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Thyroidectomy is the surgical procedure for removal of thyroid. The patient can be effect with Goiter, Thyroiditis, Hyperthyroidism, Graves disease, Thyroid nodule, Thyroid storm and thyroid cancer. These can effects patient’s metabolism and cause nervousness, restlessness, emotional liability, fast speech, tachycardia, arrhythmias, dyspnea, hoarseness, signs of tracheal or esophageal compressions, swallowing and breathing problem, increase of total cholesterol level, slowed mental functioning, pain, numbness and tingling by the area of nerve damage and in children with thyroid problem prone to serious intellectual and developmental problems.
Infants with untreated hypothyroidism present at birth are at risk of serious problems with both physical and mental development. The thyroid is a butterfly-shaped gland that sits low on the front of the neck. Your thyroid lies below your Adam’s apple, along the front of the windpipe. The thyroid has two side lobes, connected by a bridge (isthmus) in the middle. When the thyroid is its normal size, you can’t feel it. This gland produces thyroid hormones, which are important for regulation of body’s production of energy, body’s temperature, growth and development.
The thyroid glands consist of two separate groups of cells that produce hormones. Follicular cell produces, stores, And release thyroxin (T4) and triiodothyronine (T3). This hormone play a major role in Thyroidectomy 3 Regulation of basal metabolic rate. Thyroid hormones effect every cell and all the organs of the body. Too much thyroid hormones speed everything up and too little thyroid hormone slow things down. The pituitary gland and the thyroid gland work together.
The pituitary gland (located near the base of the brain) makes, stores, and releases thyroid-stimulating hormone (TSH). When TSH is secreted by the pituitary gland, it causes the thyroid gland to release more T3 and T4. A high TSH level means there isn’t enough thyroid hormone, and a low TSH level means there is too much. PTH (parathyroid hormone) is made by the parathyroid glands, which are four pea-sized glands that lie behind the thyroid gland. If the blood calcium level is too low, the parathyroid glands release more PTH.
This causes the bones to release more calcium into the blood and reduces the amount of calcium released by the kidneys into the urine. Also, vitamin D is converted to a more active form, causing the intestines to absorb more calcium and phosphorus. If the calcium level is too high, the parathyroid glands release less PTH, and the whole process is reversed. PTH levels that are too high or too low can cause problems with the kidneys and bones and cause changes in calcium and vitamin D levels.
During thyroidectomy the thyroid isthmus which is located about the level of tracheal ring will be removed and the trachea and esophagus are involved during procedure. Thyroid gland is highly vascularized. The superior and inferior thyroid arteries will be involved in thyroidectomy. There are three main veins that drain the venous plexus on the anterior surface Thyroidectomy 4 of the thyroid. They include the superior, middle, and inferior thyroid veins, and each drains its respective portion of the thyroid.
The principal innervation of the thyroid gland is derived from the superior, middle, and inferior cervical sympathetic ganglia of the autonomic nervous system and parasympathetic fibers from the vagus nerves. These nerves reach the thyroid gland by coursing with the blood vessels (superior and inferior thyroid periarterial plexuses). Equipment/Supplies: Equipment and supplies used during Thyroidectomy include: Suction, Electro surgical unit with dispersive electrode, Sequential compression device with disposable leg wraps, Foot board table extension, Fiber-optic head light, IV bag or sand bag is needed .
Prep set, Basic pack, Basin set, Suction tubing, Electrosurgical pencil (monopolar &bipolar), Peanuts, Kittners for dissection, Bulb syringe,(2)#10 blades loaded on #7 knives handle, #15 loaded on #7 knife handle, Needle magnet or counter, Basin set, Antiembolitic hose, Skin closure Steri-Strips or subcuticular running suture, Penrose, Thyroid sheet and clip applier should be available sizes small and x-small. Thyroidectomy 5 Position: During procedure the patient positioned supine with neck extended head.
This is done by applying a roll towel or sand bag under patient’s shoulder. Instrument set: Thyroidectomy set used during procedure this include: Thyroid procedure tray, Tracheostomy tray, Spring retractor. Light angle clamps with fine points, (2) lahey clamps, Bipolar forcep and cord, Jacobs fine tips, Thyroid clamp, Tenotomy scissors, Metzenbaum, 2-right angle(1)long and (1) small, 2-Debakeyes, 2- Adson with teeth, 2- cushing vein,1-weithlaner, 1- Frazier suction tubing, 2-Needle holder,2-Tonsil schnidt, 2-Babcock,2-kocher,6-Allis, 6-Mosquito and right angle mixture.
Back Table: The back table is set up with a basin and a thyroidectomy set with all accountable supplies. They are include: sponges, Kittenrs, Penrose, Vessle loops, Sutures, Knife blades, Hypos, Bovie tips, Scratcher. A thyroidectomy tray place on the center of the table leaving enough space for any additional supplies or item that may be needed during procedure. Thyroidectomy 6 Mayo Stand:
The mayo stand is draped with Mayo stand draped and a towel is placed on top of the mayo and roll towel is placed to place instrumentation such as 2-right angles, 2-debakey, 2-adsons, Jacobs fine tips, Thyroid clamps, tenotomy scissors, Spring retractor,2#10 blades loaded on #3 knife handle and 1 #15 blade loaded on a #7 knife handle and bovie tip with scratcher for hemostasis. Medications: Medication that may use during thyroidectomy: lidocaine(xylocaine) with epinephrine, Irrigation solution 0. 9% sodium chloride is used for irrigation,Dexamethasone for post-operative nausea is prescribed and Tylenol may be used for post-operative pain.
Thyroidectomy 7 Sutures: During the procedure 3-0 vicril on taper needle to approximate the neck of muscle and to close the subcutaneous layer. Silk ties use for tie the inferior thyroid artery. Steri-Strips use to close the skin. Complications: Thyroid surgery is generally a safe surgery. But there is a risk of complications, including: Hoarseness and change of voice. The nerves that control your voice can be damaged during thyroid surgery. This is less common if your surgeon has a lot of experience or if you are having a lobectomy rather than a total thyroidectomy.
Hypoparathyroidism. Hypoparathyroidism can occur if the parathyroid glands camera are mistakenly removed or damaged during a total thyroidectomy. This is not as common if you have a lobectomy. Some other complications hemorrhage and infection. Thyroidectomy 8 Thyroidectomy The thyroidectomy is the procedure to remove the thyroid gland due to tumor in the gland, high level of thyroid hormones. Also it is used to remove all part of goiter which causing the enlargement of thyroid gland will passes to neighbor structures in neck.
It also may cause Thyroid storm which is a rare form of hyperthyroidism in which extremely high thyroid hormone levels cause severe illness. Thyroid nodule can cause thyroidectomy. Cancer and thyroiditis may need to be treated by thyroidectomy. The surgeon using couple test to diagnose the thyroid. These test include: Anti-TPO antibodies, Thyroid ultra sound, Thyroid scan, Thyroid biopsy, Blood test to check T3 and T4 hormones, CT scans, PET Scam and MRI scan can help identify the extent of spread. Once the patient advises of the diagnosis she or he schedule for surgery.
The patient signs all necessary documentations and the surgeon explains any procedure and concerns the patient might have. The patient transport to pre-op lab and all the test perform before surgery. If requested the surgeon may give anxiety medication to patient. Thyroidectomy 9 Patient is brought to surgery room under general anesthesia. The patient will placed in the supine position with small sand bag under shoulders to extend the neck. Antiembolitic hose is placed to patient. The prep solution will apply to the neck. It will apply to the lower of the lip and just above the nipple. Patient will draped by towel and thyroid sheet.
A sterile sponge is placed under the neck to prevent blood pooling under it. Patient mark the skin and “time out” is called (patient information). The surgeon makes a horizontal incision using #10 blade over the thyroid. The surgeon will reach to platysma muscle under the skin. Elevation of skin is essential to surgeon reach to thyroid. The spring retractor is passed to surgeon to retract the muscles. The surgeon separates the strap muscles and the incision will make to divide sternohyoid muscle to reach to the sternothyroidmuscle. The sternothyroid muscle will be elevated and surgeon reach the thyroid.
Surgeon identifies the laryngeal nerve and takings the vessels(middle thyroid vein) will be ligated using silk ties which pass to surgeon on a passer. Surgeon will identified the superior laryngeal nerve by releasing the sternothyroid muscle. Superior laryngeal nerve identification is the important part of the procedure. Surgeon continues blunt dissection and branches of the inferior thyroid artery are divided and ligated. Surgeon achieved hemostasis by using the ESU, care to preserve the recurrent nerve is taken by surgeon, and the thyroid completely dissected from the trachea.
The incision site is then irrigated with sodium chloride 0. 9% and a small Thyroidectomy 10 penrose drain is placed in the wound and the surgeon close the muscle with 3-0 vicryl suture on a taper needle. For skin closure Steri-Strips are used. The skin is dressed using 2 4×4 gauze these are used as intermediate dressing and paper table is applied to secure dressing. The patient will transported to Post Anesthetic Care Unit where she or he will be observed for approximately 24 hours before discharged to go home. The voice is checked when she is in PACU. The patient is also advice of pain and hemorrhage.
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