The document provides details about the history, embryology, anatomy, types of procedures, and steps involved in thyroidectomy. Some key points:
- Thyroidectomy has been performed for over 1000 years, with modern techniques developed in the 17th-19th centuries.
- The thyroid gland develops from endoderm and migrates to its final location in the neck.
- It has a complex blood supply and relationship with surrounding structures like the recurrent laryngeal nerve.
- Types of thyroidectomy include lobectomy, subtotal, total, and completion procedures.
- Preparation involves imaging, labs, and managing thyroid function. Careful dissection is needed
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The document provides details about the history, embryology, anatomy, types of procedures, and steps involved in thyroidectomy. Some key points:
- Thyroidectomy has been performed for over 1000 years, with modern techniques developed in the 17th-19th centuries.
- The thyroid gland develops from endoderm and migrates to its final location in the neck.
- It has a complex blood supply and relationship with surrounding structures like the recurrent laryngeal nerve.
- Types of thyroidectomy include lobectomy, subtotal, total, and completion procedures.
- Preparation involves imaging, labs, and managing thyroid function. Careful dissection is needed
The document provides details about the history, embryology, anatomy, types of procedures, and steps involved in thyroidectomy. Some key points:
- Thyroidectomy has been performed for over 1000 years, with modern techniques developed in the 17th-19th centuries.
- The thyroid gland develops from endoderm and migrates to its final location in the neck.
- It has a complex blood supply and relationship with surrounding structures like the recurrent laryngeal nerve.
- Types of thyroidectomy include lobectomy, subtotal, total, and completion procedures.
- Preparation involves imaging, labs, and managing thyroid function. Careful dissection is needed
The document provides details about the history, embryology, anatomy, types of procedures, and steps involved in thyroidectomy. Some key points:
- Thyroidectomy has been performed for over 1000 years, with modern techniques developed in the 17th-19th centuries.
- The thyroid gland develops from endoderm and migrates to its final location in the neck.
- It has a complex blood supply and relationship with surrounding structures like the recurrent laryngeal nerve.
- Types of thyroidectomy include lobectomy, subtotal, total, and completion procedures.
- Preparation involves imaging, labs, and managing thyroid function. Careful dissection is needed
17th century ● Emil Theoder Kocher is considered as the Father of Modern Thyroid surgery ● First thyroidectomy is considered to be done more than 1000 years ago by Abu-al-Qasim ● The earliest account of thyroidectomy was probably given by Roger Frugardi, 1170 EMBRYOLOGY ● Thyroid gland develops from the median anlage and two lateral anlagen ● Median anlage starts as a thickening of endodermal epithelium in foregut between 1st and 2nd branchial arches at base of tongue
cells proliferate – thyroid bud and then a
diverticulum – expands and migrates to lie in anterior to trachea (4-7 wks of gestation) ● The track usually disappears by birth ● Two lateral anlagen (ultimobranchial bodies) develop from caudal aspect of 4th pharyngeal pouch
fuse with median anlage as thyroid gland
descends in the neck ● Median anlage follicular cells ● Lateral anlagen parafollicular cells ANATOMY – Thyroid gland ● Thyroid gland is composed of follicles which are secreting functional units of the gland, together with a rich vascular, lymphatic and neural network ● The gland comprises of two lobes connected by isthmus, lying in midline on trachea at level of 2nd-3rd tracheal ring ● Gland is invested in a fascial capsule – 'Surgical capsule' derived from the pretracheal fascia of deep cervical fascia. It is thin and closely related to external surface of gland ● Capsule is deficient in posterior aspect of isthmus and most of posteromedial surface of lobe where gland lies in close relation to trachea ● Along upper part of posterior border of thyroid lobe and adjacent posteromedial surface fascia is thick and firmly attached to trachea – 'Ligament of Berry' ● It binds gland firmly to trachea and must be freed while releasing a lobe surgically ● RLN lies behind ligament of Berry just before it disappears in larynx behind cricothyroid joint ● Posteriorly capsule extends to blend with prevertebral fascia ● Laterally with carotid sheath ● Superiorly envelopes upper lobe of gland and extends upwards around superior pedicle ● Along upper border of isthmus fascia attaches to outer surface of trachea and cricoid ● Inferiorly fascia passes into mediastinum anterior to trachea and contains inferior thyroid veins ● Each lobe of the gland resides in a bed between trachea and larynx medially & carotid sheath and SCM laterally. ● Strap muscles lie anterior to the thyroid lobes ● Parathyroids and RLN are associated with posterior surface of each lobe ● Superior pole lies posterior to sternothyroid muscle and lateral to inferior constrictor & posterior thyroid lamina ● Inferior pole may extend to level of 6th tracheal ring ● About 40% may have a 'pyramidal lobe' arising from either lobe or isthmus and extends superiorly. It represents remnants of embryonic thyroglossal duct and lie on surface of thyroid cartilage ● Tubercle of Zukerkandl – 75% ● Pyramidal enlargment of lateral edge of thyroid lobe formed from fusion of median and lateral anlages ● Closely related to RLN, inferior thyroid A, ligament of Berry and superior parathyroid gland Arterial supply ● Superior thyroid artery ● First branch of external carotid artery ● Course along inferior constrictor muscle and enters upper pole of thyroid, and divides into superior and inferior branches ● Superior branch runs along medial surface of upper pole and along upper border of isthmus to anastose with its fellow on opposite side ● Inferior branch descends along posterior border of thyroid to anastomose with upper branch of inferior thyroid artery ● Superior thyroid A lies posterolateral to external branch of SLN ● Inferior thyroid artery ● Arises from thyrocervical trunk ● Lies deep to common carotid artery and as it nears gland divides into upper and lower branches ● Upper branch anastomoses with inferior branch of superior thyroid artery ● Lower branch runs downwards towards inferior pole of thyroid ● Inferior thyroid artery provides an important surgical landmark for RLN – In almost 70% of patients inferior thyroid artery lies anterior to the RLN. ● Thyroidea ima artery is occasionaly present – arising from aortic arch / carotid artery VENOUS DRAINAGE ● Superior thyroid vein accompanies the superior thyroid artery and joins IJV ● Middle thyroid vein originate from anterolaterla surface of gland and pass laterlally to join IJV ● Division of this vein permits adequate rotatiom of thyroid lobe to identify RLN and parathyroid glands ● Inferior thyroid vein comes from inferior boeder of gland and drain mainly to left brachiocephalic vein, but also into IJV NERVES ● Thyroid gland is innervated by symphatetic fibres from middle cervical ganglia, fibres pass into gland along with principal arteries to the gland ● Recurrent laryngeal nerve ● Provides motor supply to larynx and some sensory fibres to upper trachea and subglottis ● Right RLN arise from vagus (CN X) at base of neck, loops around subclavian artery and ascends behind right lobe of thyroid. It enters larynx behind cricothyroid muscle between arch of cricoid cartilage and inferior cornua of thyroid cartilage ● Left RLN arise from left vagus at level of arch of aorta, loops posteriorly around it and ascends in tracheo-oesophageal groove, posterior to left lobe of thyroid and enters larynx. ● Left RLN is in close relationship with inferior thyroid artery (70%) ● Non RLN – may occur rarely seen on right side ● External laryngeal nerve ● Subdivision of SLN ● SLN arises beneath nodose gangion of upper vagus and descends medial to carotid sheath, dividing into external and internal branches about 2cm above superior pole of thyroid ● Internal branch travels medially and enters posterior thyrohyoid membrane supplying sensation to supraglottis ● External branch extends medially along inferior constrictor muscle to enter cricothyroid muscle LYMPHATICS ● Lymphatic drainage of thyroid gland has been proposed by Taylor. His studies shows clinically relevant lymphatic spread in thyroid malignancy ● Central compartment of neck - – Tracheal LN – Chain of LN which lie in tracheo-oesophageal groove – One or more LN lying above isthmus – 'delphian nodes' ● B/L central LN dissection (level 6 dissection) – Clears all LN from carotid artery to other and down into superior mediastinum ● Lateral compartment of neck ● A constant group of LN lies along IJV on each side (level 2,3,4). LN in supraclavicular fossa or more laterally level 5 LN may also be involved in thyroid malignancy ● Thoracic duct on left side of neck arches up out of mediastinum and passes forwards and laterally to drain into left subclavian vein / IJV ● Lateral LN dissection – ● removal of level 2, 3, 4 and 5 LN. Vagus N, symphatheticc ganglia, phrenic N, brachial plexus and spinal accessory N are preserved PARATHYROID GLANDS ● They are small semilunar shaped, ochra coloured glands,situated in a pad of fat generally outside surgical capsule secreting PTH, which controls serum Ca metabolism ● Gland are usually 4 in numbers, two on each side, occasionally 3-6. ● Superior parathyroid glands - ● Develops from 4th pharyngeal pouch and descend only slightly during devvelopment and their position remains constant in adult life ● Generally found at level of pharyngo-oesophageal junction behind and seperate from posterior border of thyroid gland ● Supplied by branch from upper division of inferior thyroid artery ● Inferior parathyroid glands ● Arise from 3rd pharyngeal pouch along with thymus ● Descend along with thymus and have a wide range of distribution in adults ● Usually located short distance from lower pole of thyroid ● Supplied by inferior terminal branch of inferior thyroid artery Thyroidectomy ● INDICATIONS ● As therapy for patients with thyrotoxicosis ● To treat benign and malignant thyroid tumours ● To alleviate pressure symptoms (respiratory distress, dysphagia) with benign/ malignant process ● Cosmetic purpose ● To establish a definitive diasgnosis of a mass within thyroid gland, especialy when cytological analysis is either non diagnostic or indeterminate TYPES
● Thyroid lobectomy / Hemithyroidectomy
● Subtotal thyroidectomy ● Near total thyroidectomy ● Total thyroidectomy ● Completion thyroidectomy PRE OPERATIVE EVALUATION ● Ultrasonography ● Fine needle aspiration cytology – FNAC ● Thyroid function tests – TFT ● CT scan ● Thyroid uptake scan ● Laryngoscopy ● Serum Calcium, Parathormone (PTH) PRE OPERATIVE PREPARATION ● Hypothyroidism ● Hyperthyroidism PRE OPERATIVE CONSENT ● Scar ● Airway obstruction ● Voice changes ● Hypoparathyroidism ● Hypothyroidism OPERATIVE STEPS ● Anaesthesia, Positioning & Draping ● Skin incision and creation of flaps Exposure of thyroid gland Mobilization and dissection of upper pole Identification of RLN Identification of parathyroid glands Dissection of ITA and removal of gland Closure POST OPERATIVE CARE ● Look for signs of bleeding, respiratory distress ● Serum Calcium ● Removal of drain ● Reassessment of vocal cord mobility and thyroid function tests COMPLICATIONS ● Wound hemmorhage ● Wound infection ● Superior laryngeal N injury ● Recurrent laryngeal N injury ● Unilateral RLN injury ● Bilateral RLN injury ● Hypocalcemia ● Thyroid storm POST OPERATIVE MANAGEMENT ● Thyroid hormone replacement ● Radioactive iodine treatment ● External beam radiotherapy and chemotherapy RECENT ADVANCES ● Minimally invasive thyroidectomy ● Robotic transaxillary thyroid surgery ● Transoral thyroidectomy THANK YOU
Dishonour of Cheques and Negotiable Instruments - Legalsutra - Law Students' Knowledge-Base - Law School Projects, Moot Court Memorials, Class and Case Notes and More!