PREOPERATIVE DIAGNOSIS: Tertiary hyperparathyroidism.
POSTOPERATIVE DIAGNOSIS: Tertiary hyperparathyroidism.
OPERATION PERFORMED: Subtotal parathyroidectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General. Fifteen mL of 0.5% Marcaine with epinephrine for local anesthesia.
ANESTHESIOLOGIST: Bradford Doe, MD
DESCRIPTION OF OPERATION: The patient was intubated with the Xomed nerve monitor endotracheal tube. The neck was prepped and draped in the usual manner after a shoulder roll was placed. A transverse cervical incision was made, and local anesthesia was infiltrated prior to the incision and as we finished the closure. Initial incision was deep and beyond platysma. Crossing anterior jugular vein branches were doubly ligated with 2-0 silk ties and divided. Superior subplatysmal flap was developed to the thyroid notch and the inferior flap to the sternal notch. Strap muscles were divided at the midline and separated.
The right strap muscles were lifted off the right thyroid gland and slowly mobilized the right thyroid gland medially. Did identify the nerve fairly early on at the base of the neck. There were two inferior thyroid artery branches that were ligated with 2-0 silk ties and divided. Middle thyroid vein was ligated with 2-0 silk tie and divided. This allowed for mobilization of the thyroid gland medially. The right upper parathyroid gland was found at the mid aspect of the posterior thyroid gland. It was intrathyroidal. Slowly freed it from the thyroid gland, clipped the feeding vessels, and removed it. The nerve was noted to be functional at the end of this excision.
The superior vascular bundle was doubly ligated with 2-0 silk ties and divided. This allowed for further mobilization of the gland medially. We were unable to find a parathyroid gland at that level. We then subsequently freed the lower pole of the thyroid gland and we started identifying the thymus tissue and pulled it out of the chest. There was a lymph node that was submitted and this was benign. We then identified a right lower parathyroid gland with the dimensions noted above. I clipped the distal half and submitted it to pathology, and this was confirmed to be parathyroid tissue. The proximal half of the parathyroid gland was left intact.
The left strap muscles were lifted off the left thyroid gland. The middle thyroid vein was ligated with 3-0 silk ties and divided and the thyroid gland was then mobilized medially. The nerve was found at the base of the neck and traced towards the larynx. The left upper parathyroid gland was identified, found to be posterior to the mid aspect of the thyroid gland, and it measured 1.5 x 0.8 cm. We freed it from the nerve and from the thyroid gland and submitted it to pathology, and this was confirmed to be parathyroid tissue. The small vascular pedicles were clipped. The nerve was noted to be functional at this point.
We ligated the superior thyroid vascular pedicle. This was done with 2-0 silk ties x2 and with a 3-0 silk suture ligature. We mobilized the gland medially, and not finding any parathyroid tissue superiorly, we then addressed our attention inferiorly where the thymus was pulled out and we identified a parathyroid gland. This was found to be anterior to the nerve. This gland was noted to be 1.1 x 0.9 x 0.8 cm. This was removed in its entirety. The vascular pedicles were clipped.
At this point, both nerves were noted to be functional, and with assurance of hemostasis, we commenced closure. Running 4-0 Vicryls were used to approximate the strap muscles at the midline, interrupted 4-0 Vicryls were used to approximate the platysma, 5-0 Monocryl was used for the subcuticular skin closure. Local anesthesia was infiltrated. Dermabond was placed. The patient tolerated the procedure well. Sponge and needle counts were correct. Blood loss was minimal. The patient was taken to recovery room, extubated and in stable condition.
