Open Total Thyroidectomy for Graves’ Disease

1. Introduction

2. Pre-op Prep

1. A Note on Nerve Monitoring
2. Mark Incision While Patient is Awake and Can Move Neck to Better Find Crease
3. Position Patient Supine with Arms Tucked and Neck Extended
4. Pre-op Ultrasound to Confirm Incision over Isthmus and to Examine Thyroid
5. Prep and Drape Patient

3. Incision

4. Exposure of Thyroid Gland and Overlying Strap Muscles

1. Subplatysmal Flaps
2. Separate Strap Muscles
3. Expose Upper and Lower Borders of the Isthmus with the Trachea and Cricothyroid Muscle

5. Left Thyroid Dissection

1. Upper Pole Dissection and Blood Supply Ligation with Preservation of the External Branch of the Superior Laryngeal Nerve via Nerve Monitor
2. Rotate Thyroid Medially and Ligate Middle Thyroid Vein
3. Lower Pole Dissection with Preservation of Left Inferior Parathyroid Gland
4. Rotate Thyroid Medially into the Wound and Identify the Recurrent Laryngeal Nerve Within the Tracheoesophageal Groove
5. Carefully Separate Recurrent Laryngeal Nerve from Thyroid with Nerve Monitoring and Preservation of Left Superior Parathyroid Gland
6. Leave Small Thyroid Remnant Where Recurrent Laryngeal Nerve Inserts into Larynx, Which is Often Prudent in Setting of Inflammation to Prevent Nerve Traction Injury
7. Divide Attachments of Thyroid to Trachea to Complete Left Side

6. Summary of Left Side and Confirmation of Intact Recurrent Laryngeal Nerve and Viable Parathyroid Before Proceeding with Right Side

7. Right Thyroid Dissection

1. Separate Sternothyroid Muscle from Thyroid
2. Upper Pole Dissection and Blood Supply Ligation with Preservation of the External Branch of the Superior Laryngeal Nerve via Nerve Monitor
3. Rotate Thyroid Medially for Middle Thyroid Vein Ligation and for Lower Pole Dissection with Preservation of Right Inferior Parathyroid Gland
4. Rotate Thyroid Medially into the Wound and Identify the Recurrent Laryngeal Nerve Within the Tracheoesophageal Groove and the Right Superior Parathyroid Gland
5. Carefully Separate Recurrent Laryngeal Nerve from Thyroid with Nerve Monitoring and Preservation of Right Superior Parathyroid Gland
6. Leave Small Thyroid Remnant Where Recurrent Laryngeal Nerve Inserts into Larynx, Which is Often Prudent in Setting of Inflammation to Prevent Nerve Traction Injury
7. Divide Attachments of Thyroid to Trachea to Complete Total Thyroidectomy

8. Specimen Orientation for Pathology

9. Final Inspection, Irrigation, and Hemostasis with Valsalva from Anesthesia and Surgicel

10. Closure

1. Sternohyoid Muscle with 4-0 Vicryl Interrupted Sutures
2. Release Neck Extension and Close Platysma with 4-0 Vicryl Interrupted Sutures
3. Deep Dermal Layer to Take Tension off the Skin
4. Skin with Running, Knotless 5-0 Monocryl Subcuticular Suture and Steri-Strips

11. Post-op Remarks