DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Papillary thyroid carcinoma with left cervical metastasis.
POSTOPERATIVE DIAGNOSIS: Papillary thyroid carcinoma with bilateral cervical lymph node metastases.
OPERATIONS PERFORMED:
1. Total thyroidectomy.
2. Bilateral paratracheal lymph node dissection.
3. Left modified cervical lymphadenectomy.
4. Intraoperative nerve monitoring.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: Approximately 20 mL.
INTRAOPERATIVE FINDINGS: The patient was noted to have multiple pigmented lesions involving the cervical nodes on the left side, with the largest one measuring roughly 3 to 4 cm in diameter. Nodes along the entire length of the internal jugular chain as well as the posterior cervical triangle were involved on the left side. Paratracheal nodes below the level of the thyroid gland on both sides of the neck were involved with disease. There was no nerve invasion or invasion of surrounding structures, including the trachea or blood vessels.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, and after induction of satisfactory general endotracheal anesthesia using the Xomed nerve monitoring endotracheal tube, the patient was suitably grounded. The neck was prepped with Betadine and draped off in a sterile fashion. A J-shaped incision starting in a transverse skin crease just above the sternal notch was extended to the left in the skin crease to behind the SCM muscle, then up along the left posterior neck to the area of the mastoid tip. Incision line in the area of the parotid gland was infiltrated with epinephrine solution 1:250,000 concentration. A total of approximately 130 mL were injected. After adequate time for vasoconstriction and hydrodissection, skin incision was made sharply and taken down through the subcutaneous tissue and platysma muscle layer. Subplatysmal flaps were elevated.
We first started with the thyroidectomy. A midline raphe was identified and the strap muscles were dissected laterally to expose the thyroid gland. Starting on the left side, the thyroid lobe was mobilized. The inferior thyroid vessels were identified and transected between 4-0 silk ligature. The recurrent laryngeal nerve was identified. As noted, intraoperative nerve monitoring was utilized throughout the operation. We then traced the nerve superiorly and continued our dissection of the left lobe of the thyroid gland. The parathyroid gland was identified and preserved superiorly. I could not identify the parathyroid gland, but there appeared to be glandular attachment to a very firm pigmented nodularity along the deep surface of the left lobe of the thyroid gland. This was sent for frozen section evaluation and papillary thyroid carcinoma was confirmed. We therefore proceeded with a total thyroidectomy.
The superior thyroid vascular pedicle was identified and transected between 3-0 silk ligature. Then, the entire left lobe of the thyroid was elevated from lateral to medial fashion with the recurrent nerve fully visualized along its entire length into the insertion behind the cricoid. There were some pigmented nodes in the area of the cricothyroid membrane and this was also harvested and sent separately. The isthmus was thus freed from the tracheal wall, then we proceeded with dissection of the left lobe of the thyroid gland. The superior thyroid pedicle was transected between 3-0 silk ligature. The superior parathyroid gland was identified and carefully preserved. The recurrent laryngeal nerve was identified and traced along its entire length and then the inferior vascular thyroid pedicle identified and transected. Then, we could complete the dissection of the right lobe of the thyroid gland and the entire gland was removed.
We next performed the left cervical lymphadenectomy. As noted, there were multiple pigmented nodules along the internal jugular chain with the largest one measuring about 3 to 4 cm along the upper one-third of the chain. Nodal involvement extended all the way up to the angle of the mandible. There was also nodal involvement of lymph nodes along the posterior cervical triangle, deep to the posterior belly of the digastric muscle. The fascia along the anterior border of the left SCM muscle was then incised and fascia reflected off the ventral surface. The posterior belly of the omohyoid muscle was transected and the muscle itself was incorporated into the surgical specimen. Dissection deep to the SCM muscle was carried to the posterior border, and then starting from the anterior portion of the trapezius as the posterior border of the dissection, the tissue was reflected off of the deep cervical fascia. Lymph nodes along the inferior aspect of the posterior cervical triangle were harvested and sent separately.
Dissection was continued anteriorly until the carotid sheath structures were identified. The vagus nerve and internal carotid artery were carefully preserved. The lymph nodes and surrounding tissue were reflected off of the internal jugular vein. Anteriorly, the anterior belly of the omohyoid muscle was transected off the hyoid bone and incorporated into the next specimen. The remainder of the strap muscles were preserved. The submental contents and then the submandibular triangle contents were next dissected. The fascia along the inferior border of the submandibular gland was incised and the gland was removed. Wharton’s duct was transected between 3-0 silk ligatures. Branches of the facial artery and vein were transected between 3-0 silk ligature. The superior internal jugular lymph nodes were also harvested. The spinal accessory nerve was identified and carefully preserved and then the entire neck section specimen was removed. We next examined the lower paratracheal areas on the left and right side and there was obvious pigmented nodes in this region. These were harvested separately on the left and right sides. It extended down into just behind the clavicular head. There were no other clinically involved lymph nodes in the course of our inspection and the procedure was terminated.
The wound was copiously irrigated and then inspected for hemostasis. A #7 JP drain was then placed along the bed of the left neck dissection through a separate stab incision and then looped over anteriorly to the contralateral side along the thyroid bed. The wound was closed in layers using interrupted 3-0 Vicryl to approximate the strap muscles in the midline, the platysma muscle layer with 4-0 Vicryl, and subcutaneous closure with 5-0 Monocryl, skin margins with Dermabond. Lastly, a small dermal cyst along the right upper neck was removed and wound closed with interrupted 5-0 Vicryl and Dermabond for the skin. The lesion measured approximately 6 to 7 mm. The patient tolerated the procedure without any complications. Estimated blood loss was approximately 20 mL. Sponge and needle counts were correct. The patient received 1 gram of Kefzol and 10 mg of Decadron intravenously during the course of the operation. The patient was extubated and returned to the recovery room in stable condition.
