Open Total Thyroidectomy for Graves’ Disease

CHAPTER 1

Hi, my name's Antonia Stephen, and I am an endocrine surgeon at the Massachusetts General Hospital. I perform thyroid and parathyroid surgery exclusively. It's my area of expertise. Today, we'll be performing a total thyroidectomy on a patient for Graves' disease. The patient enters the operating room and is positioned supine on the operating room table after her general endotracheal anesthesia was induced. And we do, on the endotracheal tube, have a small sensor that is positioned right at the vocal cords so that the recurrent laryngeal nerves can be monitored during the procedure. After general endotracheal anesthesia is induced, her arms are tucked at her sides and her neck is gently hyperextended. We have previously marked a crease in the patient's neck in the pre-op area as an appropriate incision for maximal cosmesis of the scar. We then perform a neck ultrasound noting the position of the thyroid and any related pathology. In this particular patient, we note that her thyroid looks slightly enlarged and inflamed and has no nodules. We also verify that the incision that we've marked is as close to the thyroid isthmus as possible as that will give us the best exposure. After the patient is prepped and draped, we then make a small incision within the skin crease that was previously marked. This is carried down through the platysma muscle, and superior and inferior subplatysmal flaps are raised. Our landmarks include superiorly, the thyroid and cricoid cartilage, and inferiorly, the sternal notch and the top of the clavicles. This is step one of the procedure, which is exposing the thyroid gland and the overlying strap muscles. Once we have raised our subplatysmal flaps, we then divide the strap muscles in the midline of the neck. This includes the sternohyoid and sternothyroid muscles. The muscles are separated from one another and underneath them is the thyroid gland. We then proceed to our first side, which is the left side, and we remove the attachments of the sternothyroid gland away from the thyroid gland itself. This needs to be done carefully, with care not to enter the thyroid gland as it will cause bleeding during the procedure. Once we've separated the thyroid gland from the sternothyroid muscle, we then proceed to dissect the upper and lower borders of the isthmus over the trachea. So we expose the trachea just below the isthmus and also just above the isthmus as well. Once this is completed and we've exposed the cricothyroid muscles in the trachea, we now proceed to the left upper pole of the thyroid where we ligate the main vessels supplying the thyroid from the superior pole. When we do this, we are careful to isolate the medial and lateral edges of the upper pole. At the medial edge of the upper pole and slightly superior to this is usually the external branch of the superior laryngeal nerve that supplies the cricothyroid muscle, as seen here. It is a very tiny nerve, and as I said, is located just medial and superior to the upper pole of the thyroid. In using the nerve monitor, we're able to detect the location of this nerve by stimulating in this region and observing the muscle stimulation or twitch of the cricothyroid muscle which was previously exposed at the upper border of the isthmus. We then rotate the thyroid medially and we approach the lower pole. At the lower pole is where we identify and preserve the parathyroid gland. This is the inferior parathyroid gland. You don't always see this gland, but when you do, it's important that it is not resected or devascularized when performing the thyroidectomy. The thyroid gland is then rotated medially and up and into the wound. It is retracted in this way in order to reveal the tracheoesophageal groove, which is where we then dissect the recurrent laryngeal nerve. The recurrent laryngeal nerve, which is the nerve to the voice box, is then carefully dissected up to its insertion in the larynx and we carefully divide the thyroid attachments alongside the nerve with care not to injure the nerve. During this procedure, we stimulate the nerve to be sure that we have maintained an intact signal and that the nerve is still functioning properly during and after the thyroid dissection. When we reach the last portion where the nerve inserts into the larynx, we often, as is true in this case, need to leave a small amount of thyroid tissue in place where the nerve inserts into the larynx. This is where the nerve is most attached to the thyroid and it also is where the nerve is most vulnerable to injury. So in this case, as you can see, we have left a small remnant of thyroid which we then suture with figure-of-8 stitches so that it is hemostatic. After this, we're able to divide the attachments of the thyroid to the trachea and we proceed to the other side. Before proceeding to the right side, we always verify that we have an intact signal on the recurrent laryngeal nerve. If we do not have an intact signal on the recurrent laryngeal nerve on the first side that we have resected, we often reconsider proceeding with the contralateral side in the event there could be a bilateral recurrent laryngeal nerve palsy which would necessitate a tracheostomy. In this case, we did note an intact nerve signal on the recurrent laryngeal nerve on the left side, the first side, we also noted viability of at least one parathyroid gland. Proceeding to the right side, we first removed the sternothyroid muscle, as we did on the other side, from the surface of the thyroid gland. We proceed to the upper pole where we once again stimulate for the location of the external branch of the superior laryngeal nerve. We subsequently dissect free the lateral attachments, which often includes the middle vein, which we ligate using the Harmonic scalpel. We came alongside the lower pole, which includes preservation of the right inferior parathyroid gland. We rotate the thyroid up and into the neck, and then as we did on the other side, identify the location of the recurrent laryngeal nerve, identify the nerve visually, and carefully dissect it free from the thyroid as it ascends towards the larynx. Once again, we are leaving a small remnant of thyroid in place where the nerve inserts into the larynx, as shown here, and this is suture ligated with 2-0 silk stitches. The remaining attachments of the thyroid gland to the trachea are divided using the Bovie electrocautery and the specimen is removed, marked, and sent to pathology. We then irrigate and carefully check for hemostasis. We often have the anesthesiologist do a Valsalva maneuver to increase the venous pressure and reveal any bleeding. We then place Surgicel in the wound, in particular, over the thyroid remnants that we previously described, and we then close the wound. We use 4-0 Vicryl interrupted sutures to close the sternohyoid muscle. I do not close the sternothyroid muscle as it does not normally meet in the midline of the neck. We then remove the retractor from the incision and close the platysma with interrupted 4-0 Vicryl stitches. We place a deep dermal layer to take the tension off the skin and then place a running, knotless 5-0 Monocryl subcuticular suture and Steri-Strips.

CHAPTER 2

So, I just wanna explain the nerve monitoring that we do during the thyroidectomy procedure. The recurrent laryngeal nerves which innervate the vocal cords, the most important nerve in terms of voice function, sit right next to the thyroid, this is obviously a two-dimensional view, so the nerve is coming up underneath the thyroid and right here, this area here that we'll see during the surgery is where the recurrent laryngeal nerve inserts into the airway and then ascends to innervate the vocal cords which are inside the larynx. So when we are performing the thyroidectomy procedure, we are outside the airway, we're not inside the airway. So when we stimulate the nerve here using a nerve stimulator, we won't be able to see the muscle movement of the vocal cords because they're inside the airway, which is not where we are. So the endotracheal tube, which is here, is equipped with a small sensor and the sensor sits right next to the vocal cords so that during the procedure, we're able to stimulate the nerve and then detect, when you'll hear the beep from the nerve stimulator, that there is electrical stimulation of the vocal cord when we do that. If the nerve were to lose function during the surgery, and that can happen for a number of reasons that we can talk about later, we would not get that beep or that signal from the vocal cord as detected by the sensor on the ET tube. So it's actually very important to mark the neck incision when the patient is awake, able to move her neck, and before there are drapes covering the rest of her body. And the reason for that is the most important factor in the cosmesis of this neck incision, which will be visible to the patient, is that it's marked in a natural skin crease. And the only way you can see those skin creases is by marking the patient when she can move her neck and before the rest of her is covered up for symmetry. So as you can see here, she's already been marked in the pre-op area while she was awake and able to move. All right, insufflation. So now we're gonna extend the patient's neck. And as you can see, as we extend the neck, the creases disappear. So that's why it's important to mark the patient prior to neck extension 'cause you will not be able to detect an adequate crease after you've positioned the patient for the surgery. Do you see how the creases are disappearing there? Okay, there we go. So now she has a nice smooth neck. So picking out a crease at this point would be much more difficult than when she can unextend her neck or tip her chin down. We wanna make sure she's not hyperextended. And then if we can drop the table, put the back up. So I always do an ultrasound after we've positioned the patient - and backup just a tad more, please, Daniel. And we position the patient with her arms tucked by her side, neck extended, and back elevated. Okay. All right, so on the ultrasound, here's the thyroid gland here, the carotid artery here, the windpipe with the cartilaginous rings are here. This is the isthmus of the thyroid, and one of the reasons to do the ultrasound is that the incision is best positioned right over the isthmus of the thyroid in order to gain ideal access to visualization of the recurrent laryngeal nerves. So you can see here, here's the isthmus of the thyroid, which is the bridge that connects the two lobes and it's right on where I marked the incision. So that's what I'm looking over here. And so she has thyroid tissue on either side. The thyroid tissue is clearly not normal. One of the reasons why we're doing the procedure. She does not have a large goiter. She has a slightly enlarged thyroid that looks quite inflamed and heterogeneous. The carotid artery is here and the jugular vein is just lateral to that. This is the sternocleidomastoid muscle, and once again, the trachea in the midline. So this is a ChloraPrep, an alcohol-based prep solution. I make sure not to use the colored one, a lot of them are red, because the patient will have this on their neck and it will be visible. And as you can see here, we have the electrodes for the nerve monitoring system plugged in with a sticker ground and a needle ground that we placed in the patient right after she went to sleep. So in terms of draping, there's many different ways you can drape for a thyroid and really the only important principle is to create a sterile field. And I also like to have it somewhat wide on the neck so that once again you can see those landmarks if you need to, especially when marking the incision. Thanks, Kat. Once again, right now is not the ideal time to select your incision because you will not be able to see the patient's landmarks once they're draped, and you also, because you've extended the neck, will not be able to recreate the skin creases, which are so important in terms of designing a cosmetically appealing incision. So as you can see, she's already marked. Okay, so the first thing we do is start with a timeout.

CHAPTER 3

So as we talked about, we've already marked her, the incision is always located in between the thyroid and cricoid cartilages, which are above it, and the sternal notch, which is below it 'cause that's where the thyroid's gonna be. Ruler. Ruler. That's okay, I got you. You know what I meant. So I usually make the incision somewhere between three and five centimeters. So we're gonna do about four for her. And make sure our lights are in the right position. It's very important that the lights are coming in directly from above the patient and directly from below. If they're positioned to the side, then your head gets in the way of the light while you're operating. Okay, are we okay to start? Guys up there? Yes. Okay, incision. Incision. The incision just goes right through the dermis, just into the subcutaneous fat.

CHAPTER 4

And then, Bovie, and I do his, remember? No, no Adsons. Fine Kelly. And we hold sort of pressure to stop the bleeding. The neck is very vascular so I use the coag for the Bovie to get through the subcutaneous fat and often a little bit of dermis as well. And to be very careful not to pass point through this to get to what's called the anterior jugular veins, which live just under the platysma. So now we're going through the platysma muscle. That's right through there, Rich. Good. And you can see the fibers, yep, of the platysma muscle right there. Rich is dividing the fibers of the platysma muscle, and as you can see, the neck is very vascular. Give me a buzz. Yeah, right here. That's what I was wondering too. So Rich is being really careful he's not passing point. We're gonna get the dermis right there just to get the full incision. And as you can see here, there are some anterior jugular veins, here and here. Matthew, do you see this? Short DeBakeys, please. Now we are going to obtain a little hemostasis at the skin edge. Get right there, and we're gonna raise what's called subplatysmal flaps. Once again, so be super careful here, Rich, 'cause of the AJ there. This is the time when it's easiest to get into an anterior jugular vein. So, you wanna stay superficial, and as Rich is doing, you wanna hold the Bovie so it's almost parallel to the skin. Yes, there you go, as he just adjusted. This is the superior subplatysmal flap. A little bit of platysma here. Way up there, Rich, or way up here. Yep, there you go. Just through that to the corner. And the superior aspect of this, you should be able to palpate the thyroid and cricoid cartilages. Now we're gonna do our lower flap. So this is the inferior subplatysmal flap. Once again, avoiding the anterior jugular veins and coming right underneath the platysma. So that right under there, Rich. A little higher here. Right under that. Yeah, there you go. It always feels like you're going too superficial on the lower flap, you're not. As long as you don't buttonhole the skin, you wanna stay reasonably superficial. And right through to the corner here. Through the platysma there. And these flaps allow you to gain access to the thyroid gland. So when you feel down here, you're really feeling for the sternal notch and the top of the clavicular heads. Take the small Weitlaner, please, Kat. So through a relatively small incision with these flaps up and down, superior and inferior. Okay, so now what we're gonna do is divide the strap muscles in the midline as Rich was indicating right between the anterior jugular vein. Suction, please. Slightly more towards me there, Rich. Just 'cause I'm worried about that big one right there. See it's right... Okay. Sometimes the anterior jugular veins are very close to the midline and then it's very challenging to stay out of them. But Rich is doing a good job. Hold this right here. There's one right here. So I would say stay right - that's one too. It's right here, so right back there probably. Let go for one second, Rich. They're very close together. Yeah, they are. So there's the muscle. So we're looking for the strap muscle underneath the veins. But if you pick up right here, so that might get you sort of underneath the... A little more towards me. Good. So there's your muscle, right? So the first muscle we see is one of the midline strap muscles. Let's get the Harmonic for this. The sternohyoid muscle is the first one. So this is the Harmonic scalpel. It's an energy device that divides tissues and seals vessels. Because the AJs, the anterior jugular veins are so close, I want Rich to use this instead of the Bovie 'cause it's less likely to bleed. So right now, he's dividing the, slow, the sternohyoid muscle in the midline. You can do this using the Bovie, the only thing is, is that if there is a little vessel there that you catch, it bleeds a lot more with the Bovie than with the Harmonic. The Harmonic generates heat with ultrasound. So this metal blade here is actually ultrasounding to generate the heat that seals the vessel and divides the tissue. Okay, put this right here. There are a few different energy devices that people use during thyroidectomies, one is the Harmonic scalpel, another one is the LigaSure device. Great. All right, so I'll go up. Hold this here. So he's holding the left sternohyoid muscle, I'm holding the right sternohyoid muscle, and we're going up in the midline, dividing these muscles. We're separating them, we're not actually dividing the muscle, we're separating them. Baby abdominal, please, retractor. Hold that right there, please, Rich, for one second while we go up just a little higher. And it might seem like we're getting a little more room than we need, but it's always good to get a little extra exposure when you're doing these procedures. Okay, and I wanna make sure I can feel the cricoid and thyroid cartilages there before I stop going. That's good, Rich. Thank you. All right. So is there a side we need to do first? On Graves', it doesn't really matter. Yep, exactly. Okay, so we'll do your side, hold this. So he's holding the sternohyoid muscle, and underneath the sternohyoid muscle is the other midline strap which is called the sternothyroid muscle, which is right here. So, sternohyoid, sternothyroid. And right now, Rich is separating those two muscles from each other. Good. Okay, and now we're gonna take this one. Remember, Rich, right - backup your forceps a tad. Good. And then just a little bit at a time right underneath. And underneath the sternothyroid muscle is the thyroid gland. So back up your forceps a bit 'cause you don't wanna grab the thyroid. There you go. So way up there. Good. Nice. Perfect. Staying way up here. So we're now separating the sternothyroid muscle from the surface of the thyroid gland. And we're using the Bovie for this. Give me a buzz. Now, she has Graves' disease, which is an inflammatory condition of the thyroid gland. So we might see some evidence of that inflammation as we separate the muscle away from it and as we perform the procedure. Just a tad there, Rich. Thank you. So we're gonna do a total thyroidectomy. We just separated the muscle off the first side, which is the left side. I'm gonna choose not to separate the muscle off the right side until I've finished the left thyroidectomy. The reason for that is if there is a problem with the recurrent laryngeal nerve on the left side, I may choose not to perform the right thyroidectomy today. We can talk a little bit more about that later. Baby abdominal, please. Can you tilt the table slightly towards me, please, Daniel. Hold that right there. There we go. Hold that. So the first thing that I like to do... Can I have a second forceps, please, Kat. Is I like to separate the upper and lower borders of the isthmus over the trachea. So I'm exposing the trachea just below and above the isthmus. A little buzz there, and you're gonna need to come around that vessel probably. A right angle, please. Yeah, right angle to Rich, please. So we're just right at the base of the isthmus, we'll draw you a little picture of this. Good. Come a little deeper, right on the trachea. There you go. Excellent. And then we're gonna seal this lower isthmic vessel using the Harmonic scalpel. Let me put a small clip on that. Can I have a small clip, please, Kat. Matt, you can come step in a little closer. It's probably gonna be more comfortable for your arm. Okay, great. And then let's get the Bovie back. Second forceps, please. A little tap right there, please, Rich. Great. So here is the trachea. Give me a buzz. Great. And we can see evidence, give me a nice long buzz there as well, evidence of the thyroid inflammation as the thyroid is slightly adherent to the trachea. And if you guys can get a little view of the white trachea. So put your finger right on the trachea there, Rich. Just be careful not to buzz into the... Yeah, it's white. Yeah, I saw that. There's the trachea at the lower border of the isthmus. We're gonna adjust this just a tad. Hold that right there. So now we're at the upper border of the isthmus. Little vessel there. Little buzz. Yeah, little vessel pyramidal lobe combo. So here's the trachea at the upper border of the isthmus of the thyroid. And there's a triangular muscle here, that's the cricothyroid muscle. The cricothyroid muscle contributes to voice function. It's not as important as the vocal cord, right angle to Rich, but it fine-tunes the voice and it is innervated not by the recurrent laryngeal nerve but by the external branch of the superior laryngeal nerve, which we will identify using the nerve monitor, shortly. Go a little deeper, Rich. I think you're gonna be happier a little deeper. Yeah, there we go. Just like we did at the bottom of the isthmus, the top of the isthmus has a little vessel here as well. It often does. Let go of that for a second there, Rich, just so we have some slack on it. Thank you. And once again, we're sealing it using the Harmonic scalpel. Good. Second forceps, please, Kat. A little buzz here, please, Rich. Once again, seeing evidence of inflammation consistent with the Graves' disease. Right here, Rich, I think, yeah. Little buzz. Okay, so if you come in here, this is the upper border of the isthmus. So the isthmus of the thyroid is right here. And right up here on either side are the triangular-shaped cricothyroid muscles that sit right on top of the trachea and have the function of fine-tuning the voice in terms of pitch and voice projection. Give me a little buzz here, Rich. Excellent. Okay, take that out. Marking pen, please. All right, so just to draw a quick picture of what we've done so far. Here's the trachea, here's the thyroid gland. We took the muscle off the thyroid on the left side. We then separated here, this is the isthmus, the lower border of the isthmus and the upper border of the isthmus have been exposed. Up here, are the triangular-shaped cricothyroid muscles. And the next thing we're gonna do is go to the upper pole on the left and stimulate the external branch of the superior laryngeal nerve, which sits just medial to the upper pole of the thyroid gland. Baby abdominal, please. Great. You can grab and buzz it or we can. It's a little higher here, try this. Good, Rich.

CHAPTER 5

Okay, so we're gonna give that to you, Matthew. So we're now approaching the upper pole of the thyroid. Once again, lots of evidence of thyroid inflammation here. Here's the sternothyroid muscle. Hold that right there, Rich. You got a little vessel in the thyroid right there so stay way up near your forceps. Remember, we don't really mind getting into that muscle. We do mind getting into the thyroid. Great. So even if you end up dividing a bit of that muscle to expose... So we're just talking about the fact that you can actually divide a little bit of the sternothyroid muscle in order to expose the upper pole. Okay, and there's this... All right, so now, up here under the retractor is what we call the upper pole of the thyroid. And I am going to define the medial and lateral borders of that, which are on our drawing, lateral border here, medial border here. So it's the medial border where the external branch of the superior laryngeal nerve is usually located. Can I have the nerve monitor on, please. I placed a Kelly on the upper pole, and it's really important to keep this Kelly low enough so you don't pull on the superior laryngeal nerve. What's the setting up? It's at 2. So now we're gonna watch for the twitch of the cricothyroid muscle here. There it goes. So nevermind the beep right now, the twitch of the cricothyroid muscle is me stimulating the external branch of the superior laryngeal nerve just medial to the upper pole of the thyroid. Right angle to Rich, please. Doing great there, Matthew. Thank you. Forceps. So I'm gonna move that out of the way. This vessel right here? Yeah, the whole, sort of the whole thing there, I think. Yep. Good. Even if you go through a little. There we go. Perfect. Medium clip, please. So I like to secure the upper pole with clips or ties. Slide it down. Close this side up, thank you, Rich, because it definitely can bleed. Another one, please. So we are now clipping the vessels in the upper pole of the thyroid. I double ligate it so I put at least one tie and one clip or two clips. 15, please. And once again, the external branch of the superior laryngeal nerve is sitting just medial and above where we're dividing this. Spread, please, Rich. Great. Since we have that clamped with the... Good. So that was the upper pole vessels. Okay, right angle to Rich, please. See right there, Rich. So stay kind of close-ish to the clips there, but you see what you wanna take next, right? Yeah, it's gonna be just... Perfect. Once again, you've got some inflammation so you may need to pop through that indurated tissue. Yeah, there we go. Come out for one... Yeah, I guess it's okay. And then because these vessels are much smaller than the ones we just took, we don't need the clips or ties, we're just gonna use the Harmonic. One of the most important things about the Harmonic is that the strength of the seal of the vessel is directly proportional to how long the Harmonic is in contact with that tissue. So when you put the Harmonic on the tissue, you don't wanna pull up through it or rush through it, you want it to sort of melt away. Okay, we're gonna rotate around this way. May I have a step stool, please? Forceps. Okay. Yeah, I would say get your right angle there, Rich, 'cause sometimes the... So we're now rotating the thyroid medially, and this is where we often see a more superficial vessel that runs just lateral. It's called the middle thyroid vein. And I believe Dr. Guyer has that under his right angle and we're gonna be dividing it with the Harmonic right now. So this is the middle thyroid vein, often very close to the sternothyroid muscle extending laterally from the thyroid. Great. Peanut. Now, as we move down to the lower pole of the thyroid, we're gonna start thinking about the lower parathyroid gland. You can grab that and I'll clip it. Small clip, please. It's pretty small... Yeah. And now the Harmonic, this is probably a branch of the middle vein that we're dividing. Once again, I'm making sure the vessel is not under any tension when I divide it with the Harmonic or it won't seal as well. Okay, so Matthew, you're gonna reach down here. So this is where we start thinking about the inferior... Do you wanna go come below him? The inferior parathyroid gland. Sometimes we see the parathyroid gland, sometimes we don't. We prefer to see at least one that looks viable. That may be it right in there. Could be. So right now, we're looking for the, we have the trachea here, we're looking for the lower parathyroid gland right at the lower pole of the thyroid. At this point, the recurrent laryngeal nerve should be deeper and more lateral and then tucking under the TE groove, the tracheoesophageal groove. So I'm gonna have you stay right up on the thyroid here, Rich, start with this. Start with this. Come out. Good. 2-0 tie, please. Thank you. So now if you look back at our picture while Rich ties that, we took down the upper pole here, we were careful to preserve the external branch of the superior laryngeal nerve, which was just medial and above the upper pole. We then came alongside, marking pen, please, the lateral portion of the thyroid and we divided the middle vein, right here. And we're now working down here at the lower pole with the parathyroid gland likely sitting somewhere in this region. Harmonic. You can maybe close and move out there, Rich. Thank you. Metz, please. Metz to Rich. Hold on one second. Clip, please. Medium? I put the Harmonic kind of, small, close to your tie, Rich, so I just wanna make sure it doesn't... Slide. Yeah, come off later so we'll reinforce that. Good. Okay. Forceps, please. So one of the reasons I like to expose the upper and lower borders of the isthmus early on in the surgery, which we did a little while ago, is that when you come back down to the lower pole to identify and preserve the parathyroid gland, you've already exposed your trachea and that can be very helpful in terms of the anatomy of the parathyroid gland and the recurrent laryngeal nerve, which we have not drawn in yet. Peanut, please. So we're now pulling the thyroid up and medial, and let's see if we can get a signal and Rich is gonna take the right angle. Okay, so now we are stimulating the recurrent laryngeal nerve within the tracheoesophageal groove. Marking pen, please. This is the recurrent laryngeal nerve. It's deep to the middle vein. Forceps, please. Hold on one second, Rich, let's get that little blue thing out. I would stay way, yeah, see like right here. Perfect. 2-0 tie, please. Thank you. And then just move that like right here. So... One of the things that can happen with Graves' disease because it's an inflammatory condition, is sometimes the parathyroids can get pulled up closer to the thyroid than normal and then it can be more challenging to preserve them. We wanna preserve the parathyroid glands and their blood supply. And so we always look adjacent to the thyroid gland to see if we see a parathyroid gland. And I think I might see one that we need to preserve. Can I have a medium clip, please, Kat. Yeah, exactly. So we'll peel that down. So you think it kind of sucked into the inflammation there? Okay, maybe close, and move out, Rich. Great. Knife, please. And then Metz, please, to Rich. Knife back. Thank you. Forceps. Can we turn the Bovie down to 15? So on the thyroid here is a little bit of what looks like fat. I can't say for sure it's a parathyroid but I'm definitely gonna peel it down and check it out. Ooh, yeah, definitely is a parathyroid. So if you look in here, classic Graves' disease. The Graves' disease has pulled this parathyroid gland up and into under its capsule of inflammation. So we're gonna peel this thing down. And as you see, I've turned the Bovie down to a very low setting because we're getting closer and closer to the recurrent laryngeal nerve. The parathyroid gland, as you can see, it looks a little bit like fat but it's just a little bit darker or browner than fat. And that's how we identified it as a parathyroid. Do you see that there, Matthew? Yep. I see it right there. So we're pulling the thyroid up towards me. And then we are detaching the parathyroid from the thyroid gland so that we can leave it behind when we remove the thyroid. Good. So we'll put that there and then leave it like on the blood supply here. Right there. Right angle to Rich, please. Right there. Nerve monitor, please. So now that we're getting closer to the recurrent laryngeal nerve, I start to test things to make sure that we haven't inadvertently pulled it up. Tie, please, 2-0, for Rich. We are now working still at the lower pole of the thyroid, coming around more laterally, and very soon, we'll be able to approach the recurrent laryngeal nerve. So the clip, as you probably have recognized, is not gonna stay in the patient. It's just stopping the back bleeding from the thyroid while we complete the procedure. The tie will stay in. Knife, please. And Metz up to Rich. Knife is back. All right, thank you. Okay. I'm gonna adjust to you, Matthew. You don't have to pull very hard. So there's our parathyroid, which has moved outside the thyroid, which we're very pleased with 'cause that means as we start the nerve dissection, we will not be removing the parathyroid. All right, so let's just see where we are here. I would say probably a right angle here. Can I have the nerve monitor, please? See if we can get our signal out here. Good. So you can pick that up. Go right on the trachea there, Rich. Perfect. 2-0 tie, please. So you can see the parathyroid has a browner color, typical yellow fat color. And every single one of these tiny vessels that Dr. Guyer's tying right now or securing could bleed later and cause what's called the neck hematoma. So it's really important that he tie these very carefully, which he's doing. Thank you, Rich. That's perfect. Scissors, please. Knife is back. So now we've actually pretty much uncovered most of the trachea here. So, Rich, you can buzz this, give me a buzz. So we're right on top of the trachea. Once you come off the trachea to the side, beware of the recurrent laryngeal nerve because that's where the tracheoesophageal groove starts and that's when you have to start to really pay attention. So when you're no longer on top of the trachea but you're lateral to the trachea, you have to be careful of the recurrent laryngeal nerve. Perfect. Nice. I will probably wouldn't buzz that 'cause we don't know how close the nerve is. This, we may be able to take. Nerve monitor, please. Yep. Right angle to Rich. 2-0 tie, please. Once again, an attachment that is medial to the nerve. The parathyroid still looks viable. So it's very important to check. So I'm checking it out and it looks viable. It looks nice, like a nice color as opposed to a black color, which could mean that it's ischemic and will not survive the operation. And close and move that way. Good. Knife, please. That's a decent-sized vessel there, Rich. Can we get a new blade on that, Kat? I have a new one... Great. Thank you so much. Yeah, let's put a medium clip, please. And Matthew, can you pull just a bit? Thank you. So we're double ligating this vessel because it's a more substantial looking vessel. Okay, Matthew, you're gonna go above Rich. Just be careful of the Bovie there. Hold that right there. Right angle to Rich. Let's clean up the isthmus a bit so we can rotate the thyroid over to find the nerve. That looks like it could even be a little bit of a pyramidal lobe, right? Going upside the back here I think. Yeah, there's a little muscle there too so we'll just come right through it there. Thanks, Kat. Once again, important to take your time with the Harmonic so it can make a nice seal on the vessel. Okay, so this is actually, I talk about this a lot with the residents and students. This is a sort of a critical part right here where we've taken, marking pen, please, we've taken the attachments at the upper pole, which we did earlier, and we've just cleared off the lower pole, just medial to where the recurrent laryngeal nerve is. We've flipped the thyroid up, that's what I'm doing by holding the thyroid over here, and we're now gonna start the dissection of the recurrent laryngeal nerve. So we're down to this portion, which is where the nerve comes up to insert to the larynx. Nerve monitor, please. So you can come across this little bit right here, Rich. Right on the trachea. Good. 2-0 tie. Yeah, I just got a little tiny little vessel in there. The other structure that we'll be very carefully looking for as we dissect the recurrent laryngeal nerve where it inserts, is number one, the superior parathyroid gland, and number two, the inferior thyroid artery. Take the nerve monitor, please. Thank you. Right angle to him, and medium clip to me. Knife, please. Thank you. Scissors, please. Can I get another blue clip house, please? Thank you. Okay, fine Kelly, please. So one of the most, I think, important parts of thyroid surgery is knowing what you can safely divide at the upper and lower poles without interfering with the recurrent laryngeal nerve 'cause that's gonna give you maximal exposure to the nerve. And we have the Bovie, once again, at a very low setting, it's at 15, as we divide some more superficial attachments. Nerve monitor to Rich, please. Yeah, I see it right there. Right there. Yep. So peanut, please. So we have now uncovered the recurrent laryngeal nerve. It is a white structure that runs up, and it runs up right underneath, forceps, this what we call the peduncle of the thyroid gland. That's where you'll always find the nerve coming in. So, fine Kelly, please, to Rich. So, Rich, very gently, you can see where you wanna... Nope. You're gonna go this way. Oh I see. Yeah. See what I mean? Right, create a space, don't dig down into the nerve with your tips. So, yes, keep your tips up. Very nice, very nice. I'll take the right angle. Now you're gonna come out for a sec and we're gonna take this with the right angle and then you're gonna get a tie. 2-0 tie, please. It'll take a little bit at a time, Rich, so we can dissect the nerve a little bit more. So, right now, we're right on top of the nerve and what Dr. Guyer just did with the fine Kelly is he freed the tissue above the nerve from the nerve so that we could then safely divide it. So let's make sure the nerve is down there, and I can see it underneath his tie. Yep. So Rich, when you put the right angle in this, I would come from below to above, okay? So you don't hook the nerve. And he's gonna take the right angle, please. Once again, the clip is not gonna stay in, it's just for the back bleeding so we can continue to visualize the nerve. Knife, please. Okay, scissor, I'll do the scissors from here, Rich, just so you can... Now, I am spotting something interesting here, forceps, which is just lateral to the nerve, under here is a brown, a hint of brown tissue, which is almost certainly the parathyroid gland. It's starting to poke out. Superior parathyroid gland. So my question now is, is the nerve inserting under this, what is this whitish thing right here? That's the para. Yeah, I think this... That's the fat of the para. They're going this way. So this is the superior parathyroid gland just lateral to the nerve. Can I have a fine Kelly, please? Right angle to Dr. Guyer. And Matthew, please slide your retractor up towards the head a tad. Okay, you're gonna take that bite right there. You got it. Very nice. Forceps. What was critical about what Dr. Guyer just did - 2-0 tie - is that he left the nerve down while he took the tissue above the nerve, and he was very careful not to pull the nerve up into this bite. This last bite here is right above where the nerve is inserting into the larynx. That is where the nerve is most vulnerable to injury. Tilt this up a little towards me there so you don't interfere with the blood supply of the parathyroid gland, Rich. Oh, bring up towards you? Like this way, not that way. Does that make sense? Yep. Pull out towards you. Yep, right there. I'm just pulling the clip out of your way. Good. Perfect. Nerve monitor. And as we take these attachments near the nerve, I do frequently check the signal on the nerve, which is intact. Right angle. Here, Rich, I'll come under this one, if you don't mind. Just from here, and knife to Dr. Guyer. We won't clip that. See if you can avoid that clip there. Perfect. Nice. No back bleeding. Not too much. Not too much 'cause I'm holding it. So there is the superior parathyroid gland right under Dr. Guyer's tie, going out and away from our thyroid dissection. 2-0 tie, please, for Dr. Guyer. And we are now directly on top of the nerve. Just do two throws on this. You know what, take that out and do a 3-0. 3-0 tie, please. And just lock it on the second. Got it. Peanut, please. And right now, I'm actually just kind of checking the nerve there to make sure that we haven't interfered with it. He's gonna take a right angle after that. Knife, please. Good, Rich. Thank you. Metz. Forceps. So this is a very nice view right here. This is the superior parathyroid gland just lateral to where the nerve inserts into the larynx. This is the recurrent laryngeal nerve running up and underneath the peduncle of the thyroid. So the rest of our job on this side at this point is just to separate this last portion of the nerve away from the thyroid gland. So, right angle to Rich, please. I would start with this little piece here. There's a little clip there. Small clip, please. So I stop using the Harmonic when we get very close to the nerve and I stop using the Bovie because I don't wanna create a thermal injury. Knife, please. So once we're very close to the nerve, as we are here, we start using clips and ties. Knife is back, Kat. Got it. Thank you. Can I have a fine Kelly? Let me just look at it and then you're gonna take that bite that you were wanting to take... Exactly. You're like, oh I got this. Scissors, please, to Dr. Guyer. So just do a little snip. This is a little avascular capsule of the thyroid that's right on top of the nerve. Good. So now we're actually seeing where the nerve inserts into the larynx. Right angle to Dr. Guyer. Make sure that nerve is staying down. Forceps to me. So we use 2-0 and 3-0 silk ties, mostly 2-0. When it's a very sort of fine bit of tissue, we use a 3-0. So as you probably are able to see here through the camera is that Dr. Guyer is tying the tissue right on top, peanut, of where the nerve inserts into the larynx here. Once again, where it is most vulnerable to injury. But we can see that he has not interfered with it. Scissor. Peanut. There's the nerve insertion point, right there. So this is our last little piece here. So we just now within the setting of inflammation have to decide how we can safely separate the thyroid gland from the nerve. Knife, please, to Dr. Guyer. So just knife a little bit of this capsule here to drop the nerve. Good. Push that down. Small clip, please. Back down. You'd be surprised, right? And the knife, even the tiniest vessels in the neck and the thyroid will bleed. So we put a clip on something that Dr. Guyer probably thought was nothing but I thought was maybe a little vessel, right? Okay, so here is the trickiest part of the entire thing, especially in Graves' disease, it's right where the nerve is attached here, okay? Nerve monitor. And the nerve is working beautifully. So how can we best separate here? Forceps. There's a few different ways you can do it. It sort of depends on patient to patient. Can I have a right angle, please? So one option we can try is to try to come right through the thyroid tissue as it runs along the nerve, if that comes easily. There we go. 2-0 tie. And now we're actually tying right through the thyroid tissue. So we're gonna leave a little bit of thyroid tissue right on the nerve. So you're gonna slide that down there. Perfect. So Dr. Guyer is tying these ties right alongside the nerve. You look like you're crossed. Yeah, there you go. Another one. Another uncross. Yeah. Right angle to Rich. Was that three? That was three, yes. Knife, please. So hold on, you're gonna have to come up here and you're gonna have to go down. From up here, a little bit more medial. Sorry. Right here. That far? There we go. Yes. And then go down to the trachea. There, see? Nice job. Good. Perfect. Knife is back. Scissors to Rich. Right angle. Stitch, please, 2-0 silk. So now what we're doing is we're gonna put a little figure-of-8 stitch through the thyroid tissue right near the nerve so we can safely ligate it without interfering with the nerve. This is the most difficult part of the thyroidectomy procedure is removal of the thyroid where the nerve inserts into the larynx, and this is where it needs to be decided how much of a thyroid remnant you wanna leave in order to preserve the nerve function. We're locking. We're locking. Oh, there we go. Yep. Perfect. Just make sure not to pull too hard on that. So remember, separate it this way first. Yep. Good. Peanut, please. Scissors. So Dr. Guyer has just ligated a little bit of thyroid tissue that we're leaving adjacent to the nerve. Can I have the knife, please? Thank you. This is a very nice hemostatic stitch that will not traumatize or create thermal injury to the nerve, at the point where it's most vulnerable. So we're going all the way down to the trachea here. Perfect. Stitch, please. Knife Back. Exactly. Rich, you're so smart. We did this last week. Yeah, you're like, I've kind of done this before like 50 times with you. Just wanna make sure we're not going into the cricothyroid muscle. See, there we go. It's a little superficial. Very important that these knots go down tight on this stitch so that this tissue doesn't bleed later. Is that three? Yep. Needle. Knife, please. Thank you. Right down to the trachea there. All right, peanut, please. Bovie, please, to Rich. Forceps to me. Give me a tiny little buzz right here. Good. And then he's now taking the attachments of the thyroid to the trachea here in the midline. So we've completed essentially the left thyroidectomy at this point. It's from the thyroid. Good. We'll divide this so we don't have, right there. So these are the attachments of the thyroid to the trachea right over the midline of the trachea. You have to be careful when you do this not to go too far to the other side 'cause you can actually pull up, give me a buzz, and injure the right-sided nerve if you did that. We're securing a few little bleeders from the trachea.

CHAPTER 6

Okay, so now let's just take a look at what we've done here on the left. Hold that over right there. What we wanna know before we proceed to the other side is do we have a working nerve and do we have viable parathyroid tissue. Forceps. So if you look in here, here's the nerve, nerve monitor to Rich, the recurrent laryngeal nerve which stimulates well, test it way down here past the point where we dissected it and it's working fine. So we're happy with that. We have a viable superior parathyroid gland here, this brown tissue, and we also have a viable inferior parathyroid gland right here. As you can see, the parathyroid glands usually straddle the nerve. They sit on either side. The inferior one sits more superficial and medial to the nerve and the superior one sits behind and deeper to the nerve, right there. We've left a small remnant of thyroid tissue, which is very typical in Graves disease due to the inflammatory characteristics and the adherence to the nerve. So we're very pleased with how this side went, which means we'll proceed to the other side. Give me a little buzz right here, too, Rich. Just obtaining a little hemostasis. Great. One more check on the nerve, please. Great. Okay, let's just leave this whole, I think. We'll have Matt mark it at the end. Just wanna make sure it's not back bleeding too much. Okay. All right. We're now gonna proceed to the right side. So if you wanna swap that, please. Matthew, you're gonna come over here. Just watch the stand here. Thanks, Rich. And you're gonna come above me. Forceps, please.

CHAPTER 7

So we're now back to taking the sternothyroid muscle off the thyroid. Give me a little buzz there. Good. Right there. Hang on one second, Rich. Let me help you. There we go. All right, so we're now taking the sternothyroid muscle off the thyroid and heading towards the right upper pole. Stay very superficial here, Rich. Good. And then you're gonna hold the thyroid gland over towards you. Perfect. See these little vessels here? Those are like crossing ones that you need to secure, otherwise they'll bleed. You're gonna hold it right here, Rich. Good, Matthew. And then maybe here, Rich, just come a little bit, get your Harmonic actually and divide just a little bit of the sternothyroid muscle so we can access the upper pole of the thyroid. About like this? Right there. So, what Dr. Guyer is doing now is he's dividing just a little bit of the sternothyroid muscle where it inserts into the thyroid cartilage because it's right there that that muscle hoods over the upper pole. So in order to gain access and visualization of the upper pole, we sometimes, not always, sometimes divide a little bit of the sternothyroid muscle right at that insertion point. Give me a little buzz. It also can help you identify the twitch of the external branch of the superior laryngeal nerve as we did on the other side. So right way out in the muscle there, Rich, 'cause there's a little bleeder there. Yep. Good. And once again, we're heading towards the upper pole on the right side. Okay, so we see the upper pole, we need to delineate the medial and lateral aspects of the upper pole so that we can take the vessels there and also identify the superior laryngeal nerve. Stay very lateral there, Rich, in the muscle. Good. And I'll take that Kelly, please, Kat. Right angle, please. Hold on one second. Let's get a little more muscle off here, Rich. And then we're gonna do the nerve and then we'll stay out here on the muscle. Buzz me. Okay, so here we have the upper pole of the thyroid. Nerve monitor, please. So here's the right cricothyroid muscle here. Here's the upper pole of the right thyroid gland, the vessel right here. Medial and above the upper pole is where the external branch of the superior laryngeal nerve. There's the twitch right there. So now I know that the nerve is here, I'm gonna have Dr. Guyer stay right here when he ligates. There's no twitch here, which means this is safe to take. Up here, we wanna preserve that. Forceps. Come a little, yeah, stay low in a way. There may be another vessel in there Rich, I don't know if you wanna... Good, medium clip, please. Nice. So once again, double ligating with clips the vessels at the upper pole. Knife, please. Superior pole vessels being divided right here. Good. And you're gonna have to rotate out there, Rich, carefully. Suction. Great. I would put a new blade in that knife. Thank you. So right now, instead of coming around this, sometimes I use the Harmonic directly to secure some of the upper pole after we've ligated the specific upper pole vessels, which we've already done. Now you have to be very careful when you do this that you're not anywhere near the external branch of the superior laryngeal nerve medially and you're not near or heating up the carotid laterally. There we go. Right angle. And Rich is just taking the last few attachments of the upper pole. Very important too, when you take down the upper pole, if you take it down too much or too low, you can actually encounter the insertion point of the recurrent laryngeal nerve. Marking pen, please. So right now, we're right here, at the right upper pole vessels. Here's where we stimulated that external branch, twitching this, the right cricothyroid muscle, out here is the carotid, and if you come too far down here, you could encounter the insertion point actually of the recurrent. So Dr. Guyer stayed way up here for now. Okay, Dr. Guyer, you're gonna hold that. We're now gonna go out laterally, looking for the thyroid middle vein, which is probably running. So I think they're coming, right, yeah. Just take the superficial stuff first, Rich, and then we'll get closer to the middle vein. These are just some superficial muscular attachments. Spread a little bit more. Okay. Peanut, please. You can let go of the Kelly. Hold that there. Good. I would take these attachments here, which are a little bit more towards the lower pole staying kind of high up on the thyroid there. Come on out for a second, Rich, do you have a vessel in your tip or no? No, I'm free. I'm free. Okay, good. Hold that right there. You hold this right there, Rich. Thank you. I suspect the lower or inferior parathyroid gland on the right is just outside what we're dividing. Good. Perfect. So now we've encountered back to the trachea. That is not parathyroid gland. So I looked here, thinking, could that be a parathyroid gland stuck on the thyroid? And it's not. It's thyroid tissue. Okay, you can take this right here. What you're doing is correct. Pull there. So we're now finishing up the lower pole on the right. Okay, suction. There's our trachea. So we're back to our trachea. I'll take the Bovie, please. And I'm gonna divide a few superficial attachments to the trachea. We're well medial to the nerve so that Dr. Guyer can flip this thyroid up and towards him when we dissect the nerve on the right. Excellent. So we're now getting close to approaching our peduncle. May I have the nerve monitor, please? Good. Nice job, Rich, holding that up. So there's the stimulation of the recurrent laryngeal nerve on the right. So you can come way up here, Rich. Perfect. More lower pole attachments, medial and superficial to the recurrent laryngeal nerve. This is the lower pole of the thyroid that we've elevated up and into the wound. Forceps. Great. And then if you pull up here, Rich, you can take one more of these bites here, right on the trachea. Good. And as you're taking these bites, you really need to know where the recurrent laryngeal nerve is 'cause it can start to approach. Bovie, please. Once again, some superficial attachments of the thyroid to the trachea, which will help us flip this up. So now we're down to that point again where we've taken the lower pole, we've taken the upper pole, lower pole, upper pole, and we're now ready to dissect free the recurrent laryngeal nerve. Can I have the nerve monitor, please? Which is sitting right where it should be in the tracheoesophageal groove. You can come under that, Rich. Good. Great. All right, can I have a fine Kelly, please? Very nice guys. And I'm also gonna be looking out for the superior parathyroid gland. You can take that bite right there. Superficial. Good, Rich. We're still above or superficial to the nerve at this point. Fine Kelly. So here's the peduncle of thyroid, and once again, the nerve, as we talked about on either side, is going to be inserting... I can see right there. Right underneath it. I think it's a little more medial, no? There's the parathyroid gland, superior parathyroid gland right outside that peduncle and just lateral to the nerve. There's the para. See, that's a beautiful view of the superior parathyroid gland, right here. I think this is where the nerve is running down. Nerve is, yes. So this is the trachea, so right in between here, Rich, right where you just said is gonna be the nerve. Nerve monitor to Rich. A little more lateral. You're sort of coming here. There it is. See? Yeah, yeah, yeah, yeah. Just medial to the superior parathyroid gland. We just haven't quite seen it yet. I think it's right there. Nerve monitor again. But more lateral. Yeah. See? It's deep here on the right side. And it's a little more lateral than we maybe would've thought. So we wanna drop this para down. Should I test that? Right angle to Rich, please. What's the nerve monitor set at please? It's at 2. You can go maybe try going down one. Okay. Here we go. It's 1.5. It's right here. See, it's very close. It's right there, Rich. See? Yes. See it right there? So the nerve on the right was a little more superficial than the nerve on the left, came up a little bit higher and that puts it more at risk. But we were able to successfully identify it. Can I have a right angle, please? And test this for me, please. You can test what I'm holding, but then test the nerve down here. Perfect. 2-0 tie. And I'll tie this one, Rich. We're right on top of the nerve here. Forceps to Rich. Sorry. We kind of need it. Yeah, I didn't really... It's choosing you. I know. All right, pull up with that peanut, please, Rich. I know it's gonna wanna... So actually, this is a very nice sort of demonstrated view here. So we're tying the tissue right here, anchoring the nerve, I'm sorry, anchoring the thyroid down around the nerve. Peanut, please. The superior parathyroid gland is right here. This brown structure with its blood supply coming down from the thyroid gland, and just medial to that, attached to the parathyroid gland is the recurrent laryngeal nerve. You guys all see that? Great. Test that one more time before I tie this, please. So I want Rich to test it because I wanna make sure I don't have it caught in my tie. Scissor. Right angle, please. You're gonna do the knife first, Rich. And remember, the nerve is right underneath here. So you're gonna come right, yeah. You see where you want to go. The nerve is right there. And then scissors, please, to Rich. Good. Excellent. - Take that. So that dropped the parathyroid gland down and away from the thyroid, which is good. Forceps, please. And then, peanut. And as you can see, there's often an abundant. Right angle to Rich. Come right under that, Rich, pull with this 'cause you're right on the nerve here. See that right there? Hold on, let me help you. 3-0, please. Now, that is a very important vessel there because it runs right over the recurrent laryngeal nerve. And it's important, number one, because when we divide that vessel, we don't wanna injure the nerve, and number two, we have to make sure to secure it because if it bleeds, it's very difficult to gain control of and not injure the nerve. So I'm not gonna pull up on these ties while I tie this one. Nerve monitor, please, to Rich. Nerve monitor to Rich. Good, and very gentle with your right angle here, please, Rich, 'cause if that thing rips... Pull with your peanut. Good. Small clip, please. I've seen a vessel just like this one cause a post-op neck hematoma. And when you re-operate on the patient, you have to be very careful. Stay in there for me, please. Very careful not to injure the recurrent laryngeal nerve as you gain control of the bleeding. And I'll take a small clip again. Our parathyroid gland is just lateral. Scissors, please, to Rich. Forceps. Great. So even though it sometimes takes a little extra time to ligate those vessels, it's a very important point in the case to make sure that they're secure. All right, nerve monitor, please. You can see right there. Right here, huh? Okay, great. Can we have a little squirt of water, please. Just to clean up in here. The nerve is right here, coming right up into the thyroid gland. Once again, we've successfully detached the superior parathyroid gland away from the thyroid. You can suction right on there. Peanut. Great. So, recurrent laryngeal nerve is right here inserting into the larynx. Superior parathyroid gland is right here. Thyroid is up here. May I have the Bovie, please. We likely will need a couple of stitches soon, Kat. These are attachments of the thyroid to the trachea. Well medial now to the recurrent laryngeal nerve, which is why we're okay using a heat source. But as we get closer to the nerve, we don't wanna do that. Can I have, please, let me try a right angle. Even doing this, Rich, can injure the nerve. See, I'm pulling, that's why I like to use the stitches. Stitch, please. Okay, so the nerve is inserting right here. So we're gonna stitch through the thyroid just like we did on the other side. Now I'm gonna have you take a forceps, Rich, which when I tie this and pull that thyroid towards you, so we leave less of a remnant. So what these stitches are doing is securing these last little bits of thyroid that run right alongside the nerve where the nerve inserts into the larynx. Scissors, please, to Rich. Needle holder. Actually, you know what, knife. Stitch, please. Nerve is inserting right here. Can I get another 2-0 silk, please, on an SH. Thanks, Rich. Thank you. You can lie that down that way. Yeah, there you go. Perfect. Thanks. And when you place these stitches through the thyroid, you have to make sure that you go right alongside the trachea but not into the trachea. If you go too superficial, you can get bleeding of the thyroid tissue. If you go too deep, you can create a tracheal injury. Feel free to do a little suctioning there, Rich. If it's not too much trouble. Right here. Nerve monitor. Pull that up. Great. Scissors, please, to Rich. And I'll take a forceps and a 15 blade. Needle's back. So there's our little thyroid remnant on the right side that sits right where the nerve inserts and we're down to the trachea again. Knife is back. Bovie, please, to Rich. Hold that over there, Rich. There you go. Suction to me. I'll take another forceps. So now we're gonna complete the removal of the thyroid from the trachea. Give me a buzz. Good. Buzz. Another buzz. Just hold it right on there. And then right here, give me a little buzz. Good. We got something here, Rich. So right angle to Rich. It's a little vessel coming right here. Yep. We're all the way down to the trachea. Good. That's perfect. Here's that, Kat, it's gonna fall on the floor. So we're now on top of the trachea. We're safe from the nerve. Sometimes there's a few little perforating vessels that come up. So if you just use the Bovie here, you have to be careful that you're ligating those vessels adequately. Bovie back to Rich. Give me a little buzz. Great. Little buzz. And then you can take the other side up and out. So these are the last remaining attachments of the thyroid gland to the anterior surface of the trachea. Give me a little buzz. Great. So we'll pack that in. We'll check for hemostasis in a second.

CHAPTER 8

So here's the thyroid specimen. And so if we put it right here, this is the right upper pole, which Matthew, our student, will mark with a stitch for the pathologist. And here's our diagram right here. So we have the isthmus of the thyroid here, the left lobe, the right lobe, upper pole on the left, lower pole on the left, and all the surrounding structures which are, as we hope, not with the thyroid specimen. Okay, so you're gonna mark that for us please, Matthew. And that will go for permanent pathology as the total thyroidectomy stitch at right upper pole.

CHAPTER 9

So we have a little bit of bleeding, peanut, right where the remnant, hold that right there, and then right, put that right there. It's right here, Rich. Let's start like superficial. So a little bit of bleeding right where the thyroid remnant is, adjacent to the right-sided recurrent laryngeal nerve. So this is the place that I'm most concerned about. Don't buzz me quite yet. Okay, I think you're okay. So you have to be very careful when you create heat here with the Bovie or the Harmonic that you're not injuring the nerve where it inserts into the larynx. Okay, pull that over again there, Rich. Starting to look a little better here. And you can also place a little figure-of-8 stitch there if it continues to bleed and you're worried about Bovie-ing near the nerve. Can I get another... The nerve is just behind this peduncle of thyroid, right here. Nerve monitor. Right there. This looks a little better. Good. Great. And we're gonna very diligently check for hemostasis on both sides because one of the important complications of thyroid surgery is a post-op neck hematoma, which can be potentially life-threatening because it causes edema of the larynx and the patient can actually choke. May have been run down from before. Irrigation, please. I like to irrigate with water in the neck, not saline, 'cause you can see through where the bleeding is. It also lyses red blood cells and clears it up very nicely. Okay, that looks great. We'll come back over for a Valsalva. Do you have some Surgicel? I do. All right, we're gonna check the other side first, but... All right, so we've checked the right side, we'll check it again before we close. Make sure that remnant isn't bleeding, it looks good. Here's the thyroid remnant. And one thing I'll demonstrate to everyone here is that when you've taken the retraction out, so we're not holding the thyroid up, Dr. Guyer's not using the peanut to pull the trachea up, you actually can't see the recurrent laryngeal nerve anymore. It's because it's disappeared behind the thyroid remnant here. And that's just a testament to how much retraction you often need to expose the nerve during the surgery. You have to be careful with that retraction because it can cause a traction injury to the nerve where it inserts into the larynx. So you wanna provide just the right amount. So hold that for me there, Rich. So once again, just a little bit oozy on the remnant of thyroid. Very typical. So we're gonna check that out. A little hemostasis here. Check up here. Can I have the irrigation, please. I can see our two parathyroid glands, I can see our recurrent laryngeal nerve, and I can see our little thyroid remnant, which is nicely hemostatic at this point. I can see right through the water that there's no bleeding right now. Can we have a Valsalva, please? The Valsalva increases the venous pressure in the neck, and hopefully, would reveal any bleeders that could become a problem later. You up there, Daniel? Great. Perfect. And we always check the upper pole because that can also bleed, and our clips look nice and secure. Suction. Oh, okay. Go ahead, Daniel. You can do it again. I just wanna check these upper pole clips, please. That they're all the way across that tissue. I think they look good. I think the vessel's right here, Rich, so it comes right there. Okay, we'll take the Surgicel. So I like to leave some hemostatic agents in the neck for any little oozing, especially from that little remnant. So one of the options to do that is something called Surgicel. We place that right over that remnant of thyroid near the nerve. I also like to place a little piece at the upper pole and a little piece at the lower pole, and we'll do that on both sides. Okay, hold that gently right there. And once again, piece at the thyroid remnant for hemostasis, piece tucked in at the upper pole, and then a smaller piece down here at the lower pole. So that completes the thyroid.

CHAPTER 10

So the first layer of closure is the strap muscles. I choose only to close the sternohyoid muscle, that goes to Dr. Guyer and I'll take one as well. I do not close the sternothyroid muscle because normally, the sternothyroid muscle does not meet in the midline and I worry that the patient will have symptoms when they swallow if we close that muscle. So there's that. Good. I use interrupted 4-0 Vicryls to close the sternohyoid muscle in the midline. You can begin count whenever you want, Maddie. Watch your finger there, Rich. There you go. Thank you. Put one right below you and I'll put one above you, Rich. How does that sound? So this is the sternohyoid muscle being closed in the midline over the trachea. Right here. Just a small bite there, Rich. Good. I think it's very important not to close this layer too tightly 'cause once again, the patients can get a feeling of a lump in their throat when they swallow. So I just do a very small bite on either side of the sternohyoid muscle. Just like that. Can you turn off the Harmonic so we don't have to... Please. Okay, so the sternohyoid muscle is now closed. We usually leave it a tiny bit open at the bottom so if there is some bleeding it can egress from the deep tissues and get away from the larynx and the trachea. Very important, after you've closed the strap muscles in the midline here, to let the neck extension down so you can close the platysma. Dan, can you please let the thyroid bag... Thyroid bag. Open up the thyroid bag? So he's gonna release the neck extension. We'll take Adsons, please. The next layer is the platysma. All right, thyroid bag going down. That's right. Good. Very important when you close the platysma that you only get the platysma muscle and you don't get any dermis with it. That can be sometimes challenging in thinner people because you don't wanna tack the dermis to the muscle or the scar won't heal well. I'll take a stitch, please. So there's the platysma muscle right there and what I don't wanna do is I don't wanna hook the dermis up here. I wanna stay very deep here, just in the muscle here of the platysma that you can see right here. 7, 8, 9, 10, 11, 12, 13, 14. And I usually bury these. So once again, platysma muscle, and platysma muscle only, no dermis. And can you just kind of tip her chin down to her chest a tad there, Daniel. So once again, he is getting rid of the extension, and can you make sure her chin is midline? Now, I mentioned at the beginning of the surgery that one of the most important things for cosmesis... We're gonna need another one of these, please, Kat. First closing count is correct. Thank you. Is marking the incision before the patient is positioned in the operating room so you can get a good crease. The second most important thing is making sure that you get a tension-free closure, which is a principle of plastic surgery. So that's why I put an extra layer in here between the platysma and the skin. I put what's called deep dermals to get the tension off the skin closure. These are buried vertical stitches right in the dermis. You go ahead right there. Thanks, Rich. That takes all the tension off the skin closure. And then Dr. Guyer is gonna layer a running 5-0 Monocryl knotless above the deep dermal stitches. But as you can see, if you don't place this dermal layer, all of the tension from here where the platysma is to the skin will be on your skin closure, which is not a good thing. And these should be cut very short so they don't come out of the skin. Good. Perfect. See how much that takes the tension off there? Okay, Rich, you wanna put one more right there. Yep. And then you're gonna layer a knotless 5-0 Monocryl and Steri-Strips. So once again, he's just in the deep dermis there and the purpose of this is to take the tension off that final skin closure. So you can now see that the tension is gonna be off. Do you wanna come over here, Rich? I'm fine. You're okay there? Great. Chin's like only a tiny bit... Perfect. So this is knotless. So he just goes into the skin and sews. Staying or going? She can go in four to six hours. So just an FYI to our crew here that we typically, if the procedure is uncomplicated, the patient stays for observation for four to six hours in case they get a neck hematoma. Most neck hematomas occur within four to six hours of surgery. They can then go home on bedrest with a reliable adult if they live relatively close to the hospital. Otherwise, they'll stay overnight for observation. So wound class 1, minimal blood loss, procedure is booked total thyroidectomy, one specimen, total thyroid, stitch at right upper pole for permanent, and she's gonna stay for four to six hours and then she can go home. So Dr. Guyer did a running knotless 5-0 Monocryl subcuticular suture. He's gonna give you the the needle back, Kat. And I'll take some Mastisol, please. Needle. I like to use Mastisol. It's a adhesive that helps the Steri-Strips stick. And I don't like to use Benzoin because it's dark and the patient can see it. Yeah, it's all right. Okay, so let the Mastisol dry. So probably a little more here. Good. And then a second round. Exactly the same. There you go, Rich. Just measure that right there. Great. So I like to place the Steris in a little bit of a V-configuration so that it holds together the entire incision right there. So that's gonna overlap quite a bit there, Rich. There. Good. Which is fine. And we do three layers of the Steri-Strips right on top of one another. And then we cut the Monocryl off at the skin. The Steri-Strips will stay on for up to three weeks. The longer they stay on the better because one of the primary determinants of a scar is how long the primary Steri-Strips stay on after the surgery. So the longer the better. And I'll take a clean dry gauze. So if you guys would like to just show - towel is fine. We're gonna hold some pressure as she wakes up, and we're done.

CHAPTER 11

So in this particular patient, she had a diagnosis of Graves' disease. Graves' disease often causes inflammation of the thyroid gland and there's also increased vascularity to the gland. Both of those things can make the thyroidectomy procedure more difficult. In particular, with the preservation of the recurrent laryngeal nerve and the parathyroid glands. In this particular surgery, things went very smoothly. We did make the decision not to completely dissect the recurrent laryngeal nerve up to its insertion in the larynx and instead, leave small remnants of thyroid tissue at the spot. That is often a prudent thing to do in the setting of inflammation because oftentimes separating an inflamed thyroid from this portion of the nerve can result in a traction injury. We were able to visualize both nerves, we maintained their signal, and we were able to visualize three of the four parathyroid glands.