Right Hemithyroidectomy

1. Positioning

1. Patient Positioning
1. The patient is placed supine with the arms tucked or wrapped with a sheet in a “burrito” fashion
2. All bony prominences should be padded
3. Thyroid bag is inflated to create appropriate neck extension
4. Patient is then placed in modified beach chair position
2. Ultrasound Examination
1. Identify landmarks
1. Trachea
2. Thyroid isthmus
3. Common carotid artery
4. Internal jugular vein
5. Thyroid cartilage
6. Cricoid cartilage
2. Assess thyroid lobe of interest for target nodule
3. Assess superior and inferior extent of thyroid poles
4. Assess lateral cervical lymph nodes
3. Draping
1. Prep surgical field widely
2. Drape patient such that a wide field is visible including inferior to sternal notch, superior to thyroid cartilage, and laterally beyond lateral border of sternocleidomastoid muscles bilaterally

2. Exposure

1. Make 5-cm Transverse Incision on Anterior Lower Neck
1. Identify sternal notch, cricoid cartilage
2. Place 5-cm incision in natural skin crease that will allow adequate exposure to both superior and inferior thyroid poles
3. Use scalpel to incise epidermis and dermis
4. Use electrocautery to incise subcutaneous fat and platysma
2. Elevate Subplatysmal Flaps Superiorly to the Top of Thyroid Cartilage and Inferiorly to Sternal Notch
1. Have assistant retract flap using skin hooks or small retractor
2. Maintain plane just posterior to platysma
3. Ensure appropriate retraction to prevent through-and-through injury into flap
3. Insert Self-retaining Retractor over Microfoam Tape and Incise Investing Layer of the Deep Cervical Fascia
1. Incise the fascia in the midline, using trachea as your guide
4. Retract Sternohyoid and Sternothyroid Muscles from Thyroid
1. Use blunt retractor to retract muscles laterally and fully expose thyroid lobe

3. Examination

1. Isolate/Retract Right Superior Pole Vessels Away from the Larynx
1. Preserve the external branch of the superior laryngeal nerve by creating a space medial to the vessels
2. Bluntly dissect lateral to the upper pole vessels to create a space
3. Retract upper pole caudal and place medium clips on stay side of superior pole vessels
4. Cauterize/energy device to divide caudal to clips
2. Check Right Vagus Nerve Signal
1. To ensure the circuit is intact and nerve monitor appropriately functioning
3. Divide and Ligate Middle and Lower Pole Veins
1. Continue lateral mobilization of thyroid lobe
2. Divide and ligate middle thyroid vein and lower pole vessels if seen
3. Rotate thyroid lobe medially and anteriorly

4. Preservation

1. Identify/Preserve Right Superior and Inferior Parathyroid Glands
   1. Identify both parathyroids and dissect them posteriorly, away from thyroid lobe, using blunt and electrocautery dissection
   2. Be cognizant of recurrent nerve and inferior thyroid artery location in relation to superior parathyroid
2. Develop Plane Beneath Thyroid, Identify Right Recurrent Laryngeal Nerve Using Nerve Monitor
   1. Continue to rotate thyroid medially and anteriorly
   2. Using blunt dissection, identify the recurrent nerve near the inferior thyroid artery and superior parathyroid
   3. Confirm location with nerve monitor
   4. Trace and expose the course of the nerve superiorly to cricothyroid insertion and inferiorly towards the thyroid lower pole
   5. Develop a plane posterior to the thyroid and anterior to the nerve, down to the trachea
   6. Ligate small terminal inferior thyroid artery branches with suture or clips
   7. Continue to dissect the nerve away posteriorly
   8. Release thyroid from trachea using appropriate techniques based on proximity to nerve
3. Divide the Ligament of Berry
   1. Once the nerve is safely out of harms way, Ligament of Berry can be divided
   2. Continue to release thyroid from trachea, retracting lobe anteriorly and medially; can use electrocautery or scalpel depending on proximity to nerve

5. Isthmusectomy

1. Once thyroid lobe released from trachea and only attached via isthmus, place sequential clamps on isthmus
2. Divide thyroid at isthmus to right of clamps
3. Tie clamps
4. Remove specimen, mark for pathology

6. Stabilization

1. Hemostasis of the Right Thyroid Bed
1. Assess resection bed for any bleeding
2. Cauterize areas of oozing as long as they are away from nerve
3. Place clips, stick tie, or simply hold pressure if oozing near nerve
4. Ensure previously placed clips and ties are secure
2. Positive Pressure Ventilation in Trendelenburg, Hemostasis
1. Assess for additional bleeding by placing patient in Trendelenburg and asking anesthesia to give patient Valsalva
2. Find any bleeding sources
3. Irrigate resection bed, consider hemostatic agent if indicated
3. Check Right Vagus Nerve and Recurrent Laryngeal Nerve Signals

7. Closure

1. 4-0 Vicryl to Reapproximate Sternohyoid and Sternothyroid
1. Interrupted Vicryl to cover trachea and reapproximate strap muscles to midline
2. Reapproximate Platysma and Fascial Layers
1. Interrupted Vicryl to reapproximate platysma
2. Consider interrupted Vicryl to reapproximate subcutaneous fat to minimize tension on skin
3. 5-0 Prolene Subcuticular to Close Skin
1. Place in knotless, running, subcuticular fashion
4. Apply Dermabond and Remove Prolene
1. Once Dermabond has dried, gently pull on one end of Prolene to remove in entirety