Thyroid cancer radical surgery

Radical thyroidectomy is a extensive resection of the affected thyroid gland (including the thyroid isthmus and the contralateral thyroid gland) and the cervical lymph nodes in patients with thyroid malignancy. In addition to the treatment of the thyroid itself, the scope of surgery also includes the removal of lymph nodes around the thyroid (pre-larynx, pretracheal, paratracheal, and recurrent laryngeal lymph nodes), sternocleidomastoid, internal jugular vein, and internal jugular vein. The three groups of lymph nodes were removed together, the posterior triangle of the neck (many of the authors routinely removed the accessory nerve) and the removal of the submandibular triangle and the infraorbital triangular lymph nodes. The upper mediastinum should be removed as needed. Even worse, only the extremely thin flap is retained in front of the neck to remove the subcutaneous tissue and the platysma. Indication 1. Infiltrating papillary adenocarcinoma. 2. Infiltrating follicular head adenocarcinoma. 3. Medullary carcinoma. Contraindications 1. A very poor general condition or a serious illness with other important systems or organs that is difficult to withstand major surgery. 2. There are already distant transferers. 3. Undifferentiated cancer. Preoperative preparation 1. Patients with hyperthyroidism must be treated with anti-thyroid drugs in internal medicine. The basal metabolic rate is reduced to normal or near normal (less than +15%). After the pulse rate is below 90 beats/min, stop taking anti-thyroid drugs and change to the compound. Iodine for about two weeks, the thyroid is significantly reduced, hardened, easy to operate and reduce intraoperative bleeding. The specific method is oral compound iodine solution (lugol solution), 3 times a day, 5 drops per day on the first day, 6 drops per day on the next day, and then incremented by 1 drop every day until it increases to 15 drops each time, maintaining 3 to 5 Surgery in the future. In recent years, it has been advocated to use presbyopia and compound iodine solution for preoperative preparation. The dosage of the heart is different depending on the condition, and it is 10 to 40 mg once every 6 hours. This pre-operative medication can reduce preparation time. 2. The use of sedative drugs may be ummina 0.1g or diazepam 5mg when insomnia or restlessness, once a day orally. 3. Necessary preoperative examinations such as cardiovascular function and liver and kidney function tests, basal metabolic measurements, laryngoscopy vocal cord function, x-ray examination of tracheal position and determination of blood calcium and phosphorus. 4. Basically the same subtotal resection, no hyperthyroidism, it is not necessary to prepare for thyroid cancer before the operation of hyperthyroidism. The scope of surgery is large, bleeding is more, blood preparation is at least 1000ml. 5. Before surgery, the patient's family and unit must be informed about the risk of surgery, complications, postoperative neck can have certain deformities, aesthetic effects. Tumor recurrence may occur after surgery. Surgical procedure 1. Position: Turn the head to the opposite side to fully expose the lateral and posterolateral sides of the neck. 2. Incision: On the basis of the neck-neck incision, the inner edge of the sternocleidomastoid muscle of the affected side is upward, and reaches the lower edge of the mastoid to form a hernia-shaped incision. 3. Exposure: Cut the skin, subcutaneous tissue and platysma. Such as platysma without tumor infiltration should be retained. The flap is separated deep in the platysma, the inner side can exceed the midline of the trachea, and the outer side reaches the leading edge of the trapezius muscle, which can be pressed down the collar and up to about 2 cm above the lower edge of the mandible. The flaps were turned up, down, front, and back, respectively, and sutured and fixed on the skin of the corresponding part. 4. Separate the sternocleidomastoid muscle: enter along the medial edge of the sternocleidomastoid and pull it outward. If it is unsatisfactory, it can be cut at 2cm above the attachment point of the lower end of the sternocleidomastoid muscle, and it will be turned upside down. The fascia that wraps the muscles should also be removed. 5. Resection of the sublingual muscles: After separating the sublingual muscles on both sides by the white line of the neck, the muscles of the hyoid bones are cut along the attachment edge of the clavicle and turned up, and then removed. 6. Excision of the affected side of the thyroid: removal of the affected side of the thyroid (including the isthmus and the contralateral adjacent thyroid), retaining a part of the thyroid outside the healthy side to maintain physiological function. Thyroid treatment can start from the lower pole and turn upwards. At this time, care should be taken not to damage the recurrent laryngeal nerve. The isthmus can be removed on both sides after the end of the trachea with the hemostat. The contralateral thyroid is treated with a partial or major resection. 7. Treatment of the internal jugular vein: The preservation of the internal jugular vein can be determined according to the specific case. If the cervical lymph nodes have extensive metastasis, in order to ensure the curative effect, it is advisable to remove the internal jugular vein at the same time. If the metastatic condition is not serious, or the contralateral internal jugular vein has been removed in the previous operation, the internal jugular vein should be preserved. If the internal jugular vein is to be removed, the carotid sheath should be opened and the internal jugular vein should be carefully separated to prevent bleeding or air embolism. The internal jugular vein is ligated and cut near the upper edge of the clavicle, and the proximal end should be sutured [Fig. 1-2]. Then lift the distal end of the internal jugular vein and separate it upwards. There are upper, middle and lower lymph nodes in the internal jugular vein, which should be removed together. The internal jugular vein is separated into the submandibular triangle, and is ligated and cut at the lower edge of the submandibular gland to prevent damage to the vagus nerve and carotid artery. 8. Treatment of the submandibular triangle: the submandibular triangle, except for the extensive metastasis of the upper pole lesions, generally do not remove. The muscles under the hyoid bone are cut at the lower edge of the mandible, and the sublingual muscles, the internal jugular vein, and the thyroid tissue are removed together. 9. Clear the supraclavicular lymph nodes: remove the lymph nodes and adipose tissue on the supraclavicular bone, and do not damage the brachial plexus. 10. Stitching: After completely stopping bleeding, place a soft rubber tube to drain, suture layer by layer, and dress the wound. complication 1. Postoperative dyspnea and asphyxia: This is the most critical complication after surgery, which occurs within 48 hours after surgery. Common causes are: 1 intra-incision hemorrhage, hematoma formation, compression of the trachea; 2 tracheal collapse; 3 laryngeal edema; 4 bilateral recurrent laryngeal nerve injury. Clinical manifestations include progressive dyspnea, irritability, cyanosis, and even suffocation. If it is caused by bleeding in the incision, there may be swelling of the neck and bleeding of the incision. When the above situation is found, the patient should be immediately rescued by the patient's bed, the suture should be cut open, and the incision should be opened to remove the hematoma. If the hematoma is removed, the breathing difficulties will not improve, and the tracheotomy should be performed immediately. Tracheal collapse is often softened by the pressure of the giant thyroid gland. When the gland is removed, the trachea loses support and collapses. Therefore, tracheotomy should be performed during the operation. Once the laryngeal edema appears, the head should be taken at a high position to fully supply oxygen. If it is not good, the tracheotomy should be performed in time. Bilateral recurrent laryngeal nerve injury can cause bilateral vocal cord paralysis and cause severe breathing difficulties, requiring tracheotomy. 2. Thyroid crisis: The cause has not been affirmed, the occurrence of crisis is mostly due to insufficient preparation before surgery, and the symptoms of hyperthyroidism are not well controlled. Thyroid crisis occurs in 12 to 36 hours after surgery, which is characterized by high fever, fast and weak pulse (more than 120 times per minute), irritability, paralysis, and even coma, often accompanied by vomiting and watery diarrhea. If the treatment is not timely or improper, the patient often dies very quickly. Treatment includes the following comprehensive measures: (1) Iodine: 3 to 5 ml of oral compound potassium iodide solution, 5 to 10 ml of 1% sodium iodide in an emergency, and intravenously in 500 ml of 10% glucose solution. (2) sedative: intramuscular injection of hibernation ii half a dose, once every 6 to 8 hours, reserpine 1 ~ 2mg, or heart 5mg, add glucose solution 100ml intravenous drip. (3) Hydrocortisone 200 ~ 400mg daily, intravenous drip. (4) Cooling: Apply antipyretics, hibernation drugs, physical cooling, etc. to keep the body temperature at around 37 °C. (5) Intravenously input a large amount of glucose solution. (6) Oxygen inhalation to reduce tissue hypoxia. 3. Hand and foot convulsions: Parathyroid gland is removed by surgery, contusion or blood supply is involved, can cause hypoparathyroidism, blood calcium concentration drops below 8mg%, severe cases can be reduced to 4mg% ~ 6mg%, The neuromuscular stress is significantly increased, causing hand and foot convulsions. Symptoms often appear 1 to 3 days after surgery. Most patients have mild and short-term symptoms. They only have acupuncture, numbness or strong sensation on the face, lips or hands and feet. In severe cases, facial muscles and persistent sputum in the hands and feet may occur. It may occur several times a day for 10 to 20 minutes each time. Longer. Patients with mild symptoms can take oral calcium. If the symptoms are severe, they can be intravenously injected with 10% calcium gluconate or 3% calcium chloride 10-20ml. However, it can only play a temporary role. The most effective treatment is oral dihydrogenated sterol (a, t, 10) oil, which has a special effect of increasing blood calcium content, thereby reducing neuromuscular stress. 4. Sonar: mainly caused by direct injury to the recurrent laryngeal nerve, such as cutting, suturing, and contusion; a small number of cases occur due to hematoma compression or traction of scar tissue. The former developed symptoms immediately after surgery or after general anesthesia, and the latter showed symptoms only a few days after surgery. The hoarseness caused by cutting and sewing is a permanent injury; the hoarseness caused by the contusion, pulling or hematoma compression is temporary, and the general manager treatment can gradually recover after 3 to 6 months.