Saturday, July 7, 2012

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Left thyroid lobectomy


PREOPERATIVE DIAGNOSIS: Left thyroid follicular neoplasm.

POSTOPERATIVE DIAGNOSIS: Left thyroid follicular neoplasm.

OPERATION PERFORMED: Left thyroid lobectomy and isthmusectomy with intraoperative nerve monitoring and left cervical lymph node biopsy.

OPERATION: The patient was identified in the preoperative holding area and informed consent was assured.  The patient's left side was marked.  The patient was transported to the operating room and placed supine on the operating room table.  Bilateral lower extremity sequential compression devices were placed.  A dose of IV antibiotics was administered.  After successful induction of general endotracheal anesthesia, utilizing an endotracheal tube fitted with a nerve integrity monitoring system, the patient's arms were tucked.  All pressure points were padded.  A roll was placed behind her shoulders.  She was positioned in the semi-Fowler position.  A transverse incision was made in the line of a skin crease 2 fingerbreadths cephalad to the clavicular head.  This was 4 cm in length.  Dissection was carried down through subcutaneous tissue and through the platysma muscle.  Subplatysmal flaps were raised.  The midline raphae was entered with electrocautery.  The left sternothyroid muscle was separated from the left sternohyoid muscle.  The left sternothyroid muscle was somewhat adherent to the thyroid gland and therefore the space lateral to the left sternal thyroid muscle was developed between it and the carotid sheaths, with the plans to remove a small section of the left sternal thyroid muscle en bloc with a thyroid lobe.  This allowed an excellent vision of the carotid sheaths which was opened.  The vagus nerve was identified.  Posterior and lateral to the left internal jugular vein, a grouping of 2 lymph nodes in the left level 4 were removed.  These were enlarged but soft.  Biopsy was negative for carcinoma.  The left thyroid lobectomy was then undertaken.  The anterior suspensory ligament was incised with electrocautery.  The left cricothyroid space was entered bluntly.  The left sternal thyroid muscles divided at the level of the superior pole with Harmonic Scalpel.  The individual branches of the left superior thyroid artery and vein were divided at the level of thyroid capsule with the aid of Harmonic Scalpel.  This proceeded around in to left superior parathyroid gland was dissected free.  Left lower pole of thyroid gland was then rolled anteromedially, and the left sternal thyroid muscle was divided at the level of the lower pole of thyroid gland.  Dissection in the left tracheoesophageal groove allowed us to identify the recurrent laryngeal nerve which was traced to its insertion and protected.  All vascular attachments of the thyroid gland were then divided between clips or 2-0 silk ties.  The thyroid was rolled anteromedially and the thyroid isthmus was dissected off of the anterior aspect of the trachea with electrocautery.  A clamp was placed across the right side of the thyroid isthmus and the thyroid was divided sharply.  The thyroid isthmus was ligated with a single 3-0 Vicryl suture.  The thyroid gland was passed off the field as a surgical specimen.  The left thyroid lobe revealed no obvious changes for malignancy.  A left central neck lymph node was dissected free, being sure to clip bolus, feeding blood supply, and lymphatic channels.  Pathologic analysis was consistent with benign thymic tissue.  There were no other additional concerning left central neck lymph nodes.  One final left level 3 cervical lymph node was dissected free.  This too was benign.  Therefore, the operation was terminated.  Hemostasis was excellent.  Surgicel was placed in the left tracheoesophageal groove.  The sternohyoid muscles were reapproximated in a single layer with interrupted 3-0 Vicryl sutures.  The platysma muscle was reapproximated with interrupted 3-0 Vicryl sutures.  A 3-0 Prolene suture was used to approximate the skin edges.  Surgicel was applied, and once dry, the Prolene suture was removed.  The patient was then allowed to emerge from general anesthesia, and was extubated without difficulty.  All needle, sponge, and instrument counts correct x2.  I was present through entire procedure.

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