DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right thyroid mass with anterior mediastinal involvement.
POSTOPERATIVE DIAGNOSIS: Right thyroid mass with anterior mediastinal involvement.
OPERATION PERFORMED: Right thyroid lobectomy with removal of anterior mediastinal component.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: 400 mL.
IV FLUIDS: Crystalloid 600 mL and 500 mL of albumin.
URINE OUTPUT: 400 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with history of stage I squamous cell carcinoma of the right lateral tongue, which was treated earlier this year. During a routine followup, CT scan of the neck and chest, a large substernal goitrous-appearing thyroid was noted. The patient had a previous chest x-ray, and the anterior mediastinal component of the mass was not appreciated. As the patient has developed voice changes and was noted to have right vocal cord paresis on flexible laryngoscopic evaluation in the office, right thyroid lobectomy with removal of anterior mediastinal component was recommended.
OPERATIVE FINDINGS: A very large, highly vascular right thyroid lobe extending into the anterior mediastinum with tracheal deviation to the left, measuring approximately 10.5 x 4 x 4.5 cm.
DESCRIPTION OF OPERATION: The patient was orally intubated and placed under general anesthesia. A #6.5 endotracheal tube was placed after unsuccessfully trying to intubate the patient with a #7.0 endotracheal tube. For the previous partial glossectomy procedure performed earlier this year, a #8.0 endotracheal tube had been placed. Skin markings in the previous lower limb of the MacFee incision were made. Skin was then injected with 1% lidocaine with 1:100,000 epinephrine. Compression stockings were placed, and a Foley catheter was inserted. The patient was then prepped and draped using sterile technique for right thyroid lobectomy.
The skin incision was made through the subplatysmal plane using a #15 blade. The subplatysmal flaps were elevated using sharp scalpel. The strap muscles were then identified in the midline and divided. The individual strap muscles were then carefully elevated off the underlying thyroid gland using the sharp scalpel. The thyroid gland was quite large and had evidence of significant vascularity. The smaller feeding vessels were cauterized using the bipolar cautery. The larger ones were clipped using vascular clips.
The lateral aspect of the resection was performed first to free up the large thyroid mass. The dissection was then carried out superiorly to identify the superior pole vessel. The superior pole vessels were isolated and clipped using medium vascular clips. The middle thyroid vein was identified deeper than expected and was noted to be quite large and likely due to the very large size of the mass itself.
The middle thyroid vein was isolated, clamped and suture ligated using 3-0 silk sutures. The thyroid gland was transected to the left of midline using the Bovie cautery device. The isthmus was taken out the trachea, using careful blunt and sharp dissection. The inferior pole could not be readily accessed from the neck due to, again, the fact that it extended well into the anterior mediastinum.
Large feeding vessels were noted at the area just above the clavicles. One of the vessels tore while trying to isolate it. This precipitated significant blood loss. The bleeding was controlled using 3-0 silk sutures and vascular clips. The patient was typed and crossed for 2 units of blood. No further significant bleeding occurred throughout the remainder of the case however. The iSTAT result came back at 37.
Attention was paid again to the superior pole, as the recurrent meningeal nerve could not be identified from below. The area lateral to the trachea at the cricopharyngeus was isolated. There was significant blood supply in this area as well. The vessels were cauterized using the bipolar cautery and vascular clips. The recurrent laryngeal nerve was eventually identified and followed inferiorly. The recurrent laryngeal nerve was displaced posteriorly and more lateral than expected, as again the mass was quite large and the trachea had been deviated to the left.
The superior parathyroid gland was identified in this process and preserved. The recurrent laryngeal nerve was followed inferiorly to the level just above the clavicles. Using blunt and sharp dissection, the anterior mediastinal component of the mass was eventually removed. The entire specimen was then sent to Pathology for frozen section analysis. The frozen section analysis came back as consistent with an adenomatous goiter.
The wound was irrigated with copious normal saline. Complete hemostasis was obtained using the bipolar cautery device. A 10 mm Jackson-Pratt drain was placed in the depth of the wound. The strap muscles were reapproximated in the midline using 3-0 Monocryl simple running sutures. The platysmal area was reapproximated using 3-0 Monocryl interrupted sutures. The dermal layer was reapproximated using 4-0 Monocryl interrupted mattress suture. The patient was then suctioned free of blood and secretion, prior to extubation. The patient was successfully extubated and transferred to the recovery room in stable condition.
