Assistant(s): Dr. VV
Operation: Total Thyroidectomy
Preoperative Diagnosis: Right papillary thyroid carcinoma
Postoperative Diagnosis: Same
Estimated Blood Loss: <50 cc
Synopsis: A 2 cm firm white mass in the right superior thyroid pole did not appear to invade the capsule or surrounding structures. The central lymph nodes and left thyroid lobe looked normal. The entire thyroid gland was completely resected and three identified parathyroid glands were left viably in situ.
Indications: The patient has FNA cytology showing a right 2.0 cm BRAF-positive papillary cancer. Cervical ultrasound shows no lymphadenopathy. He understands the indications, risks, benefits and alternatives to total thyroidectomy and wants to proceed today.
Description of Procedure: With the patient in the supine position, general anesthesia was satisfactorily induced via endotracheal intubation. Dr. VV adjusted a rolled sheet beneath the patient’s shoulders and prepped and draped the anterior neck in a sterile manner with iodine solution. After infiltrating with 0.5% bupivicaine local anesthetic, I made a mid-transverse incision, raised subplatysmal flaps, and parted the median raphe. The central compartment bilaterally contained no identifiable lymphadenopathy to palpation and inspection. Beginning on the right, I sequentially mobilized the right thyroid lobe which contained a 2 cm white rock-hard superior pole mass that did not appear to invade the capsule or surrounding structures; the rest of the lobe appeared normal in size and consistency. I gradually rotated the lobe medially, dividing its blood supply between fine absorbable ties. The capsule was not entered during dissection. I identified and preserved in situ the right superior and inferior parathyroid glands and both fine branches of the normal-caliber left recurrent laryngeal nerve, which branched about 1 cm caudal to the ligament of Berry.
When the right lobe was circumferentially mobilized, I dissected the isthmus away from the anterior trachea, taking the short pyramidal lobe in continuity. I then circumferentially mobilized the normal-sized left thyroid lobe, dividing its blood supply between fine ties. It was normal in shape without palpable nodularity. I identified and preserved a normal-sized left superior parathyroid gland, dissecting it free from the posterior thyroid capsule onto its vascular pedicle and it remained viable. I identified and preserved the right recurrent laryngeal nerve which was well seen at the ligament of Berry and caudally. The left inferior parathyroid gland was not seen.
The entire thyroid gland was anatomically resected together with any adherent lymph nodes. It was oriented for Pathology and sent for routine processing. Hemostasis was reliably present. Dr. VV then closed the incision in layers using running 3-0 absorbable suture for the strap muscles followed by inverted interrupted absorbable suture for platysma and running subcuticular clear monofilament 4-0 polydioxanone for skin. She applied a sterile occlusive paper strip dressing. Sponge and needle counts were correct and the patient tolerated the procedure well. I attest that I was scrubbed and operating for the key and critical portions of the case and was immediately available throughout.