Excision of thyroglossal cyst (Sistrunk operation)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• recurrence of the cyst or a discharging sinus
• bleeding and neck haematoma that can press on the airway
• wound infection or abscess
• entry into the airway or pharynx and need for repair
• injury to the hypoglossal nerve
• need to remove the middle part of the hyoid bone
• neck scar
• hypothyroidism if the swelling proves to be the only thyroid tissue

Pre-operative details for this operation

1. Clinical featuressize, midline or paramedian, moves with swallowing and tongue protrusion, any sinus or previous incision and drainage
2. History of infectionNever infectedPrevious infection, settledPrevious incision and drainagedate of last episode; surgery is deferred until active infection settles
3. Ultrasound neckcyst size and site, and whether a normal thyroid gland is present in its usual place
4. Thyroid function testsTSH if history suggests hypothyroidism or thyroid is not seen in normal place
5. FNAC / other imagingNot doneFNAC doneCT / MRI doneresult, if malignancy was suspected

Anaesthesia and position

1. AnaesthesiaGeneral, oral endotracheal tubeGeneral, nasal endotracheal tube
2. PositionSupine, neck extended with shoulder rolllower face and lips included in the field
3. Local infiltration along incisiondrug, strength of adrenaline (for example 1:200,000), volume

Operative findings

1. Cystsize in cm, site relative to hyoid (below / at / above), contents if ruptured
2. Tractseen or not seen; course relative to hyoid (in front, through, behind)
3. Pyramidal lobe / attachment to thyroidNonePyramidal lobe attached, divided
4. Sinus or skin scarNoneSinus present, excised in ellipse
5. Airway / valleculaNot enteredEntered and repaired

Procedure (steps)

1. Skin preparation and drapingantiseptic used; lower face and mouth in the field
2. Skin incisionTransverse in skin crease over the cystTransverse ellipse including sinus or scarlevel and length in cm
3. Subplatysmal flaps raised
4. Deep cervical fascia opened in midline, sternohyoid muscles retractedYes
5. Cyst dissected freestarted at inferior border; any attachment to pyramidal lobe divided
6. Tract traced to hyoidfirm cord to middle of hyoid; if not found, cyst and hyoid taken en bloc
7. Hyoid body excised in continuitymuscles detached above and below; bone cut on each side of midline, medial to lesser cornu; width of segment removed
8. Core of tissue around tract excised towards foramen caecumClassic SistrunkExtended Sistrunkfinger in mouth pressing foramen caecum region (double glove) or assistant pressure
9. Tract ligated at base of tonguesuture ligature just below foramen caecum; suture used
10. Irrigation and haemostasissaline wash, any cyst rupture and how contents were cleared

Closure, drains and dressing

1. Hyoid gapHyoid ends approximatedSternohyoid sutured to mylohyoidLeft opensuture used
2. DrainSuction drainCorrugated / Penrose drainNonesize, exit site
3. Cervical fascia / strap musclessuture used
4. Platysmaabsorbable suture
5. SkinSubcuticularInterruptedsuture material and size

Specimens and implants

1. Cyst with tract, hyoid segment and tongue-base core, sent for HPEin one piece; label superior end with a stitch
2. Sinus skin ellipseIncluded in specimenNot applicable

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Airway and neck watchlook for neck swelling, stridor or difficulty breathing; call surgeon at once if seen
2. Drainchart output; remove when under 20 ml in 24 h
3. Oral intakesips when fully awake, then soft diet
4. Analgesiadrug, dose, frequency
5. Antibioticsonly if airway or pharynx was entered or cyst was infected; drug and duration
6. Wound care and stitch removalday of dressing and suture removal if non-absorbable
7. Follow-upHPE report review; check for recurrence

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery