DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Metastatic papillary thyroid cancer.
POSTOPERATIVE DIAGNOSIS: Metastatic papillary thyroid cancer.
OPERATION PERFORMED: Total thyroidectomy with central neck dissection and intraoperative recurrent laryngeal nerve monitoring.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who previously presented as a trauma patient and ultimately was further evaluated and found to have multiple lung nodules. This was biopsied and noted to be positive for papillary thyroid cancer. She underwent followup including ultrasound which demonstrated a 2.8 cm right thyroid mass. Cervical ultrasound did not reveal any obvious suspicious lymphadenopathy.
However, CT scan demonstrated some nonspecific lymphadenopathy in the right central neck. Biopsies of these nodes were attempted; however, it was noted to be nondiagnostic as the nodes were calcified. She underwent further imaging studies including FDG-PET scan that demonstrated multiple lesions in the brain as well as lung. The patient underwent brain biopsy for these lesions and it was noted to be non-neoplastic.
After extensive discussion, it was agreed that the patient would benefit from total thyroidectomy. Risks and benefits of the surgery were explained to the patient, who elected to proceed. She understood the risks included but were not limited to bleeding, infection, nerve injury, hypoparathyroidism with hypocalcemia, as well as the risk of death. The patient agreed to proceed.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to operating room and placed supine on the operating table. Time-out was taken to verify the patient’s name and procedure. She was subsequently placed under general endotracheal anesthesia, prepped and draped in standard surgical fashion and placed in semi-Fowler with neck being hyperextended.
Attention was then turned to the anterior neck, where a transverse collar incision was made approximately 1.5 cm above the sternal notch along the Langer lines with a #15 blade scalpel. Bovie electrocautery was used to dissect through the underlying dermis and subcutaneous tissue. Flaps were raised superiorly up to the thyroid notch and inferiorly down to the sternal notch. A Mahorner retractor was assembled to allow excellent exposure to entire anterior neck. The midline raphe was identified and divided in the longitudinal fashion with Bovie electrocautery. The strap muscles were lateralized and the thyroid gland was medialized. We noted a large, dominant, firm calcified right thyroid mass. It appeared to not be infiltrating the surrounding tissue. At this point, NIM monitor was used to assess the recurrent laryngeal nerve. This was identified both audibly as well as visually. We traced it emanating to the tracheoesophageal groove. The superior as well as the inferior parathyroid glands were identified and preserved appropriately. With further medialization of the thyroid, we were then able to use 2-0 silk sutures as well as the Harmonic Focus to ligate and divide the superior as well as inferior pole vessels. Cautery as well as the knife was used to dissect the right lobe of the thyroid off of the trachea without event.
In similar fashion, the left lobe of thyroid was medialized and the straps were lateralized. The superior and inferior parathyroid glands were identified and preserved. The recurrent laryngeal nerve was identified in similar fashion and not injured. The superior and inferior pole vessels were similarly taken with 2-0 silk sutures as well as the Harmonic Focus with a combination of Bovie electrocautery as well as the knife. The right thyroid isthmus and the left thyroid was subsequently removed and passed off the field as a specimen. It was sent to pathology for frozen section, which identified negative margins.
At this point, we proceeded to perform central neck dissection. From an area of the hyoid superiorly down to the sternal notch inferiorly, as well as medially to the right carotid artery, we dissected off the central neck nodes. There were 3 enlarged nodes that were firm and approximately 1 cm in size. They were carefully dissected and lymphatics ligated with 3-0 silk sutures. It was passed off the field as a specimen. We went to the contralateral central neck; however, we did not note any evidence of significant adenopathy. At this point, hemostasis was appropriately achieved. The NIM monitor was used to confirm audibly again the function of the bilateral recurrent laryngeal nerves. We also were careful to not injure the superior laryngeal nerve.
At this point, the raphe of the midline strap muscles was closed with 3-0 running locking Vicryl suture. The platysma was closed in a transverse interrupted fashion with 3-0 Vicryl pop-offs. The skin was closed with a running 4-0 subcuticular Monocryl stitch. Steri-Strips and benzoin were placed over the incision and a dry dressing was placed over the wound. The patient was subsequently extubated and taken to the recovery room in stable condition. Sponge, needle and instrument counts were correct x2.
