Thyroidectomy

Considerations

• • Anatomy (eMedicine - Thyroid Anatomy, eMedicine - Laryngeal Nerve Anatomy, eMedicine - Parathyroid Gland Anatomy)  

    • Vasculature

      • Superior thyroid artery

      • Inferior thyroid artery

      • Superior, Middle, Inferior thyroid veins 

    • Superior Laryngeal Nerve (SLN)

    • 2014: Superior laryngeal nerve injury: effects, clinical findings, prognosis, and management options

    • Recurrent Laryngeal Nerve (RLN) 

    • 2012: Clinically relevant anatomy of recurrent laryngeal nerve

    • Parathyroid glands 

    • 2010: Surgical anatomy of the thyroid and parathyroid glands

  • Indications 

  • American Thyroid Association (ATA) - Guidelines and Surgical Statements

  • Nerve monitoring

  • 2015: Electrophysiological neural monitoring of the laryngeal nerves in thyroid surgery: review of the current literature

  • Drain placement

    • 2007: Wound drains following thyroid surgery 

  • Resident participation

  • 2017: Does resident involvement in thyroid surgery lead to increased postoperative complications?

Preparation

• • Prior to surgery, chart review for 

    • Documented indirect laryngeal exam including vocal fold position and mobility 

    • Preoperative imaging 

    • Preoperative laboratory testing 

  • Intubate with Medtronic NIM EMG ETT (for laryngeal nerve monitoring) 

    • Setup nerve monitoring machine, grab the electrodes (green and white) from the ETT box 

  • Ultrasound the neck

    • Identify the poles and borders of the thyroid 

  • Mark 2 finger-breadths (variable) above the sternal notch in a relaxed skin tension line, laterally to anterior border of SCM (variable), if possible, with the patient in a neutral upright position

  • Supine position, head at top of bed

  • Shoulder roll and donut 

  • Infiltrate local anesthesia - 1% Lidocaine with 1:100,000 Epinephrine; Avoid injecting the anterior jugular vein system

  • Prepare the entire neck, as if bilateral neck dissection is planned, face and chest

  • Dr. G musts: 

  • Place the Medtronic electrode leads (green over white with long cords) on chest / shoulder immediately following intubation and point the leads needle tips toward the neck and say "Procedure start time!" 

    • Place a Tegaderm over the marked incision after prepping and draping 

Procedure

• • Incise skin and platysma 

  • Shift the skin laterally and incise the platysma alone laterally

    • Avoid the anterior jugular vein system 

• Raise superior and inferior subplatysmal flaps with double pronged skin hook and Bovie, use peanut to counter-retract the subcutaneous tissue while the assistant retracts the skin

  • Superiorly to the cricoid

  • Inferiorly to the sternal notch

  • Maintain a diamond shaped dissection field and avoid excessive undermining

  • Ligate and divide anterior jugular veins as needed

• Place self-retaining retractor; Small Weitlaner (2-3) versus larger 

  • Identify and divide the midline raphe with Debakey and Bovie

    • Use Ligasure to divide the raphe inferiorly after feeling with your fingertip for vasculature 

  • Raise the straps blunty away from the thyroid laterally using the Miccoli retractor, peanut, and Bipolar 

  • Identify the carotid artery laterally 

  • At this point, several variable approaches may ensue that involve dissecting the superior / inferior poles, superior / inferior parathyroids and RLN in sequence 

    • Do what the anatomy and pathology give you

    • Dr. G often starts with the superior pole, identifies the RLN and releases the inferior pole

  • The RLN may be dissected 

    • Identify the triangle of the carotid, trachea, and inferior pole of the thyroid 

  • Bluntly dissect with the closed tip of the dissector in the triangle along the tracheoesophageal sulcus until the RLN is identified

  • Dissect the RLN superiorly until it enters the cricoid

  • Ligate and divide the inferior pole of the thyroid 

  • Divide Berry's ligament 

  • Ligate and divide the superior pole 

    • Avoid the SLN 

  • Divide the isthmus, if performing lobectomy

  • Place and secure drain, if needed 

  • Irrigate

  • Obtain hemostasis

  • Close 

    • Approximate the straps (3-0 Polysorb running) while leaving an inferior opening

      • Avoid penetrating the anterior jugular vein system 

    • Approximate platysma (4-0 Polysorb buried simple interrupted)

      • May incorporate the deep dermis  

    • Approximate skin subcutaneously (5-0 Biosyn buried simple interrupted)

  • Cleanse and dry skin

  • Dress

    • Mastisol

    • Steri-strips in parallel with the incision

  • Optional: skin glue

    • Telfa and Tegaderm 

  • Dr. G: If a total thyroidectomy is performed

    • Measure intra-op PTH 10 minutes after closure

Post-op

• • Medications 

    • Analgesic

      • Dr. G - around the clock 1000 mg PO Acetaminophen and 600 mg PO Ibuprofen q6h alternating. Also PRN narcotic (Dilaudid 2 mg PO q6h) 

    • Stool softener 

  • For total thyroidectomy is performed

    • • If intra-op PTH at end of case is less than 10, then start post op Calcitriol (1,25-dihydroxycholecalciferol)

      • Start post op Ca taper 

        • 3 grams elemental Ca per day for the first week

        • 2 grams elemental Ca per day for the second week

        • 1 gram elemental Ca per day for the third week,

        • then stop  

      • Start Levothyroxine at 1.3-1.5 mcg/kg 

      • If planning for post thyroidectomy RAI, consult with the Endocrinologist re decreasing the Levothyroxine dose

      • 2002: Preparation for radioactive iodine administration in differentiated thyroid cancer patients

      • If planning for thyroid suppression, start Levothyroxine at 1.7-2 mcg/kg

  • Follow-up 

    • TAV POD 2

    • RTC POD 7 

      • Repeat and document indirect laryngeal exam including vocal fold position and mobility

  • Complications 

    • Hypocalcemia secondary to hypoparathyroidism (rate ~1-3% after total thyroidectomy)

      • If there is a concern for hypoparathyroidism, order a PTH to be drawn and sent STAT 1 hour post op in the PACU

    • Iowa Protocols: Calcium Management in Thyroidectomy Patients - Hypocalcemia

    • SLN injury

    • 2001: Post-thyroidectomy superior laryngeal nerve injury

    • RLN injury

  • 2016: Risk of Complications after Thyroidectomy and Parathyroidectomy: A Case Series with Planned Chart Review

  • CPT codes 

    • 60220 - hemithyroidectomy

    • 60240 - total thyroidectomy

    • 60260 - completion thyroidectomy

High-Yield

• • Position of the RLN relative to the parathyroid glands