DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left substernal thyroid mass with tracheal compression.
POSTOPERATIVE DIAGNOSIS: Left substernal thyroid mass with tracheal compression.
OPERATION PERFORMED:
1. Left substernal hemithyroidectomy.
2. Parathyroid reimplantation.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal tube.
ESTIMATED BLOOD LOSS: 60 mL.
OPERATIVE FINDINGS:
1. Large multinodular left substernal thyroid crossing midline and extending into the chest and right above the subclavian artery. This returned as follicular lesion, deferred to permanent frozen section.
2. Left recurrent laryngeal nerve identified and preserved throughout the case.
3. Left superior parathyroid identified and preserved.
4. Left inferior parathyroid reimplanted in the left sternocleidomastoid muscle anteriorly.
SPECIMENS: Left hemithyroid sent to Pathology.
COMPLICATIONS: None.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female with slowly growing, large left substernal thyroid mass with calcifications and tracheal compression. Informed consent was obtained after explaining the risks, benefits, and alternatives to the procedure.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under general endotracheal tube anesthesia with recurrent laryngeal nerve, endotracheal tube placed by the anesthesia staff and confirmed using the GlideScope. With the neck extended, a lower neck skin crease incision was marked with the marking pen and injected with 1% lidocaine with 1:100,000 epinephrine. Appropriate surgical time-outs were called x2. The neck and chest were prepped with Betadine solution and scrubbed and draped sterilely.
A skin incision was made sharply and carried down through platysma with Bovie electrocautery. Subplatysmal flaps were elevated superiorly and inferiorly. The strap muscles were split in the midline. The left sternohyoid muscles were split superiorly to allow for better exposure. The middle thyroid vein was identified and divided with Harmonic scalpel and tied distally with 3-0 silk suture. Dissection proceeded inferiorly, staying in close proximity to the surface of the capsule of the gland. The inferior pole vessels were divided with Harmonic scalpel and tied distally with 3-0 silk suture. The recurrent laryngeal nerve was identified just lateral to the tracheoesophageal groove and dissected toward its entry point at the cricothyroid membrane.
Large substernal extension was dissected bluntly and reflected into the neck. Dissection then proceeded towards the isthmus. The large left-sided mass was seen to be crossing the midline. The isthmus was dissected bluntly away from the trachea and then divided with the Harmonic scalpel. Dissection then proceeded superiorly, staying in close proximity to the surface of the capsule of the gland. The superior parathyroid gland was seen and dissected free from the undersurface of the gland and kept intact with its blood supply intact. The superior pole vessels were divided with Harmonic scalpel and tied distally with 2-0 silk suture. Berry’s ligaments were then divided with Harmonic scalpel with the recurrent laryngeal nerve under direct visualization. The left hemithyroid was then sent off the table to Pathology as a specimen, which returned as follicular lesion, deferred to permanent on frozen section.
Meticulous bipolar cautery was used for hemostasis after the bed was copiously irrigated. A 7-French closed suction drain was brought through a separate stab incision and secured to the skin with 2-0 nylon. The strap muscles were reapproximated with 3-0 Vicryl. The platysma was reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Vicryl and Dermabond. A pressure dressing was applied. The patient was then awoken from anesthesia and extubated and taken to the recovery room in stable and awake condition. Prior to skin closure, left inferior parathyroid gland that was seen to be somewhat dusky following dissection was minced and reinserted into the left sternocleidomastoid muscle and marked with a 4-0 Prolene suture. Sponge and needle counts were reported to be correct by the nursing staff. The patient was then awoken from anesthesia and extubated and taken to the recovery room in stable and awake condition.
