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General Surgery
Left Thyroid Lobectomy as Completion of Total Thyroidectomy with Central Neck Lymph Node Dis
Built from Atlas of Thyroid Surgery
What’s inside
11 sections · 98 slides
Overview
- Procedure overview
Overview and principles
What the operation is, its goals, and its timing
- What this operation is
- Complications to prevent
- Order that protects key structures
- Redo surgery raises the risk
- Timing the completion procedure
Central neck anatomy
The level VI compartment and the recurrent laryngeal nerve
- Boundaries of the level VI central neck
- What the central neck contains
- Therapeutic versus prophylactic dissection
- Dissect both sides of the nerve
- Left versus right recurrent laryngeal nerve
- Left recurrent laryngeal nerve in the tracheoesophageal groove
- Left recurrent laryngeal nerve (second view)
Case and preparation
The patient, outpatient plan, monitoring, and positioning
- The patient
- The surgical plan
- Outpatient surgery
- Voice checks and nerve monitoring
- Antibiotics
- Positioning on the table
- Airway and monitoring setup
- Patient position with shoulder roll and head cradle
- Skin prep and draping
Exposure of the thyroid
Scar excision, flaps, and opening the strap muscles
- Opening the old scar
- Skin marking and old scar excision
- Platysma incision at the midline
- Platysma separated at the midline (second view)
- Raising the subplatysmal flaps
- Superior subplatysmal flap creation
- Inferior subplatysmal flap creation
- Retraction of platysmal flaps to expose strap muscles
- Superior subplatysmal flap (additional view)
- Inferior subplatysmal flap (additional view)
- Opening the strap muscles
- Strap muscle incision along the linea alba
- Strap muscles split at the midline (second view)
Lateral and superior pole dissection
Freeing the lobe, the middle thyroid vein, and the superior pole
- Mobilizing the lobe laterally
- Dividing the middle thyroid vein
- Lateral mobilization and middle thyroid vein division
- Lateral mobilization of the left lobe (additional view)
- Superior pole and the EBSLN
- Superior pole vessel mobilization
- Avascular space of Reeve opened
- Avascular space of Reeve (additional view)
- Ligating the superior pole
- Superior pole vessels elevated with Gemini forceps
- Superior pole vessels elevated (additional view)
- Transection of superior pole vessels
- Avoiding nerve stretch
Nerve and parathyroid protection
Finding the RLN and preserving the inferior and superior glands
- Finding the left RLN
- Confirming the RLN
- Left recurrent laryngeal nerve identification
- Left recurrent laryngeal nerve identification with nerve stimulator
- Preserving the inferior parathyroid
- Left inferior parathyroid gland preservation
- Tracing the RLN to Berry's ligament
- Left recurrent laryngeal nerve dissection toward Berry's ligament
- Left superior parathyroid gland identification
- Freeing the inferior pole attachments
- Transection of inferior pole attachments to the trachea
- Preserving the superior parathyroid
- Motor branch and nerve checks
- Left superior parathyroid gland dissection
- Superior parathyroid attachments transected
- Superior parathyroid dissection (additional view)
Berry's ligament and tracheal dissection
Detaching the ligament and freeing the lobe from the trachea
- Transecting Berry's ligament
- Transection of Berry's ligament
- Berry's ligament detached from the trachea
- Detaching the lobe from the trachea
- Dissecting the thyroid lobe off the trachea
- Thyroid lobe separated from the trachea (additional view)
- Thyroid lobe separated from the trachea (additional view)
- Thyroid attachments to the trachea divided (additional view)
Central neck lymph node dissection
Removing level VI nodes en bloc while protecting the nerve
- The central dissection in this case
- En bloc node removal
- Central neck lymph node dissection
- Central neck compartment exposure (additional view)
- Central neck lymph node dissection with Harmonic Focus
- Fibroadipose tissue dissected off the left RLN (additional view)
- Central neck dissection (additional view)
- Paratracheal dissection into the thoracic inlet
- Paratracheal lymph node dissection (additional view)
- Pretracheal lymph node dissection
- Pretracheal dissection (additional view)
- Protecting the thoracic duct
- If a parathyroid loses its blood supply
Closure and complications
Irrigation, layered closure, recovery, and thoracic duct injury
- Irrigation and Valsalva
- Irrigation and Fibrillar placement
- Closing in layers
- Strap muscle and platysma closure
- Skin closure with running Monocryl and Dermabond
- Why the closure is left open below
- After the operation
- Thoracic duct injury
Summary
The operation and its key numbers in one view
- 3 mo
- Summary of the operation
- References
- References
- Atlas of Thyroid Surgery