Thyroidectomy
This operation is based on careful dissection of various tissue planes between the muscles, vessels, and thyroid gland. Some type of self-retaining retractor is inserted to hold apart the skin aps. In the presence of a large thyroid gland division of sternohyoid and sternothyroid muscles may be needed. In these cases, the anterior margins of the sternocleidomastoid muscles can be freed.
To avoid bleeding, a vertical incision is placed exactly in the midline of the neck between the sternohyoid muscles, extending from the thyroid notch to the level of the sternal notch.
The patient is immediately placed in a semisitting position. Adequate precautions should be taken to prevent hyperextension of the neck. Oxygen therapy is administered, 4 to 5 L per minute, until the patient has reacted. A sterile tracheotomy set should always be available in the event of acute collapse of the trachea. Parenteral uids are given until the patient can take adequate fluids by mouth.
The addition of sodium iodide and calcium gluconate depends on the patient’s general condition. Liquids by mouth are permitted as tolerated. Opiates or sedatives are used as necessary. Early complications include hemorrhage into the wound, hoarseness and temporary aphonia, vocal cord paralysis, and postoperative thyroid “storm.” The most important postoperative complication is hemorrhage in the wound. If wound hemorrhage is suspected, the dressing is removed, several skin sutures are taken out, the blood is evacuated under aseptic conditions, and major bleeding points are ligated.
Bilateral injury of the recurrent laryngeal nerve may result in paralysis of both vocal cords and may require tracheotomy. The salient symptoms of postoperative crisis are high fever, severe tachycardia, extreme restlessness, excessive sweating, sleeplessness, vomiting, diarrhea, and delirium. Ice caps or cooling blankets, sedation, and parenteral high-calorie fluids, to which 1 g of sodium iodide and 100 mg of corticoids have been added, are indicated. The continued administration of approximately 15 mg of a satisfactory corticoid preparation per hour in an intravenous drip is recommended. Oxygen, antipyretics, and multivitamin preparations are also administered.
Propranolol may be given or the tachycardia.
Postoperative hypoparathyroidism requires calcium gluconate 10% intravenously.
Vitamin D2 is administered at a dosage suffcient to maintain a normal serum calcium level. No added oral calcium other than a glass of milk with each meal is required.
Thyroid replacement with levothyroxine is given daily to prevent the recurrence of nontoxic nodular goiter. Any drains are removed on the first postoperative day. The patient is allowed to go home as soon as he or she is self-suffcient.
To avoid bleeding, a vertical incision is placed exactly in the midline of the neck between the sternohyoid muscles, extending from the thyroid notch to the level of the sternal notch.
At this point the loose fascia over the thyroid gland should be picked up with forceps and incised with the scalpel in order to develop a cleavage plane between the thyroid gland and the sternothyroid muscle.
This is one of the most important steps in a thyroidectomy. Many difficulties may be encountered unless the proper cleavage plane is entered at this time. When the fascia of the sternothyroid muscle has been completely incised and rejected, the blood vessels in the capsule of the thyroid gland are clearly visible.
If an effort is made to free the entire lateral surface of the gland by finger dissection, it must be remembered that in some instances the middle thyroid vein is quite large and may be torn accidentally by this maneuver, resulting in troublesome bleeding.
To avoid bleeding, a vertical incision is placed exactly in the midline of the neck between the sternohyoid muscles, extending from the thyroid notch to the level of the sternal notch.
At this point the loose fascia over the thyroid gland should be picked up with forceps and incised with the scalpel in order to develop a cleavage plane between the thyroid gland and the sternothyroid muscle.
There is no difficulty with healing or function after transverse incision of these muscles if this is done in the upper third to avoid injury to the motor nerve supply. The freed margin of the sternocleidomastoid muscle on either side is retracted laterally to avoid its inclusion.
The addition of sodium iodide and calcium gluconate depends on the patient’s general condition. Liquids by mouth are permitted as tolerated. Opiates or sedatives are used as necessary. Early complications include hemorrhage into the wound, hoarseness and temporary aphonia, vocal cord paralysis, and postoperative thyroid “storm.” The most important postoperative complication is hemorrhage in the wound. If wound hemorrhage is suspected, the dressing is removed, several skin sutures are taken out, the blood is evacuated under aseptic conditions, and major bleeding points are ligated.
Bilateral injury of the recurrent laryngeal nerve may result in paralysis of both vocal cords and may require tracheotomy. The salient symptoms of postoperative crisis are high fever, severe tachycardia, extreme restlessness, excessive sweating, sleeplessness, vomiting, diarrhea, and delirium. Ice caps or cooling blankets, sedation, and parenteral high-calorie fluids, to which 1 g of sodium iodide and 100 mg of corticoids have been added, are indicated. The continued administration of approximately 15 mg of a satisfactory corticoid preparation per hour in an intravenous drip is recommended. Oxygen, antipyretics, and multivitamin preparations are also administered.
Propranolol may be given or the tachycardia.
Postoperative hypoparathyroidism requires calcium gluconate 10% intravenously.
Vitamin D2 is administered at a dosage suffcient to maintain a normal serum calcium level. No added oral calcium other than a glass of milk with each meal is required.
Thyroid replacement with levothyroxine is given daily to prevent the recurrence of nontoxic nodular goiter. Any drains are removed on the first postoperative day. The patient is allowed to go home as soon as he or she is self-suffcient.
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