on my side now. Watch your fingers. Okay, so we’re going to use the Metz. So, sometimes you see the situation where there is a branch coming off the anterior jugular that’s going up on the skin flap. So what you do is you - exactly, pull down on that - and I typically use Metz to create a plane, and then now you can see where to go. Nice. Good - use your finger, exactly. Feel good? Yeah. Good. Nice. Okay, so we’re just going to get hemostasis here. Now, the next step, I like to protect the skin with microfoam, so we'll take the microfoam pieces, which Chelsea's been nice enough to cut already. And then a Weitlaner retractor. Okay, so once again, this is the deep cervical fascia. We're now going to get ready to incise it in the midline between these two anterior jugular veins. You can see this one is much larger than this vein probably because of the mass effect of the large right thyroid nodule. So we will palpate. Here's the thyroid cartilage, so the midline is somewhere here. Go ahead open that up. Right angle, please. Okay - perfect. Okay, so now what we're looking for is the sternohyoid muscle. Here's one muscle belly, I think that's mine. Here you go. Still think it's mine. Baby Rich. So you can now see the sternothyroid muscle being exposed. Because it's a large thyroid nodule, I like to separate the sternohyoid from sternothyroid, so first we'll finish our midline dissection. Yep, grab that. Okay so you can see we're right here on the sternal notch - okay - which is far low as we need to go. We're going to take a little bit of this, and you want to be mindful as you go behind the sternal notch that they can have a high innominate artery, which would obviously make for a very bad day to get into. That would end up - you can possibly end up having to enter the chest in the situation. Exactly. Okay, can you buzz me here? Looks like it's gonna bleed. Okay, so we've now exposed the sterno - can you hold that over for a second, Dana? This is the left sternothyroid muscle over here. This is the right sternothyroid muscle. Okay, so we’re first going to separate the sternohyoid and sternothyroid just to give ourselves a little bit of wiggle room for such a large thyroid nodule, and I really find is one of the key steps when you have a very large thyroid nodule and you’re trying to take it out of an incision that's actually smaller than the nodule. Okay, so we’ve basically separated now the two as you can see, and we're now going to take off the sternothyroid muscle. Stay right up against the border of the muscle. Little bit closer - that’s thyroid - up here. Good. Buzz that vessel. Good. Okay. We're now taking down this kind of cotton can - oh no, Bovie it. We're now going to Bovie this cotton candy looking stuff because there's very small vessels in there. Take a lady finger retractor now. And what I'm using is the retractor to kind of hook underneath the muscle, and then Dana is going to pull the thyroid towards herself and we're providing traction, countertraction. So we’re going to keep pulling the thyroid nodule towards the medial side here. And we'll get a peanut. So she's pointing at the carotid artery, and there's the middle thyroid vein probably right there - or inferior thyroid veins - hard to tell at this point. So Dana, why don't you take a right angle and take that vein now before we - or I rip it. And Chelsea, we’re going to use medium clips. Okay, and pull that close and go towards you. Nice. One more. Alright, open up the - great. And then see if you can pull that little more towards yourself there. Okay, can I borrow your DeBakey for a second? And then open - close- I’m sorry - go towards you. Okay. So now we're going to look upwards. Okay, so you can see the upper pole of the thyroid is still going underneath this muscle right here - the sternothyroid. Okay, so we're going to continue dissecting that down. Sucker on, please. Okay - and as you can see now again we got the carotid, and we're now dissecting around the upper pole vessels here. Now going to go look medially, baby Rich. Now, this is the trachea. Here's the thyroid cartilage. You can see that knob right there. So what we're trying to find here is the space between the thyroid and the cricothyroid muscle. Preferably staying out of the large vessels that are on the thyroid. Borrow the Bovie. Thank you. I’ll take a medium clip. Back up the sucker. Medium clip. Okay, there's another one over here. What you can see here is we have the cricothyroid muscle right here, and this is the thyroid over here. Okay, and we create a little space here. The external branch of the superior laryngeal nerve is going to be up in this area. Okay, so what we got to do next is carefully dissect the upper pole down without getting into the external branch of the superior laryngeal. Medium clips.

CHAPTER 4

Okay and then Dana, you're going to hold like this. Okay, so what I’m to do next here is I’m going to chopstick my way down around the upper pole on this side. Alright, so take a Jacobson Schnidt - can you give us a sucker? I'm looking for a space between the cricothyroid muscle and the thyroid pole, which looks like it’s right about there. Can you Bovie that - the flim-flam stuff above my Jacobson Schnidt? Don't go too high up. Okay. Now I'll take a big Kelly. Okay Dana - just going to do your clips, okay? You gotta leave the clamps - you gotta leave that retractor in. And this is the Hodin technique here for taking down the upper pole. Okay - hold that down there for a second. Take some irrigation please. Okay, so what you guys can see here, is a - here is the rest of the upper pole of the thyroid, okay? Big Kelly. Okay, can you hold the retractor? Medium clips. Another is right there. I though those were... Okay, take the other Kelly off. Okay, medium clips. So what I'm doing now is I'm taking the second set of medium clips and I'm putting them almost at a perpendicular angle to the first set. And you going to see it still going. So I’m brushing the muscle away. Alright, Dana if you could hold that retractor for a second. Yep. So again, here is the carotid artery, and it's coming right adjacent to this upper pole. So I'm very carefully separating the upper pole from the carotid artery and getting down to the vertebral body, which is the deepest part of our dissection. Medium clip. Okay, you want to use the Bovie there - Dana, you have an extra, third hand there? Nope - stay right underneath the clips - you’re going into thyroid there. And then go ahead go to that last piece. So if you guys can see this, here is the upper pole that Dana just took down. Here is some flim-flam stuff that's holding it down to - towards the vertebral body, and you can see there's no vessel in there - there's no parathyroid gland - that's what we're checking for. Okay, so I'm just going to go ahead and take that with the electrocautery and actually some clips first. Okay. And then you want to go ahead and take that down there. Okay, so that's - that takes care of our upper pole. Just get that little bit there. Medium body wall retractor. And you can see here there is muscle that’s just very loosely attached to his thyroid right here, which we're going to take next. Right angle. Good, and then keep coming across exactly. Okay - hold on one second. We're getting back to where we took down that middle of thyroidal vein, and you can see a lot of this stuff can be done bluntly. Okay, now I'm going to swing down here, and see if we can find the inferior pole to this mass. Take a peanut. And I think we’re going to need a lady finger. Alright, Dana, you want to hold that up? And I got this one. Okay, so it's like kinda up and out. Got it? So again, here are the - it’s probably the inferior thyroidal artery is right here. Okay, and that vascular bundle there - Jacobson Schnidt - keep holding up. And you can see, it's probably bifurcating so there’s a branch here, and there's a branch here. We're going to take these now, being very mindful to not take too much; otherwise, you could lose the blood supply to the inferior parathyroid. Actually, can I have a right angle first? Okay, medium clips. Dr. Phitayakorn, what are the Bovie settings you used? It should be 25, 25. Generally, you want to use kind of lower energy than you would say for the belly because there’s potential for scatter, and you don't want to accidentally damage the nerve. Okay great, so that takes care of our inferior pole. So at this point in time, I typically like to find the trachea because it is a fixed landmark for us. And I think it's right here - Jacobson Schnidt. Okay, so there you guys can see the trachea right here. Okay? So we're going to take this vessel right here, and that'll mark the extent of our hemithyroidectomy on the left side. Let's go right underneath the vein. Good. Medium clips. And my practice is just to put two clips on the side of staying in, one clip on the side that’s coming out. Thank you. Okay so now... You can see here - if I bring the retractor over - just got this one band left. Go ahead and do the same thing again. Medium clips. Thank you. And just lift your Jacobson off the skin there so I don't burn it. Great. Okay peanut - actually I’ll take a sucker instead So come back over here again. Okay, so as you guys can see now, here's the trachea, okay? And the nerve then is going to be passing somewhere along here. So we’re now going to - do you have an Allis? I'll take a towel clamp. Okay so first we're going to get our vagal nerve signal. Okay? And the vagus nerve should be just lateral to the carotid. So let's open up the carotid sheath a little bit here. What you see is vagus. There we go. Okay, so that's our positive control signal. Okay, that says that the vagus nerve is intact. The signal then is going all the way down to the recurrent - go down - to the recurrent laryngeal, back up again, and then to the vocal cords, so we know we have not damaged anything and that the nerve monitor works. Get me a wide body wall. We're now going to dissect - and separate this kind of flim-flammy stuff. Okay, right angle. You got it. Okay, cauterize that. Oh yes, I'm sorry Josh - it's working now. When you hear that beep, that means it’s actually working - whereas before, all we heard was the clicking. Okay, so again - I like this - this is probably one of the superior parathyroid glands here. Or the superior parathyroid gland I should say, not one of, right there. You see when you kind of push there, there’s kinda this sensation - there’s something- some sort of mass - that's kind of moving back there - that's probably the parathyroid gland. And there is the inferior parathyroid gland right there okay? So we'll now try to separate it off of the thyroid. Okay, so you grab the parathyroid like - like this and kind of pull it this way, and then you can just Bovie this off here if you like. Nice and gentle here. Yep. Okay, that's a vessel there, so medium clip - actually a small clip. So grab the vessel - Yep, good. Thanks Chelsea. Thanks Jeff. Okay. Nice. Okay. Okay that wasn't as good. Small clip. Maybe medium clip would better. Okay, how’s that? Much better. Okay. Alright, I'll take some irrigation. So we have the inferior para kind of hanging on here, okay. And we're just going to check real quick with our nerve monitor because sometimes the nerve can travel right next to the inferior parathyroid gland. Okay, then I would take the medium clip on that band first. I can hold the retractor if you'd like. Okay. Right angle. And now we're gonna - we’ve created a little band here, which is all that’s holding the para on there. Just check it with the nerve monitor real quick and then medium clip it. Just two clips down - I don’t think you’re going to get another one in there - it's too tight. Can I have another clip, please? Okay, Bovie. And down towards the trachea. Good, alright. Okay so that leaves the inferior parathyroid gland intact and sitting happily right there. Okay? Off the thyroid. So that is how you could inadvertently remove parathyroid gland quite easily. Okay, now we're going to go back to looking for the nerve.

CHAPTER 5

So if I was the nerve, you can see that much of the thyroid's already up in the air, so if I was the nerve, I would be down here somewhere in this kind of region. So what I'm going to do is just very gently separate off this loose tissue, which hopefully will then reveal the nerve. You see- this structure. Right there, that’s beeping. Can you see that Dana? Okay. I can. You want to go ahead and lift up like that. I'm just going to very gently make sure the structure is inserting. Okay so we're going to take off this top piece, okay, so you going to bring this piece down like like that - great. Okay, Bovie. Okay, and then you hold up like that - great. Right angle. Okay. Go ahead and Bovie - nice and gentle. So what you’re hearing there is a false signal. It’s beeping because it's touching the trachea basically. Okay, I’ll take a right angle. Alright, Dana can you take this vein? I think I’m going to rip it. Okay, two medium clips, please. And one clip on top, please. All right. That didn’t work. Go ahead and suction there, Dana. Small clip. Another clip applier. I think that one is jammed up there, Chelsea. One more. Okay, now I think the easiest thing Dana, maybe you come on this side. Jacobson Schnidt. Okay, so he appears to have a lymph node right underneath where the nerve should be. See that node right there? Yes. Alright, so find the nerve. So that way? The lymph node is... I think so. Okay, so go ahead and take your Jacobson here, and you want to dissect now, you know, right on top of the nerve, going in the direction that it's going. Okay, so you’ve got to turn your hand. You think it’s that right there? Exactly. Okay, can you guys see that? The white structure? Yes. This is the nerve, okay? And as typical in men, it's very large, okay? But you can see it's a nerve. Number one it’s white. Number two it’s got a racing stripe on the front of it, okay? That's a sure sign that it’s the nerve. Okay, and as you can see, it’s going in the direction of the nerve, and it's inserting right up under here, okay, which means all of this is free and clear. Okay, so now we’ve got to establish here - this is either a lymph node or it's the posterior tubercle of the thyroid. Okay, with our luck, it’s probably the posterior tubercle of the thyroid - which probably has to come off. So, exactly - yep, pull that over. Okay, use your Bovie. Good. So that looks like thyroid, doesn't it? It does. Yeah, okay. Okay, now we agreed your nerve's over here, right? Good, okay, so you’re going to have to try to get this posterior tubercle off, which unfortunately seems very stuck. So I think it's this piece here - you see how it kind of comes up like that - and I think there's a plane on this side of it. Okay, so just carefully try to dissect and see what you can do. You might have to use your other hand to hold - here, I can hold the retractor if you need it still. Kind of stuck - huh? Yeah. Alright, well let's- let's do this then: let's take this piece off here, okay? And then we can come back and look at that thing again. Okay. So a right angle to Dana. Okay and what I would do is I would - exactly - come over here and try to come out somewhere over here, okay? You don’t want to come out over here because then you going to amputate it - come out down here somewhere so you can get a plane - yep, exactly, yep. Nice, okay, pop through. Okay - we’ll just stim it to be on the safe side. Okay - medium clips. One more. 15 blade. Great, hold this. Thank you. Okay, alright now let's dry that off for yourself. Take a peanut. So this is still trachea, right? That looks like it's all going to come up with you - agreed? Okay. Agreed. So then now we need to get the piece off that’s stuck near the nerve, okay, so show me the nerve again. Okay, good. Let go - take your right angle out. Good, now take the Schnidt, okay, and gently trace the nerve up to its insertion point. Yep, nice and gentle - gentle spreads - alright because you don’t want to go into the nerve. Okay good, so there you go. So this piece is clear, right? Because you’ve established nerves going that way, okay, so take your Jacobson or your right angle and go from there and come up here somewhere. Can I have a right angle, please? Come up against the thyroid. Nice - okay. Small clip. Okay, gentle spread there or even just close and go towards the nerve. Other one. Okay- 15 blade. Okay, knife back. Okay now you do that again. Right, but this time you're coming up. Like here? No, over here. Go in there, come over here somewhere. Right, because it’s all free, right? Yes. Medium clip. Okay, spread. Sorry, one more for me. Yep. 15 blade. Sorry, two. Okay, now there’s a large vessel that’s back here that’s going to give us some problems. Sorry for the reaching. Okay - Metz. You got them. Okay. Should be getting there. Okay. Another vessel. Let's just do this stim here real quick before you keep going. Okay - you touch the nerve down there again. Good. Okay. Okay great. Go ahead and take that vessel, and then I think we can start doing our… Small clip. Can I have a forceps, please? 15 blade. Knife back. Okay, so now what you’re going to do is you're going to take this SpongeBob. Moistened. Okay, so we call this a nerve patty or SpongeBob. It’s SpongeBob because of the you know, here's the belt, here's the crotch, okay, so it's SpongeBob Squarepants. No official endorsement I guess since we're videotaping this. So now we use this to basically protect the nerve and cover up our clip so we don't accidentally arc onto them. And we’re going to get the Bovie. Okay, so just so we're clear - okay this is trachea, okay, and you're going to go from - you going to get that band, and then you going to kind of coast up here, okay. Okay. Hold on a second. Alright, now you're going to coast a little more, right? Watch that forceps - alright? You’re putting that forceps right in nerve territory. Okay - you’re leaving a little bit of thyroid behind, right? You can see it splitting there. So we need to be a little lower. Hold on a second. Okay. No. Try again. Alright, let’s switch for second. Okay, looks like we’re not free enough yet. Okay, so, what I want you to do is hold the thyroid over there with your thumb. Right angle. Okay. Medium clips. One more. Actually make that another one after this. Thank you. 15 blade. Thank you. Knife is back. Stimulator. Okay, can you hold this up gently for a second, Dana? Okay, right angle. I just want to check and make sure we're well away from the nerve before I clip this. Okay, medium clips. Is injury to the recurrent laryngeal - is it - sort of a typical male complication in the sense like urinary incontinence... 15 blade. Only happens in a certain percentage... well, national average is about 1%, but we strive for much lower here, so... Of course. Okay, so that's all loose flim-flam stuff. Bovie. You guys can see here there's a superior parathyroid gland. It's a little bit ischemic on the top but it's otherwise happy and it's laying directly on top of the recurrent laryngeal nerve. Actually, I can show you... Maybe. See the nerve? This is superior parathyroid gland - this is the nerve - but you can see when you let go of the retraction, it all just kind of blends on top of each other, you know, and that's how it's very easy to injure these structures. Okay, so nerve, okay? Superior parathyroid gland, and if I let go of the retraction, you can see it gets very easy to blur everything together. Okay, now the nerve is right there. It's inserting right there, okay? Yeah. Okay. Sorry. Can I have another pair of pickups? Yep. There is one. No, I think this will do - thanks though, Chelsea. Okay, let me see where you are. Okay, let's take all that down. So right now she's going through the ligament of Berry, okay? Hold on one second. I'm just going to make absolutely sure the nerve is inserting at that point because this is getting very close to everything. Okay, so if I pull this out like this - okay, what I want you to do is slide the nerve stem into that space. You want a plane between the trachea, and this whole piece of whatever this is - thyroid - here. Right? Because this is where you want to go. Right. Okay, then it should be - okay. See now how I created that plane? Good, you can arc onto me just try not to arc onto this clip. If you need to cover up with the SpongeBob - that's fine. Okay - hold on a second. Okay. Oh, that's really - it's really, really stuck. Okay. So now we're going to lift that up. Yep. Can you remove the stimulator, Chelsea? Yes. Thank you. Okay - hold on a second. Okay. Alright, there we go - last push. Yep. Can I have a forceps, please? Just get this piece right there. Don't use your forceps because you’re going to arc onto yourself. Good, there you go. Go back right here. Keep going. Okay. There. See how when it releases, it kinda - fruh. Yeah.

CHAPTER 6

Okay, so that’s the ah-ha moment. Go ahead. Watch the skin. Okay now, this looks as if it’s becoming a pyramidal lobe, right? Yes. Okay, so now we're looking at the lobe, okay? And you guys can see it's much smaller because the blood is now out of it, right, so it's essentially exsanguinated - that's why it's such a smaller nodule. Okay, so there is a vessel going right here, right, so I would say let's take it like here. Yes. Okay. Okay? We're going to need another of the Prolene stitches, okay? So you need two total. Maybe take a little bit of this flim flam stuff up here first. Good. Okay, so now you can get into that plane, so I think it's just, you know, like just score from there to there. No - you went right across the vein - go down this way. See the vein? Here's the end of it. Oh, yep. So stay on - and finish on that side - on my side of it, you know what I mean, the left side - the patient’s left. Yeah. The patient's left. Watch the skin. Okay, let me move this retractor over. Baby Rich. Thank you. Okay. Chelsea, can you hold this? Okay - why don’t you score when I lift it up, okay? Okay. There you go. I got this side - you got the other side. Okay, let me just take that last piece off. Okay, medium clips. Hold on a second - don’t Bovie at all. See it's going down here. Another one. Want one more? No, I'm good thanks. Okay. Okay, we’re going to need a marking stitch. This is the superior pole. This was the inferior pole. This whole thing was the nodule as you can see here, and we check the back to make sure we didn't inadvertently take a parathyroid gland. It's all clean, which makes sense because we did see two parathyroid glands already, but people can always have more than 4. Can you grab that wide body wall retractor on the Mayo stand there? Okay since you got the camera on you, identify the critical structures here. So you have the trachea here. You guys see this? Trachea, we have the inferior parathyroid, the superior parathyroid sitting here, right in there. And, what else would you point out? So this is the cricothyroid muscle right there, okay? Here’s the top. Here's the thyroid cartilage right here. Okay? And then, I was going to show you - can't really see the nerve anymore - the nerve has fallen backwards. That's about it. You can see the rings of the trachea, and as you can see, the thyroid went pretty far down - I mean you know - we're all the way down here - well behind his sternum. That wasn't too far back there. Okay. Alright you want to check your vagus now?

CHAPTER 7

Hey Josh - far left dial - can you move it three clicks to the right? We’re going to need the appendiceal I think - I think that wide body wall is too shallow for you. He's got a deep neck - there you go. One more click to the right then. Perfect. Remember, he's deep. Good. Perfect. Alright, so that's our positive signal from the vagus nerve, which confirms that the recurrent laryngeal nerve is completely intact. Okay? Alright Josh, can we have head down and some positive pressure ventilation? Do you want me to go to the other side or...? I’ll go to the other side. You’re going to stitch the lobe though - don’t forget, okay. Remind me we got to stitch other lobe. Okay, coming up to - can you get the 40, you think? Okay, you gotta get your retractor in place. Great, release. So we do this - it’s called Valsalva maneuver, so that we're generating very, very high venous pressure. So the idea is that if he's going to bleed, he does it here in the operating room where we can still see it. Oh look, there’s the external branch of the superior laryngeal. You guys see that? You don’t usually see that. That little nerve there? Should be the external branch of the superior laryngeal. Oh, here’s a bleeder. Can you Bovie me? Bovie, got it. And you guys can also see how high up this goes. I don’t know if you guys can get an angle in there - I mean, it's like way up there. Do you see how high up is upper pole went to? Okay, great. Alright, another one when you're ready to Josh. Okay - release Josh. Thank you very much. We’re gonna take a break in a little bit here. Okay, I'll take the baby Rich and the Prolene stitch. Sure. Okay, so you're going to put the stitch - oops - yeah, put the stitching over there, and then tie this off, and it should stop bleeding. And then you're going to run it as a locking stitch, okay? Okay. Along the lines. Along the creases. And leave yourself a decent enough tail because you're going to tie back to yourself when your run back up again. Snap. Okay. Alright, now you're going to run it and lock it. I know this is weird because I know you're trying usually to not lock yourself, so... Nice, full bite all the way through what you Bovied. It's amazing how vascular the thyroid is. Yeah. Let's just run down. Okay. Alright. See, it still looks a little wet up there - I'm thinking that might just be run down. Ready? Yep. Surgicel. You can release. No problem. Okay. Look good to you? Yes, it looks great. Okay. Alright, some down here. I'm going to put a little on the trachea since this is kinda... Oh, so you guys can see here - let go of that for a second. He has a very wide trachea, which is very typical of a man, okay? This is only half his trachea - and you can see how wide it is. Some more Surgicel, sorry about that. Thanks. Okay. Can you bring the back back up, Josh?

CHAPTER 8

And we’ll take a - we’re gonna need three of those Vicryl stitches, and then 1 Prolene and Histoacryl to close. Okay you’re looking for the sternothyroid, right? You’re right - you’re right. Yeah. Say again. Yeah, disconnect all of them. Thanks, Josh. And you’re going to do a figure-of-eight like last time. With large right thyroid nodule. Benign. Oh wait, is that the right one? Nope - sorry. Big bite. Yep. On FNA - Frank, Nancy, Alpha. But symptomatic. Please evaluate for malignancy. Okay, and then I run the - what I do is I grab the deep cervical fascia, sternohyoid - sternohyoid, deep cervical fascia, but avoid these anterior jugular veins. And you going to run it all the way down to the bottom, leave a gap at the bottom. Grab some of this first. the deep cervical fascia, yep. Just watch the anterior jugular vein. Real superficial, remember, come real close to the edge; otherwise, you're going to nick the anterior jugular, because it's not a strength layer, you know? So you don't have to worry about... Yeah, it seems like I had muscle in that one. It's right here. The more layers between you and the trachea, the better if you ever have to come back again. So take this in two - two as well. Take the muscle and fascia separately? Yeah, take the muscle first, and then - that's okay, then pull with the - Yeah, and back up, alright, and then pull that. Yeah, there you go. Sorry, what do you want for suture. I dropped one, so we... 4-0. Okay. Thank you very much, Joy. You can just do a shallow one there, that's fine. That last stitch, so... What happened? It didn't sit down tight that time. That's okay. Just a little gap, it'll be fine. You're leaving a gap, anyways, so probably just going to pull on the one length. Okay. Free needle back. So again, deep cervical fascia is now back together again - looks very beautiful. So we're now going to put the platysma together, and Joy if you can release the thyroid bag, I think the valve is on my side. We need a stitch for each of us. So you see the difference in men and women with the platysma? Oh yeah, his is much thicker. Yeah. So as far as nerve identification goes and landmarks, men are much easier than... It looks like it's puckering the skin, want me to take mine out? Yeah. Just a very shallow stitch. You don't have to go so far deep. Men are - it's much easier, but they do tend to grow much larger nodules, and they tend to - for whatever reason - delay medical care. So the biggest ones I've ever removed, they’re always in men. And those are the ones, you know, where you have to split the sternum, do a mini sternotomy to get it out, and all that gross stuff. And they’ve had it for years. Yeah. And they're huge, you know - they’re just big guys, you know, so you can't even tell they have it. Right. But it’s nice because their nerve is big and trachea is big. The ones that are tricky are the ones where it's a woman with a large, multinodular goiter because you know it's going to be small nerve, and it's probably going to be displaced. I think you also saw - and it’s a good example in this case - of a 5-centimeter incision is plenty. Oh, definitely. You know, even though the nodule itself is more than 5. It still, I thought, came out pretty nicely, and the key as you saw was the delivering it up, so it’s essentially - yeah - so it's essentially out of the wound. Hey Margo, we're almost getting ready to close. So I do what's called a knotless subcuticular closure, meaning there's basically no knot in here, so I close with the Prolene. using a subcuticular stitch, and then I put Histoacryl or Dermanond on top, and then once it sets, I pull the stitch out. Diagnostic right hemithyroidectomy and isthmusectomy. I'm sorry - diagnostic right hemithyroidectomy. Yep. and isthmusectomy? Isthmusectomy, yep. One specimen. Right thyroid lobe and isthmus. So one of the goals in thyroid surgery is cosmesis. These patients don't feel bad to begin with, so you need to make the scar looks as nice as possible. And that's why we spend a lot of time closing the skin, making sure it looks really nice. Okay. So this is Histoacryl. It's kind of runny, so I put it on in layers and just slowly build it up and spread it out over the wound. Alright Josh, I'm going to take the drapes off, okay? Let me know if I'm going to pull the tube out. Okay - needle’s coming out of the chest. Needle’s out. So we start with a 5-centimeter incision and we're ending now with a five - actually .5 - ish. 5.4-ish incision, and that’s just from normal stretch of the wound.

CHAPTER 9

So I think the operation went really well. As you guys saw, we were able to remove the right thyroid lobe with a very large nodule in it and his isthmus segment of his thyroid very safely and with no complications.