PROCEDURES PERFORMED:
1. Minimally invasive video-assisted thyroidectomy, total.
2. Continuous laryngeal nerve integrity monitoring x2 hours.
PREOPERATIVE DIAGNOSES:
1. Dyshormonogenetic multinodular goiter.
2. Hypothyroidism.
POSTOPERATIVE DIAGNOSES:
1. Dyshormonogenetic multinodular goiter.
2. Hypothyroidism.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 5 mL.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old girl with congenital hypothyroidism and dyshormonogenetic multinodular goiter with an increasing left dominant thyroid nodule.
After discussion of risks and benefits, including altered treatment options such as fine needle biopsy, the patient elected to proceed with minimally invasive video-assisted thyroidectomy, total, under general anesthesia through a minimally invasive approach.
DETAILS OF PROCEDURE: The patient was brought to the operating room and placed in the supine position for minimally invasive video-assisted thyroidectomy, total, and induced and intubated per Anesthesia.
The patient was intubated with 7.0 Xomed nerve integrity monitoring endotracheal tube. Direct laryngoscopy was performed to confirm accurate placement of the EMG contact electrodes to the vocalis muscles and endolarynx bilaterally. Subdermal ground electrodes were placed.
All electrodes were hooked up to the nerve monitor, which was turned on and set for continuous laryngeal nerve monitoring for the remainder of the two hour procedure. Only short-acting muscle relaxant was used for intubation. No further muscle relaxant given and no topical laryngeal anesthetic used.
After confirming the correct patient and procedure using standard time-out technique, the neck was prepped and draped in the standard sterile fashion. A 2.5 cm horizontal skin incision was made in the previously identified skin crease.
Dissection was carried down to the subplatysmal plane. The flaps were elevated and strap muscles were divided in the midline and retracted laterally on the right. The thyroid gland was mobilized medially.
Using the 5 mm endoscope with video assistance, the superior pole was addressed with identification and preservation of the cricothyroid muscle and superior laryngeal nerve medially. The integrity of the nerve was confirmed with the nerve stimulator and monitor.
The superior pole vasculature was taken with the Harmonic scalpel in such a way as to preserve the integrity of the nerve. This allowed better mobilization of the thyroid gland medially.
The recurrent laryngeal nerve was identified, its integrity confirmed with the nerve stimulator monitor. The inferior and superior parathyroid glands were preserved along with their blood supply. The recurrent nerve was followed to its insertion at the cricothyroid membrane. Berry’s ligament was sharply transected and attention was turned to the contralateral side.
Dissection on the left side proceeded as described on the right. Specifically, the superior and recurrent laryngeal nerves were identified and their integrity confirmed with a nerve stimulator monitor.
Superior and inferior parathyroid glands were preserved along with their blood supply. The recurrent nerve was followed to its insertion near the cricothyroid membrane. Berry’s ligament sharply transected and the thyroid gland was passed off the field and sent for frozen histologic diagnosis, which was consistent with a follicular lesion without evidence of malignancy.
Hemostasis was obtained. The integrity of the recurrent nerves was confirmed bilaterally. It was noted that the first tracheal ring on the right side had been partially cut while cutting through Berry’s ligament.
There was no evidence of air leak and the membranous trachea was intact. The tracheal cartilage was reapproximated with a 5-0 Prolene suture. The wound was then closed in layers over a suction drain. The patient returned to anesthesia care, awakened, extubated and taken to the recovery room in good condition.
