Sunday, March 28, 2010

Neck Surgery

THYROIDECTOMY


 

Definition

Removal of all or a portion of the thyroid gland.


 

Discussion

The thyroid is a highly vascular gland composed of two lobes connected by a narrow bridge (isthmus). It is located on the anterior aspect of the trachea adjacent to the second, third, and fourth rings. Thyroid lobectomy os performed for the treatment of some thyroid nodules and carcinomas. Total thyroidectomy is indicated for certain carcinomas and to relieve tracheal or esophageal compression. Infrequently, a portion of the gland may be substernal, necessitating a more extensive procedure.


 

Procedure

The incision is made above the sterna notch. The platysma muscle is incised ad retracted. The strap muscles are separated or devided. Blunt and sharp dissection are employed until the thyroid is exposed. Care is taken to avoid injury to the recurrent and superior laryngeal nerves and the parathyroid glands. The gland is mobilized. All or portion of the gland is removed. Hemostasis is obtained. The wound may be irrigated, and a drain may be inserted. Incision is closed in layers by interrupted stitches.


 

Preparation of the Patient

The patient is supine with a rolled sheet or small sandbag placed between the scapulae (extending the neck). A padded footboard is placed on the table. The table is position in reverse Tredelenberg. Arms may be extended on armboards. Apply electrosurgical dispersive pad.


 

Skin Preparation

Begin at the anterior neck extending upward to just below the infra-auricular border and lower lip, and downward to 2.5 to 5cm (1 to 2 inches) above the nipples; continue down to the table at the neck, around the shoulders, and at the sides.


 

Draping

Folded towels, a sterile adhesive plastic drape (optional), and a sheet with a small fenestration.


 

Equipment

Eletrosurgical unit

Suction

Footboard extension (padded) for table


 

Instrumentation

Thyroid tray

Limited procedure tray

Sping retractor

Right angle clamps with fine points (2)

Lahey clamps (extra available)


 

Supplies

Basin set

Blades (2) No. 10, (1) No. 5

Needle magnet or counter

Suction tubing

Electrosurgical pencil

Dissectors (e.g. peanut)

Small drain (e.g. ¼" Penrose)

Fine suture (e.g., 4-0 silk to mark line of incision) or marking pen

Bulb syringe


 

Special Notes

A fine silk suture may be pressed against the neck to mark the line of incision.

Usually straight Crile or mosquito clamps are used. Have extra clamps on hand, for the surgeon may prefer to clamp and cut many times before ligating.

The dressing is secured by a "thyroid collar" (e.g., Queen Anne's dressing). After the wound is dressed in the usual manner, a collar is made with towel folded in thirds lengthwise, The towel is wrapped around the neck, and the ends of the collar are crossed and secured by adhesive tape.

The scrub person should keep the back table sterile until the patient is extubated, breathing satisfactorily, and taken from the room (i.e., prepared for tracheostomy if airway becomes compromised).

In many institutions a tracheostomy tray accompanies the patient to the recovery room and later to the patient's room until any consideration of airway obstruction secondary to edema or hematoma has passed.


 


 


 

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