Open Total Thyroidectomy for Graves’ Disease
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Procedure Outline
Table of Contents
- 1. Introduction
- 2. Pre-op Prep
- 3. Incision
- 4. Exposure of Thyroid Gland and Overlying Strap Muscles
- 5. Left Thyroid Dissection
- 6. Summary of Left Side and Confirmation of Intact Recurrent Laryngeal Nerve and Viable Parathyroid Before Proceeding with Right Side
- 7. Right Thyroid Dissection
- 8. Specimen Orientation for Pathology
- 9. Final Inspection, Irrigation, and Hemostasis with Valsalva from Anesthesia and Surgicel
- 10. Closure
- 11. Post-op Remarks
- A Note on Nerve Monitoring
- Mark Incision While Patient is Awake and Can Move Neck to Better Find Crease
- Position Patient Supine with Arms Tucked and Neck Extended
- Pre-op Ultrasound to Confirm Incision over Isthmus and to Examine Thyroid
- Prep and Drape Patient
- Subplatysmal Flaps
- Separate Strap Muscles
- Expose Upper and Lower Borders of the Isthmus with the Trachea and Cricothyroid Muscle
- Upper Pole Dissection and Blood Supply Ligation with Preservation of the External Branch of the Superior Laryngeal Nerve via Nerve Monitor
- Rotate Thyroid Medially and Ligate Middle Thyroid Vein
- Lower Pole Dissection with Preservation of Left Inferior Parathyroid Gland
- Rotate Thyroid Medially into the Wound and Identify the Recurrent Laryngeal Nerve Within the Tracheoesophageal Groove
- Carefully Separate Recurrent Laryngeal Nerve from Thyroid with Nerve Monitoring and Preservation of Left Superior Parathyroid Gland
- Leave Small Thyroid Remnant Where Recurrent Laryngeal Nerve Inserts into Larynx, Which is Often Prudent in Setting of Inflammation to Prevent Nerve Traction Injury
- Divide Attachments of Thyroid to Trachea to Complete Left Side
- Separate Sternothyroid Muscle from Thyroid
- Upper Pole Dissection and Blood Supply Ligation with Preservation of the External Branch of the Superior Laryngeal Nerve via Nerve Monitor
- Rotate Thyroid Medially for Middle Thyroid Vein Ligation and for Lower Pole Dissection with Preservation of Right Inferior Parathyroid Gland
- Rotate Thyroid Medially into the Wound and Identify the Recurrent Laryngeal Nerve Within the Tracheoesophageal Groove and the Right Superior Parathyroid Gland
- Carefully Separate Recurrent Laryngeal Nerve from Thyroid with Nerve Monitoring and Preservation of Right Superior Parathyroid Gland
- Leave Small Thyroid Remnant Where Recurrent Laryngeal Nerve Inserts into Larynx, Which is Often Prudent in Setting of Inflammation to Prevent Nerve Traction Injury
- Divide Attachments of Thyroid to Trachea to Complete Total Thyroidectomy
- Sternohyoid Muscle with 4-0 Vicryl Interrupted Sutures
- Release Neck Extension and Close Platysma with 4-0 Vicryl Interrupted Sutures
- Deep Dermal Layer to Take Tension off the Skin
- Skin with Running, Knotless 5-0 Monocryl Subcuticular Suture and Steri-Strips
