DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Dominant right thyroid nodule and multinodular gland with Hashimoto’s thyroiditis.
POSTOPERATIVE DIAGNOSIS: Dominant right thyroid nodule and multinodular gland with Hashimoto’s thyroiditis.
OPERATION PERFORMED: Total thyroidectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Approximately 75 mL.
SPECIMENS: The entire thyroid.
DRAINS: Two 7 mm Hemovac drains, which were left draining in the tracheoesophageal area, exiting via separate stab wounds.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the OR table in the supine position. After adequate general endotracheal anesthesia, the patient was prepped and draped in a sterile fashion. A horizontal incision was made low on the neck in the natural skin crease, overlying the thyroid gland, with the use of the skin knife. The incision was carried down through the subcutaneous tissues and the platysma muscle with the use of electrocautery. A superior subplatysmal flap was then elevated to the mid portion of the thyroid cartilage and an inferior subplatysmal flap elevated to the suprasternal notch. The skin flaps were held back and sutured in position with interrupted sutures of 2-0 silk. The strap muscles were then divided in the midline and retracted laterally. Initially, the strap muscles overlying the right lobe of the gland were grasped with Allis clamps and retracted laterally.
Dissection then began within the capsule of the gland with the capsule being dissected off of the right lobe. As the dissection proceeded laterally, a large nodule involving the right lobe was identified. As the soft tissues were retracted laterally, the dissection proceeded laterally within the thyroid capsule with identification of the right middle thyroid vein. The middle thyroid vein was then divided and tied with 2-0 silk ties. Dissection was then turned superiorly, remained within the capsule of the gland, and as the dissection proceeded superiorly, the right superior parathyroid gland was identified. This was dissected off of the gland with its blood supply remaining intact. The right superior thyroid artery and vein were also identified and these were divided and tied with 2-0 silk ties. The dissection was then turned back laterally and medially, remaining within the capsule of the gland as well as then proceeding inferiorly.
As the inferior dissection continued, the right inferior parathyroid gland was also identified. This was dissected off of the gland with its blood supply remaining intact. The dissection proceeded inferiorly, where the right inferior thyroid artery and vein were identified and these were divided and tied with 2-0 silk ties. The right lobe of the gland was now retracted anteriorly and medially with dissection proceeding into the tracheoesophageal groove. The dissection remained within the capsule of the gland. As the dissection proceeded medially, multiple tiny nodules involving the thyroid were identified. The right recurrent laryngeal nerve was eventually identified. The dissection was then turned cephalically dissecting above the nerve to the point where the nerve entered into the larynx. Once the nerve was out of harm’s way, the right lobe was dissected off of the trachea by dividing Berry’s ligament with the entire right lobe being removed. The isthmus was then elevated off the anterior wall of the trachea. The isthmus and right lobe were then divided from the left lobe and sent for pathologic sectioning. It was reported that the dominant nodule appeared to be benign.
While awaiting the pathology reports, the strap muscles overlying the right lobe of the gland were retracted laterally using Allis clamps. Dissection proceeded over the right lobe of the gland within the thyroid capsule. As the dissection proceeded laterally, multiple nodules also were identified within the left lobe. Even though the pathology was benign, in view of the multiple nodules, it was decided that the left lobe would also be removed. The left middle thyroid vein was divided and tied with 2-0 silk ties. Dissection was then again turned superiorly, remaining within the capsule. As the dissection proceeded superiorly, the left superior parathyroid gland was identified and this was dissected off of the gland with its blood supply remaining intact. As the dissection again proceeded superiorly, the left superior thyroid artery and vein were identified and these were divided and tied with 2-0 silk ties. The dissection was then turned inferiorly where the gland was very adherent and stuck with multiple nodules encountered as the dissection attempted to remain within the capsule.
The dissection proceeded inferiorly until the left inferior thyroid artery and vein were identified. The left inferior parathyroid gland was never identified. The inferior thyroid artery and vein were divided and tied with 2-0 silk ties. The left lobe was then retracted superiorly and medially proceeding into the tracheoesophageal groove. As the dissection proceeded into the tracheoesophageal groove, the tissues were very adherent and multiple nodules again were encountered. The dissection proceeded slowly. The left recurrent laryngeal nerve was eventually identified. Dissection then proceeded above the nerve to the point where it entered into the larynx. Once the nerve was out of the way of dissection, the left lobe was dissected and separated from the trachea by dividing Berry’s ligament. The left lobe was eventually removed in its entirety.
Hemostasis was then obtained with bipolar cautery as well as with multiple 2-0 silk ties. The wound was then irrigated with copious amounts of normal saline solution. Two 7 mm Hemovac drains were then placed in tracheoesophageal grooves bilaterally, exiting inferior stab wounds. The drains were held and sutured in position with interrupted sutures of 2-0 silk. The sutures on the skin flaps were released. The strap muscles were then closed in the midline with a running suture of 3-0 Vicryl. The platysmal layer was then closed with a running suture of 3-0 Vicryl. The skin was closed with a running suture of 5-0 Prolene. The procedure was then ended with the patient tolerating the procedure well. The patient was awakened in the operating room, having tolerated the procedure well. The patient was transported to the recovery room in stable condition.
