subtotal thyroidectomy

Subtotal thyroidectomy is a procedure for the treatment of hyperthyroidism, simple goiter, multiple thyroid adenomas, giant thyroid adenomas or giant cysts. It is an effective means for treating simple goiter, hyperthyroidism, and thyroid cyst. Anyone who meets the indications should be active in early surgery. However, there were recurrences after surgery, and the recurrence rate was 4-6%, mostly in patients under 40 years old. Treatment of diseases: thyroid adenoma simple goiter Indication 1. Hyperthyroidism (including primary and secondary hyperthyroidism). 2. Simple goiter, large mass, and symptoms of compression. 3. Multiple thyroid adenomas, giant thyroid adenomas or giant cysts. Contraindications 1. Age is small, the condition is mild, and the thyroid enlargement is not obvious. 2. Older age, combined with severe heart, liver, kidney and other diseases and difficult to tolerate surgery. 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. Use of sedative drugs: When there is insomnia or restlessness, rumin 0.1g or diazepam 5mg can be used, orally once a night. 3. Necessary preoperative examinations: such as cardiovascular function and liver and kidney function tests, basal metabolism measurement, laryngoscopy vocal cord function, x-ray examination of tracheal position and blood calcium, phosphorus determination. Surgical procedure 1. Position: supine position, raise the shoulders, make the head recline, to fully reveal the neck [Figure 1-1]; the sides of the head are fixed with small sandbags to prevent the head from moving around the head to move the incision. 2. Incision: 2 transverse fingers above the sternum, arc-shaped incision along the dermatoglyph, the two ends reach the outer edge of the sternocleidomastoid muscle; if the gland is larger, the incision can be extended upward and upward. The skin, subcutaneous tissue and platysma were cut open, and the upper and lower flaps were pulled with tissue forceps, and separated by loose knives between the loose tissues behind the platysma, up to the lower edge of the thyroid cartilage, and the sternal stem was cut. This gap has fewer blood vessels, and it is often easy to bleed when it is too deep or too shallow. The incision was protected with a sterile towel, the incision was pulled with a small hook, and the anterior cervical veins were sutured with a 4 gauge wire. 3. Cut off the anterior thyroid muscles and expose the thyroid: cut the fascia on the medial margin of the sternocleidomastoid muscles on both sides, separate the sternocleidomast muscle from the anterior cervical muscle group, and then cut the deep ribs longitudinally at the midline of the neck. Membrane, and then use the vascular clamp to separate the muscles, deep into the thyroid capsule. Extend the thyroid gland between the thyroid gland and the pseudo-envelope with the index finger and the shank, and gently detach the thyroid gland between the thyroid gland and the pseudo-envelope, and cut it across the vascular clamp to expand the thyroid gland. Note that the cross-section of the muscle should not be at the same level as the skin incision, avoiding the formation of scar adhesion after healing. 4. Treatment of the upper thyroid: usually first surgery is performed from the right lobe. In order to facilitate the treatment of the upper pole, the thyroid suspensory ligament is firstly separated and ligated on the inner side of the upper pole. The ligament has blood vessels. The separation should be careful and the ligation should be firm. Then, along the outer edge of the thyroid lobes, the upper pole is peeled by hand to fully reveal the upper pole of the right lobe. Pull the right lobe of the thyroid gland downward (or suture a needle at the right upper pole of the thyroid, then pull the upper thyroid gland downward), and then use a small hook to pull the upper end of the anterior thyroid muscles upward to expose the upper pole. . The operator holds the upper end of the left thumb, the middle finger, and the middle finger. The right hand-held right angle pliers are moved from the medial side along the thyroid gland to the outside of the venous body. The left index finger is pressed against the left finger and is outwardly passed out. The upper extremity is ligated about 0.5 to 1.0 cm away from the upper pole [Fig. 1-7]. The vascular tube was clamped between the ligature and the upper pole, and the blood vessel was cut between the vascular clamps, and the vascular stump was sewed together. Note that the vascular ligation and suture should be firm here, otherwise the blood vessels will be retracted, bleeding is more, and handling is difficult. The upper extremity should be treated as close as possible to the gland to prevent damage to the lateral branch of the superior laryngeal nerve. Continue to bluntly separate the posterior thyroid gland, when the blood vessel branches, can be ligated and cut. The thyroid gland is gently pulled inward, and the middle thyroid vein can be found in the middle of the outer edge of the gland. After separation, it is ligated and cut. 5. Treatment of the lower thyroid: the thyroid is pulled inward and upward, and the thyroid is separated from the outer edge of the thyroid. The lower end of the thyroid anterior muscle is pulled down with a small hook to expose the lower pole, in the lower pole, the lower thyroid vein. It is lighter, generally has 3 to 4 branches on each side, and it is more inward and lower. After being found, it is ligated and cut. In a few cases, there is the lower thyroid artery, and if so, it should be ligated and cut. The inferior thyroid artery generally does not need to be exposed or ligated to avoid damage to the recurrent nerve and cause thyroid ischemia and dysfunction. If ligation is required, intracapsular ligation should be used, without ligating the trunk, and only ligation of the branch of the inferior thyroid artery away from the recurrent laryngeal nerve and into the true capsule and gland. It is generally not necessary to routinely expose the recurrent laryngeal nerve. 6. Treatment of the isthmus: After completely dissociating the lower thyroid gland, pull the gland to the outside to reveal the thyroid isthmus. Use the vascular clamp to separate the isthmus from the front of the trachea at the lower edge of the isthmus, and pierce the tip of the pliers from above the isthmus [Figure 1- 13]. The vascular clamp was opened, the gap between the isthmus and the trachea was enlarged, and two thick wires were introduced, which were cut between the two ligatures after being ligated to the left and right of the isthmus. If the isthmus is wider, the two rows of vascular clamps can be used to clamp, cut, ligature or sew, and the cut isthmus continues to be separated to the front outer side of the trachea [Fig. 1-14]. At this point, the right thyroid has been largely separated. 7. Wedge-cut thyroid: The thyroid body is turned forward from the outer edge of the gland to reveal the posterior aspect of the gland, and the boundary of the resected gland is determined. The parathyroid gland must be preserved under the tangential line and the recurrent laryngeal nerve should be avoided. A small row of glandular vascular clamps are used to hold a small amount of glandular tissue along a predetermined cutting line on the outside. The thyroid is then wedged over the vascular clamp. The amount of gland removed is determined by the degree of patient poisoning. For patients with hyperthyroidism, about 90% of the glands should be removed. Generally, the residual glandular tissue on each side covers a parathyroid gland and a recurrent laryngeal nerve, which is enough to maintain its physiological function without recurrence. For patients with nodular goiter, it should be more appropriate (about 2 times the retention of the patient's retention). The capsule behind the gland should also be preserved as much as possible to prevent damage to the parathyroid glands and recurrent laryngeal nerves. In order to reduce the bleeding of the section, the surgeon or assistant can use the left hand to press the lower thyroid artery under the forceps with the left hand, or between the two rows of vascular clamps, to stop bleeding while cutting to reduce bleeding. The bleeding points on the residual surface of the gland should be ligated or sutured, and then the edges are sutured. When sewing, pay attention to the needle not too deep, so as not to sew the recurrent nerve. The resected thyroid fossa was blocked with hot saline gauze. After the right lobe is removed, the left lobe is removed by the same method. 8. Drainage and suture incision: After the bilateral thyroid residual surface was completely sutured and hemostasis, the wound was applied to the wound with hot saline gauze. At this time, the patient's shoulder pad is taken out to facilitate the patient's neck to relax, remove the hot saline gauze; check the bleeding point, see the entire wound without bleeding, in the left and right glandular fossa, respectively, the tube-shaped rubber sheet Or a thin drainage tube with a diameter of 3 to 5 mm, which is taken out from the inner edge of the sternocleidomastoid muscle and the incision and fixed. The incision is sutured layer by layer. 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.