OPERATIVE SURGERIES:

THYROIDECTOMY &
TRACHEOSTOMY
SUBMITTED TO: SUBMITTED BY:
DR. DEVENDER KUMAR DR. JANAK
ASSOCIATE PROFESSOR & H.O.D. BAMS INTERN
DR. NAMRTA SHARMA UG BATCH 2018
ASSITANT PROFESSOR

DEPARTMENT OF SHALYA TANTRA

DAYANAND AYURVEDIC COLLEGE, JALANDHAR
 THYROIDECTOMY

 DEFINATION:- Surgical removal of all or part of the thyroid gland can be a treatment
for thyroid cancer and other conditions.
 SURGICAL ANATOMY OF THYROID GLAND

 Thyroid gland is present in the neck, enclosed by pretracheal fascia which is a part of deep
cervical fascia.
 It has a right and left lobe joined by the isthmus in frontof 2 nd, 3rd and 4th tracheal rings. It
weighs about 20-25 g.
 A projection from the isthmus usually on the left side is called pyramidal lobe. It is attached
to the hyoid bone by a fibrous band or muscle fibres called levator glandulae thyroideae.
 Arterial supply :-Superior thyroid artery, Inferior thyroid artery, Thyroidea ima artery.
 Venous drainage :- Superior thyroid vein, Middle thyroid vein ,Inferior thyroid veins.
 Nerves in relationship with thyroid gland:- Superior laryngeal nerve, Recurrent laryngeal
nerve (RLN).
 INDICATIONS

 All goitres with symptoms-

1. MNG (Multinodular goiter)
2. Toxic goitre
3. Colloid goitre
4. Malignant goitre
 CONTRAINDICATIONS

 Asymptomatic goitre,
 Hashimoto’s thyroiditis,
 Anaplastic carcinoma thyroid.
 POSITION OF THE PATIENT

 Supine with extended neck by keeping a sandbag under the shoulders.

 Head end of the patient is elevated to about 30° to reduce venous congestion. This
position is called anti Trendelenburg position.
 Anaesthesia:- GA.
 Preparation of the parts :- Betadine and spirit
 PROCEDURE

 Incision:- 6-8 cm collar neck incision or crease incision.

 Layers Opened :-
1. Skin, platysma, subcutaneous tissue in the line of incision
2. Deep fascia is incised vertically.
3. Strap muscles are separated ( can be cut in very largest goitres).
4. Pretracheal fascia is incised.
5. Thyroid gland is mobilised by using blunt dissection.
6. Assess the entire gland to know whether it is a solitar) nodule or multinodular goitre.
7. One of the lobes is mobilised by dividing middle thyroid vein (single, short, thin, vein).
8. Then, upper pole is dissected. This pedicle contains superior thyroid artery and veins. They are ligated and divided
in between. All major arteries should be ligated twice proximally. Example: Superior thyroid artery.
 PROCEDURE....

1. Upper pole should be ligated as close to the gland as possible to avoid damage to external
laryngeal nerve.
2. Inferior thyroid artery used to be ligated well away from the gland. It has a horizontal
course. It is thick and pulsatile. Then, the branches of inferior thyroid artery are ligated.
This will avoid injury to recurrent laryngeal nerve and it will prevent hypoparathyroidism
also. Multiple veins, present in the lower pole are ligated and divided.
3. Isthmus is separated from trachea, both above and below.
4. In subtotal thyroidectomy the entire isthmus, parts of the right and left lobes are removed
in flush with tracheal surface, leaving behind tissue in the tracheo-oesophageal groove to
protect recurrent laryngeal nerve and parathyroid gland. Cut edges of thyroid gland are
sutured by using vicryl sutures. In total thyroidectomy almost entire gland is removed
 PRECAUTIONS

 Any structure directly entering the gland is unlikely to be RLN and hence, can safely be
divided.
 Recurrent laryngeal nerve enters the thyrohyoid membrane, after running a vertical
course, in the tracheo-oesophageal groove.
 CLOSURE

 A suction drain is kept in the thyroid bed.

 Deep fascia-continuous vicryl.
 Subcutaneous fat-vicryl
 Skin-interrupted silk/subcuticular sutures
 A bandage is applied
 POSTOPERATIVE MANAGEMENT

 NPO for 6-8 hours fo1lowed by liquid diet

 Antibiotics are not necessary
 Head end must be elevated to reduce oedema of the wound
 In toxic goitres, propranolol must be continued after surgery and slowly tapered over a
week
 Blood transfusion depending upon blood loss
 Drain removal after 2-3 days (once it stops draining)
 Suture removal after 4-5 days
 POSTOPERATIVE COMPLICATIONS

 Haemorrhage: Tension haematoma.

 Thyrotoxic crisis in patients with toxic goitre
 Tracheomalacia-resulting in stridor
 Recurrent laryngeal nerve paralysis
 Hypothyroidism
 Hypoparathyroidism
 Wound infection
 ADVISE AT DISCHARGE

 This depends on the type of indication for thyroid surgery, e.g. those who undergo
subtotal thyroidectomy for thyrotoxicosis have to be closely followed for recurrent
thyrotoxicosis or hypothyroidism.
 If calcium levels are low, it has to be supplemented.
TRACHEOSTOMY
 TRACHEOSTOMY

 An opening made in the trachea is tracheostomy.

 INDICATIONS

 Emergency
1. Choking of the larynx due to dentures, foreign bodies fish bones, etc.
2. Stridor due to diphtheria, carcinoma larynx and bilatera recurrent laryngeal nerve paralysis after
thyroidectomy).
 Elective
1. Coma
2. Tetanus
3. Barbiturate poisoning
4. Head injuries
5. Pulmonary insufficiency
 CONTRAINDICATIONS

 Anaplastic carcinoma thyroid patients presenting with stridor due to infiltration of growth
into trachea. It may not be possible to do a tracheostomy or an attempt to do tracheostomy
may result in the growth fungating through the incision (which is best avoided). In such
patients, endotracheal intubation is done if possible. If not possible, no other intervention
is done
 POSITION OF THE PATIENT

 Supine with extension of the neck and head by keeping a sandbag or a pillow under the
shoulders.
 Anaesthesia
Local infiltration anaesthesia
 Preparation of the parts
Betadine and spirit
 PROCEDURE

 Incision: Transverse curved incision for about 3-4 cm is made at the level of 2nd tracheal ring.
 Dissection: Skin, subcutaneous tissue and deep fascia are incised. Isthmus of thyroid is separated.
 Procedure: A transverse cut is made in the 2nd tracheal cartilage, its edge is held with Allis forceps
and a small cuff of cartilage is removed. 'Cricoid hook' can be used to stabilise the trachea (found
more useful in children).
 A suitable-sized tracheostomy tube is introduced within.
 The cuff of tracheostomy tube is inflated by using 2-5 ml of air and is held in place by passing a
tape around the neck.
 Confirm that the tube is in the trachea, not in the subcutaneous plane.
 Confirm air entry on both sides of lung.
 CLOSURE

 Few interrupted skin sutures by the side of the tracheostomy tube and dressing is applied.
 POSTOPERATIVE MANAGEMENT

 Suction of tracheostomy tube, regular dressing

 Humidification of air
 Check for air entry
 POSTOPERATIVE COMPLICATIONS

 Wound infection
 Air leakage
 Improper air entry
 Cricoid stenosis (high tracheostomy)
 CLOSURE OF TRACHEOSTOMY

 Once the foreign body is removed, tracheostomy is blocked for few hours, if there is NO
RESPIRATORY DISTRESS, cuff is deflated and the tube is removed. A few skin sutures
can be put or dressing is applied. It closes automatically.
 ADVICE AT DISCHARGE

 Tracheostomy done after laryngectomy is permanent. Patients should learn to use metal
tracheostomy, cleaning the tubes etc.
 Confirm air entry well once the tracheostomy tube is introduced within the trachea.
THANKYOU