Editing Thyroidectomy (section)

== Technique ==
TT, GA (?with nerve monitoring ETT), shoulder roll and head ring with neck extended, supine with back raised 20 degree, arms tucked in, headlight/loupes

* Nerve monitoring - 2x     external leads inserted to skin and taped down with tegaderm

Prep and drape, IV Abx (although there is no proof for thyroidectomy), TEDs

Mark anatomy - borders of SCM, manubrium, midline

Incision between medial edges of SCM, finger's breadth above sternum

Through platysma

Dissection to raise upper and lower sub-platysmal flaps

* Develop inferior flap to     level of sternal notch, upper flap to thyroid notch
* Aware of anterior jugular     veins - can be suture ligated if necessary

Joll's retractor

Lateralise strap muscles (can be divided transversely if large goitre)

Dissect larger side of thyroid first, with primary operator standing on contralateral side

* Use peanut to dissect loose     areolar tissue between gland and strap muscle towards lateral edge
* Lateralise dissection but     don't need to go too far

Upper pole

* Clear as much of upper pole     as you easily can using blunt dissection, peanut, right angle
* Open up Reeve's avascular     space (medial) with blunt dissection
* Ligate individual terminal     branches of superior thyroid artery close to capsule
* Look for EBSLN and protect,     but don't go chasing too much
* Complete upper pole and look     for upper parathyroid

* If bleeding here, pack, sort     out lights/assistant etc, usually the vessel doesn't retract too far, so     just be careful and localise it. Danger is in damaging the parathyroids in     a panicked hunt for the vessel.

Middle pole

* Roll thyroid medially with     gentle traction - retracting in the axial plane, not rotating the upper     pole, to avoid distorting RLN's path
* Follow dissection caudally,     ligating middle thyroid vein branches as you go
* Be very aware of RLN and try     to keep a bloodless field (can either identify it at the top or the     bottom)
* Tubercle of Zuckerkandl

Finding RLN

* Should be in     tracheoesophageal groove
* Runs near suspensory ligament     of Berry (most common site of injury) - almost always posterolateral to     the fibres
* Tubercle of Zuckerkandl

Lower pole

* Continue caudally
* Ligate ITA branches as you go     - take close to thyroid capsule - RLN can be closely associated, and also     don't want to devascularise parathyroid
* Look for lower parathyroid     gland
** Auto-transplant if it is      intra-thyroid, appears dusky, or has no vascular pedicle

Ligament of Berry divided and enter avascular plane between thyroid isthmus and trachea

Change to other side - swap sides with assistant

Inspect anterior mediastinum

Haemostasis

Reapproximate strap muscles

LA - Erb's point - 2-3cm above the clavicle at the posterior border of SCM

Close platysma