Open Total Thyroidectomy and Central Neck Dissection for Papillary Thyroid Cancer in the Setting of Hashimoto's Thyroiditis

1. Introduction

2. Pre-op Prep

1. Position Patient Supine with Arms Tucked and Neck Extended
2. Pre-op Ultrasound to Confirm Incision over Isthmus and to Examine Thyroid and Cancer
3. Mark Incision While Patient is Awake and Can Move Neck to Better Find Crease
4. Prep and Drape Patient
5. Nerve Monitoring Setup

3. Incision

4. Exposure of the Thyroid Gland and Overlying Strap Muscles

1. Subplatysmal Flaps
2. Separate Strap Muscles

5. Central Neck Dissection to the Level of the Innominate Artery

6. Pyramidal Lobe Dissection for Superior Border of Isthmus

7. Left Thyroid Dissection

1. Separate Sternothyroid Muscle from Thyroid
2. Upper Pole Dissection and Blood Supply Ligation with Preservation of the External Branch of the Superior Laryngeal Nerve via Nerve Monitor
3. Rotate Thyroid Medially for Middle Thyroid Vein Ligation and for Lower Pole Dissection with Preservation of Left Inferior Parathyroid Gland
4. Rotate thyroid Medially into the Wound and Identify the Recurrent Laryngeal Nerve Within the Tracheoesophageal Groove
5. Carefully Separate Recurrent Laryngeal Nerve from Thyroid with Nerve Monitoring and Preservation of Left Superior Parathyroid Gland
6. Leave Small Thyroid Remnant Where Recurrent Laryngeal Nerve Inserts into Larynx, Which is Often Prudent in the Setting of Inflammation to Prevent Nerve Traction Injury
7. Divide Attachments of Thyroid to Trachea to Complete Left Side

8. Summary of Left Side and Confirmation of Intact Recurrent Laryngeal Nerve and Viable Parathyroid Before Proceeding with Right Side

9. Right Thyroid Dissection

1. Separate Sternothyroid Muscle from Thyroid
2. Upper Pole Dissection and Blood Supply Ligation with Preservation of the External Branch of the Superior Laryngeal Nerve via Nerve Monitor
3. Rotate Thyroid Medially for Middle Thyroid Vein Ligation and for Lower Pole Dissection with Preservation of Right Inferior Parathyroid Gland
4. Rotate thyroid Medially into the Wound, Identify the Recurrent Laryngeal Nerve Within the Tracheoesophageal Groove, and Preserve the Right Superior Parathyroid Gland
5. Carefully Separate Recurrent Laryngeal Nerve from Thyroid with Nerve Monitoring
6. Leave Small Thyroid Remnant Where Recurrent Laryngeal Nerve Inserts into Larynx, Which is Often Prudent in the Setting of Inflammation to Prevent Nerve Traction Injury
7. Divide Attachments of Thyroid to Trachea to Complete Total Thyroidectomy

10. Specimen Orientation for Pathology

11. Final Inspection, Irrigation, and Hemostasis with Valsalva from Anesthesia, Surgicel, and Tisseel

12. Closure

1. Sternohyoid Muscle with 4-0 Vicryl Interrupted Sutures
2. Release Neck Extension and Close Platysma with 4-0 Vicryl Interrupted Sutures
3. Deep Dermal Layer to Take Tension off the Skin
4. Skin with Running, Knotless 5-0 Monocryl Subcuticular Suture and Steri-Strips

13. Post-op Remarks