Click icon to add picture

THYR

OIDECTO

MY

Kaidy

Wat

erm

an &

Der

ek W

oodru

ff

THE THYROID

The thyroid sits anteriorly to the trachea and the esophagus

Contains two types of hormone-producing cells

Follicular Cells: produce thyroxine and triiodothyronine

Parafollicular Cells: produce calcitonin

The adult thyroid weighs anywhere from 12 to 25 grams

“H” shaped

The organ shrinks as you age

Two lobes

THE PARATHYROIDS

Range from 2 to 6

Small, flat, oval structures that lie on the dorsal side of the thyroid gland

Produce parathormone which maintains the normal relationship between blood and skeletal calcium

Removal of these glands would result in tetany and death

Care must be taken not to damage these glands during a thyroidectomy

PATHOPHYSIOLOGY OF THE THYROID AND PARATHYROIDS Hyperthyroidism (thyrotoxicosis): when the thyroid gland

produces too much thyroxine hormone Symptoms: nervousness, tachycardia, sweating, tremors,

arrhythmias, hair loss, and dyspnea

Thyroid Carcinoma: cancer of the thyroid Symptoms: hoarseness, may show signs of hyper- or

hypothyroidism depending on tumor type, may be asymptomatic

Hyperparathyroidism: when the parathyroid glands produce an excess of parathyroid hormone

Symptoms: asymptomatic in early stages, skeletal damage

Hypoparathyroidism: parathyroid glands don’t produce enough parathyroid hormone

Symptoms: anxiety, depression, brittle nails, dry skin, thin hair, tetany (a severe complication)

DIAGNOSTIC EXAMS AND PREOPERATIVE TESTING Patient history and physical

Ultrasound

Laryngoscopy

Biopsy

Scans

Serum levels of TSH

ANESTHESIA AND POSITIONING

Anesthesia is general

The patient is positioned in the supine position with neck extended

SKIN PREP, DRAPING, AND INCISION

Skin is prepped from the point of the chin down to the mid-chest of the patient and laterally as far as possible

Wadded absorptive towels are placed bilaterally and the thyroid sheet is used

The incision is symmetrical and transverse following the Langer lines over the thyroid. The size of incision varies, it is generally done two fingerbreadths above the clavicular head.

Basic set, prep set, #10 and #15 blades, sutures, dressings, Bovie, basin set

Thyroid drapes and ¼” Penrose drain

Suction, ESU, roll or thyroid rest for extending the neck

Thyroidectomy set, bipolar forceps with cord, liga clip appliers and clips

SUPPLIES, EQUIPMENT AND INSTRUMENTS

Great care must be taken to ensure that the parathyroid glands are spared and protected

A Queen Anne’s dressing or thyroid collar may be used along with the drain

SPECIAL CONSIDERATIONS

THE P

ROCEDURE

STEP ONE

O P E R A T I V E P R O C E D U R E

• The incision is made and extended through the subcutaneous tissues and the platysma muscle.

• Superior and inferior flaps are mobilized and retractors are placed

T E C H N I C A L C O N S I D E R A T I O N S

• Hemostasis will be secured as the procedure progresses

• Usually via Bovie

• May clamp and tie some vessels

• May use ligating clips

STEP TWO

O P E R A T I V E P R O C E D U R E

• The strap muscles are separated and the thyroid lobe is exposed. The middle thyroid vein is exposed, divided, and ligated

• Vessels are identified, divided and ligated (laryngeal nerves and superior vessels must be identified)

T E C H N I C A L C O N S I D E R A T I O N S

• Keep fresh, dry sponges available, mosquito hemostats may be used

• Ligation may require the use of small right angle clamps and ligature on a passer

STEP THREE

O P E R A T I V E P R O C E D U R E

• Parathyroid glands, inferior thyroid artery and recurrent laryngeal nerve are identified.

• Parathyroid glands are mobilized and vascular supply is preserved

T E C H N I C A L C O N S I D E R A T I O N S

• Keep two clamps, scissors, and ties ready

STEP FOUR

O P E R A T I V E P R O C E D U R E

• Branches of the inferior thyroid artery are divided and ligated. The superior connective tissue is divided. Hemostasis is achieved with ESU. (Recurrent nerve must be spared)

T E C H N I C A L C O N S I D E R A T I O N S

• May alternate between sharp dissection, blunt dissection and ESU

STEP FIVE

O P E R A T I V E P R O C E D U R E

• The thyroid is dissected from the trachea.

T E C H N I C A L C O N S I D E R A T I O N S

• If only one lobe is taken, the isthmus is divided so that it is removed with resected lobe as is the pyramidal lobe.

STEP SIX

O P E R A T I V E P R O C E D U R E

• Hemostasis is achieved after lobe or lobes are removed, a drain may be placed. The wound is closed.

T E C H N I C A L C O N S I D E R A T I O N S

• Sequence is irrigation, placement of wound drain, and closure.

• Initiate count.

POSTO

PERAT

IVE

CONSIDERAT

IONS

POSTOP CONSIDERATIONS

• Immediate postoperative care:• Check voice as soon as possible• Transport to PACU• Tracheotomy tray available

• Prognosis• Return to normal activities• Medications usually required for life

• Complications:• Hemorrhage• Wound Infection• Damage to nearby structures

Click icon to add picture

PEARL O

F W

ISDOM

•Mai

ntain

the

inte

grity

of th

e st

erile

fiel

d until

the

patie

nt

is e

xtubat

ed, b

reat

hing fr

eely, a

nd has

bee

n tran

spor

ted

to th

e PA

CU. Em

ergen

cy tr

acheo

tom

y is

a p

ossi

bility

.