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Right Thyroidectomy, Isthmectomy, Continuous Recurrent Laryngeal Nerve Monitoring Operative Example

DESCRIPTION OF OPERATION: The patient was intubated with a Xomed nerve monitor endotracheal tube. The neck was extended with a shoulder roll and a transverse cervical incision was made along the skin crease, leaning to the right side. The skin incision was made and the platysma was divided. A superior flap was developed to the thyroid notch and inferior flap to the sternal notch. Crossing jugular veins were ligated with 2-0 and 3-0 silk ties. The strap muscles were separated in the midline. The right strap muscles were then lifted off of a markedly enlarged right thyroid gland. The lateral border of the gland was identified. The middle thyroid vein and its branches were doubly ligated with 3-0 silk ties and divided. The recurrent laryngeal nerve was identified at the base of the neck and we traced this superiorly. The inferior thyroid vascular bundle was noted to be quite anterior to this. We doubly ligated this with 2-0 silk ties and divided it as it entered the thyroid gland. The inferior right parathyroid gland was identified. It was noted to be adherent to the thyroid gland. We separated the two glands and placed the right inferior parathyroid gland in the base of the neck. We then identified the superior pole of the right thyroid gland. The superior thyroid vascular bundle was doubly ligated with 2-0 silk ties and divided. The right upper parathyroid gland was separated from the thyroid gland. This was also adherent to the thyroid gland. We then mobilized the gland medially. A small amount of thyroid tissue was left behind in the upper pole. The stump was doubly ligated with 2-0 silk ties and divided. This allowed us to mobilize the thyroid gland medially, and we slowly separated the nerve from the posterior surface of the thyroid gland. This nerve was adherent to the thyroid gland. The gland was left intact as we separated the thyroid gland from it, and then we lifted the thyroid gland off of the trachea. Dissection was then carried beyond the isthmus, and with the right thyroid gland in the isthmus lifted off of the trachea, we then clamped the medial aspect of the right thyroid lobe and we then excised the specimen. The stump was then suture ligated with running 2-0 silk stitch. Specimen was sent for pathology, and on analysis, there was no evidence of a malignancy. The thyroid stump was inspected. No bleeding was noted. No bleeding was noted from the right upper or lower parathyroid glands. The recurrent laryngeal nerve was noted to be functional throughout its course, and the inferior and superior vascular bundles were noted to be hemostatic. With assurance of hemostasis, the strap muscles were closed with running 4-0 Vicryls, platysma was closed with interrupted 4-0 Vicryls, and 5-0 Monocryls were used for subcuticular skin closure. Local anesthesia was infiltrated. The patient tolerated the procedure well. Sponge and needle counts were correct. Blood loss was minimal. The patient was extubated and taken to the recovery room in stable condition.

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