Open Total Thyroidectomy and Central Neck Dissection for Papillary Thyroid Cancer in the Setting of Hashimoto's Thyroiditis

CHAPTER 1

My name is Antonia Stephen, and I'm an endocrine surgeon at the Massachusetts General Hospital. I specialize in thyroid and parathyroid surgery, and exclusively do thyroid and parathyroid surgery. Today we will be performing a total thyroidectomy on a 23-year-old patient. She has a history of Hashimoto's thyroiditis, which is an inflammatory condition of the thyroid gland, and she was recently noted to have a thyroid nodule in the isthmus of her thyroid, or the bridge between the two lobes. A biopsy of this nodule revealed papillary thyroid carcinoma. We recommended that the patient undergo a total thyroidectomy, and central neck lymph node exploration. During this procedure, we will first plan to bring the patient to the operating room. She'll be positioned supine on the operating room table. We will be placing an endotracheal tube with a sensor on it that sits adjacent to the vocal cords, in order to monitor the function of the recurrent laryngeal nerves during the surgery. Once general endotracheal anesthesia is induced, the patient's arms are tucked by her side, and her neck is gently hyperextended. We'll then perform an ultrasound, noting the position of the tumor. We have previously marked the patient's incision within a skin crease in the pre-op area, and we will verify that the position of that incision is adjacent to the tumor and the isthmus so that we gain maximal exposure. We also examine the thyroid, and examine around the thyroid for any lymph nodes when we perform this preoperative ultrasound. After the ultrasound is performed and the incision location is verified, the patient's neck is prepped and draped in the usual sterile fashion. We then make an approximately three to five-centimeter incision, in this case, likely a four-centimeter incision, within the skin crease and carry it down through the platysma muscle. Step one of the procedure is exposing the strap muscles and the underlying thyroid. Once we've gone through the platysma, superior and inferior subplatysmal flaps are raised, and the landmarks for these flaps include superiorly the thyroid and cricoid cartilage, and inferiorly the sternal notch and the top of the clavicular heads. Once the superior and inferior flaps are raised, we divide the strap muscles in the midline of the neck, after which time we then divide the attachments of the sternothyroid muscle from the thyroid gland. We are then planning to dissect the upper and lower borders of the isthmus over the trachea. And in this case, because we are interested in resecting the pretracheal and central neck lymph nodes, we will proceed to the lower isthmus, down to the level of the innominate artery, in order to resect the entire packet of fatty lymphatic tissue, between the lower border of the isthmus and the innominate artery right above the trachea. After this, we proceed to the left upper pole. At the left upper pole, we are careful to identify using the nerve monitor, the external branch of the superior laryngeal nerve. When we take down the upper pole, we're careful not to injure that nerve, and we use the nerve monitor to watch the twitch of the cricothyroid muscle, in order to correctly identify the location of this nerve and avoid injuring it. We ligate the superior pole, rotate the thyroid gland up, dissect at the inferior pole, where we preserve the inferior parathyroid gland. At this time, we also complete the central neck dissection and connect it up with the pretracheal lymph nodes that we previously resected. We then trace the recurrent laryngeal nerve, which we've identified within the tracheal esophageal groove, up and into the larynx with care not to injure, and also to preserve the superior parathyroid gland on that side. In many cases, we often end up leaving a small remnant of thyroid, where the nerve inserts into the larynx. This is particularly true in cases like this one, where we have Hashimoto's and inflammatory thyroid disease. We will then plan to proceed to the right side, after verifying an intact signal on the left recurrent laryngeal nerve. Similarly, on the right, we'll take down the superior pole, with care not to injure the superior laryngeal nerve. We rotate the thyroid medially, dissect free the lower pole of the thyroid, and preserve the inferior parathyroid gland on the right as well. We then identify the recurrent laryngeal nerve, and carefully trace the nerve to its insertion in the larynx, once again likely leaving a small remnant of thyroid tissue. We then divide the attachments of the thyroid to the trachea using the Bovie electrocautery. We then close the neck with interrupted 4-0 Vicryl sutures to the sternohyoid muscle and the platysma. We also place a deep dermal layer of vertical buried stitches, also using a 4-0 Vicryl, and we close the skin with a running 5-0 Monocryl subcuticular suture. Steri-Strips are placed, and the patient is awakened from generally anesthesia.

CHAPTER 2

So once again, the positioning, arms tucked, neck extended, neck already marked before her neck is extended so we can identify appropriate skin creases. And now we're gonna do the ultrasound. So this patient has a isthmic papillary thyroid cancer, the isthmus being the bridge between the two lobes. For smaller papillary thyroid cancers, a hemithyroidectomy may be appropriate, and this tumor meets the size criteria for that. But because it's positioned right in the middle, we have to do a total thyroidectomy. So here is the tumor right here, this dark mass. Here is the trachea, the windpipe. So the tumor is sitting right on top of the trachea, once again, right in the isthmus of the thyroid. So here's the tumor, slightly over to the right. Her thyroid gland is over here. It's a little heterogeneous in appearance because the patient has a diagnosis of Hashimoto's, which is an inflammatory condition of the thyroid. And if we move over this way, this is the left lobe of the thyroid here. Once again heterogeneous, because of the Hashimoto's. Left carotid artery is over here, and the esophagus is back here. Probably right there is the temp probe in the esophagus. So left lobe of the thyroid, trachea, isthmus of the thyroid, right lobe of the thyroid. The entire thyroid is heterogeneous due to inflammation. And then right here is the papillary thyroid tumor, darker or hypoechoic than the surrounding thyroid tissues. She's had a detailed ultrasound demonstrating no obvious enlarged lymph nodes, but we'll inspect for those as well around the thyroid, up and down in particular, below the lower pole of the thyroid on each side. Once again, carotid artery here, jugular vein here, sternocleidomastoid. And then we're gonna just gonna document that our incision is right over the isthmus of the thyroid. So I'm placing the probe on the incision, and I'm looking over on the ultrasound to show that the isthmus is right here. That'll give us this best exposure for the operation. So as you can see here, she's extended, so her creases are not as obvious, but she has a neck crease right here, which would be too high for the thyroidectomy. And if you come out here, you can start to see the natural contour of her skin coming out here. So when she was not extended, you could see that this was actually also a potential crease. Because she's so young, you're not gonna see them as obviously as you would in an older person. But if you look right out here, you can see the natural skin line. Putting the incision in that skin line is really critical for good cosmesis for her scar as it heals. And once again, we prep with a clear ChloraPrep solution, that we then let dry for three minutes. So this is the stimulator part of the voice nerve monitor. So we're passing that up to anesthesia to get plugged in there. It's a pretty simple system. He has all the electrodes plugged in there. Two of the electrodes are from the ET tube, that will detect the electrical activity when we stimulate the nerve. Two of them are grounds, and one of them is a stimulator. So there's a total of five.

CHAPTER 3

So when I'm palpating here and making this incision, I feel the sternal notch, 'cause that's gonna give me the midline. We like to make the incision symmetric. Symmetry is very important in terms of scar healing. If you have an incision off to the side, even if it's exactly the same length and appearance, an incision that's in the middle and symmetric will be less noticeable when you're visualizing the person. So we always try to make this symmetric. And then once again, we make it usually between three and five centimeters for an averaged-size thyroid. Because we're gonna be looking at her lymph nodes and we have an isthmic tumor, we'll make it closer to five for her. Actually, maybe we'll make it a little closer to four. We'll mark out both, okay. We can do our time out whenever you're ready. Doesn't it look a little higher on that side? Pardon me? Looks a little higher on that, do you know what I'm saying? Yeah, yeah, yeah. But there's the skin line, so... All right. See the skin line there? Everyone ready for a timeout? Yes. Okay. We have the same team here. So once again, four-centimeter incision within a skin crease. In addition to being within this crease, we can also match it up to the contour of a more obvious crease, marking pin. This crease we couldn't use because it's too high up and away from the thyroid, but we can match the contour because that is her natural skin tendency, the tendency of her natural skin lines. Once again, this is all about the cosmesis of the incision. Okay to start? Yes. And we're making it four centimeters total, two on each side. I'll take the fine Kelly. Very nice. Knife down.

CHAPTER 4

Once again, we start with the coag, not with the cut function of the Bovie. And right now we're going through the dermis and the subcutaneous fat. He is now going through the platysma. And once again, dermis again. And now platysma. Here's the edge of the platysma, good. And a few more platysma fibers here that Dr. Guyer's gonna divide. That's a little vessel, so just buzz back and forth. Yeah, forcep. Short DeBakey's, please. So now we're gonna raise our subplatysmal flaps. We'll start with the superior underneath the platysma, going up, with care not to interfere with the anterior jugular veins that sit right underneath the platysma. Feeling up for the thyroid and cricoid cartilages as the upper border of our flap. Stay high there Rich, please. The key to avoiding the anterior jugular veins is to stay really high, right underneath the platysma. If you get any deep to it, you run the risk of getting into an anterior jugular vein. This is the inferior subplatysmal flap. Here's the edge of the platysma that I'm picking up. Dr. Guyer's Bovie-ing just right underneath that platysma and then right through it right here Rich, thank you. Give me a buzz. We're gonna make these flaps a little bit more extensive than the last patient, because she has a diagnosis of cancer, this patient does. So we wanna be able to see around the thyroid to explore what's called her central neck lymph nodes, the lymph nodes around the thyroid, which are commonly involved in papillary thyroid cancer. So once again, feeling down towards the top of the clavicle and the sternal notch. You wanna take a feel of that too, Matt? Sure. And I'll take a... So it's cartilage up here, thyroid cricoid cartilage, and then down towards the top of the clavicle and the sternal notch. The AJ's a little less obvious here. Yep. I think you can see one right here, though. Yep, and maybe one right here, the anterior jugular vein. Let me just release a little tension on here. So the other thing to be careful of, in terms of scar healing, is not to retract this incision too aggressively. So that's why I took a notch. So this can stretch it, and lead to ischemia of the skin edges, so I'm releasing a little tension. I'm just gonna take a little bit right here, see this? Oh yes, yes. Okay, so now we're gonna divide the strap muscles in the midline. Divide them from each other. Suction, please. I'm feeling for the trachea here, which is a good landmark for our midline. You might have a vein right there. I see it right there, yeah. Yep, the anterior jugular vein, just to the left of the midline. Also, do not wanna interfere with one of those. So now we're getting down to the sternohyoid muscle. This is the left side, and we're just separating these muscles from each other. We don't actually divide the sternohyoid muscle. Gimme a buzz. There's a midline right there. We'll take a baby abdominal please. Matthew, if you could hold that, harmonic please to Rich. And just to ensure slightly better hemostasis, than with the Bovie, we're gonna use the Harmonic for this last bit. So take that towards, yeah, that's perfect. Right where you are right now is great. And we're going straight down to the sternal notch. Just wanna make sure we can get underneath the tumor, so we can access what's called the pretracheal lymph nodes. Maybe one more. Thank you, thank you. And I'm gonna have you, Matthew, just come - yeah, there you go. We're getting a little extra exposure for the central neck lymph nodes. Right here, Rich. Now you're gonna go up above Dr. Guyer, and I'll take that if you take that, please, hold that right there. Can you adjust the light just a tad there, please Rich? Once again, continuing to divide the right and left sternohyoid muscles from each other, to gain exposure to the thyroid gland and the surrounding lymph nodes. And we're up to the thyroid and cricoid cartilages there. All righty, so I think I'm palpating the tumor. I think it's right smack in the midline, so we'll probably do Dr. Guyer's side first. We're gonna separate this out. There you go. He's holding the sternohyoid muscle, and he's now gonna separate the sternohyoid muscle from the underlying sternothyroid muscle, after which time we'll separate the sternothyroid muscle from the underlying thyroid. Give me a little buzz, good. Come sort of this way. Yeah, good. And then down just a tad there, please. Okay, now give me a buzz. Great, and then... Get right there, and lift up. Hold right here, and then back your forcep up a bit, that's good. And then right under your forcep, just a little at a time there Rich, 'cause the tumor's right under there. So one of the things we'll be looking for as we do this, is to make sure that the tumor is not invading the sternothyroid muscle. If it is, we will plan to resect the muscle along with the tumor. Back up just a tad there, there you go. Way up here. So he's holding the sternothyroid muscle, and the thyroid is just below my forcep right here. And back up your forcep, there you go. Give me a buzz, buzz. Good, okay. All right, let's take a Richardson retractor, please. You can let go of that, Rich.

CHAPTER 5

Matthew, you're gonna hold right here. So here's the thyroid tumor. Like I said, a slightly unusual case because it's right smack in the middle between the two lobes. Right there. It's right in the isthmus, yep. So we're gonna pull up what's called the pretracheal, second forcep, or central neck lymph node tissue, from just below the isthmus, give me a buzz. So we did not do this in the last surgery, because it was for benign disease. So the first thing here is to open up the fascia above the lymph nodes, buzz me here. Go a little lower. So what are we gonna find down here Rich, that we often find down here, especially in younger people? Do you know? Veins? The thymus. Yeah. Oh, thymus. You can come right through that. Oh, I see. Yeah. So right now I'm just seeing some fatty tissue, and what we call some thymic tissue. This is the thymus here, this fatty tissue right here. We're not interested in the thymus. We're interested in potentially the lymph nodes that live near the thymus. That could be a small lymph node right there. Harmonic please? Yeah, that's what I was thinking about. Yep, there's definitely some veins down here. We ligated them on the last case. Feeling for the trachea there. Just hold that in a tad. Forcep, second forcep. That looks like it could be a little node in there. It does, very much so, yeah. Give me a buzz there. Give me a small buzz here, good. And then... Good. We'll leave the thymus down. Give me a buzz here, and right there. So come through that. So what you wanna think about doing here, Rich, is you're just sweeping all the fatty tissue at the bottom part of the isthmus up towards the thyroid. So you can, get that, so you can remove it with the thyroid and inspect for any lymph nodes. So there's a little vein right there, yep. Can I have a - let's take a medium clip. Harmonic. So this, you could call this a pretracheal lymph node dissection, right there. Buzz me here please, good. Right there, great. Great, little buzz. Now you have to be very careful during this step not to go to the side of the trachea inadvertently, 'cause that's where the recurrent laryngeal nerve is. Perfect, so here's our trachea. This is the pretracheal lymph node packet, which is part of the central neck lymph nodes, also called level six lymph nodes. Hold on one second, let's just see. Is that - that looks like a little node right there. It's also important to keep in mind, don't go off the trachea though here, stay over here. It's also important to keep in mind that patients with Hashimoto's can have benign lymph nodes around the thyroid as part of the inflammatory response. Could you clean that up? So we don't know that any of these lymph nodes are cancerous or just from the Hashimoto's, but we're gonna resect all of them anyway. Okay, so thyroid tumor in the isthmus right here. Pretracheal lymph node packet right here. There's a lymph node right there, that you can see that's bleeding a little bit. I would say that most of these lymph nodes, at least to my eye, look more consistent with inflammatory lymph nodes, not cancerous lymph nodes. But we won't know for sure until we get the final pathology.

CHAPTER 6

Matt, can you go up above Dr. Guyer? We're gonna try to take down our pyramidal lobe. We're gonna be a little bit more vigilant, just watch the the ET tube, about taking out the pyramidal lobe in this patient because she has cancer, and we wanna clear as much thyroid tissue as we can. So you can kinda see the pyramidal lobe right here. See it? Yes, very much so. I can, it stops right up there. Yep, pull that down. Give me a buzz, good. So right now we're over the thyroid and cricoid cartilages, and we're peeling down what's called the pyramidal lobe from the upper midline, right here. There also can be a lymph node up here called the Delphian lymph node, I haven't seen that. And that can become involved in cancer when there is lymph node involvement. So I would say here, stay up towards the - yep. Give me a buzz, and then right under there, good. Hold this towards you. So let's just go a little bit, give me a buzz. Another one. So there are cricothyroid muscles. Yeah, very nice. The ones we saw in the other case. So we had to take down the upper midline, right, right angle to Dr. Guyer, please. In order to see those. Hold this towards you. And then under here. Good, great. Can I have a small clip, please? Yep. Good, suction, so get your Bovie back there Rich, and just peel this down a little bit more from - so stay high up here. Not, you don't wanna get anywhere near the muscle. Give me a little buzz, good. And then take that towards you. You don't wanna do too much over here 'cause it can start to bleed, but maybe just a tad right there. Okay, so here are cricothyroid muscles, marking pen, please. You can relax on that for a second now. So just like on the last case, we have the trachea here. Thyroid gland is here, isthmic tumor right here. So what we did on the first case, which was benign disease, is we dissected right here and right here, here are the cricothyroid muscles. In this case we took this entire lymph node packet from the lower part of the isthmus here. So we dissected here, and running right along here, which is the level to which we want to go down to, to complete a pretracheal lymph node dissection, is the innominate artery. Okay, so let's just make sure we can feel that. Yep, so you wanna go just to on top of the trachea, we'll have, so you won't be able to see the innominate artery in her, you usually can't, but we can feel it. And we've taken out all the tissue between the lower border of the isthmus and the innominate artery. Do you wanna feel that, Matthew? Suction.

CHAPTER 7

Okay, so we're gonna go to your side first here. Hold right there, so he's now holding up it once again, the sternothyroid muscle. We're gonna slowly peel the sternothyroid muscle off the surface of the thyroid gland, and then we're gonna approach our upper pole, buzz. Okay, hold right up there, just the sternothyroid muscle, Rich. No, don't hold the sternohyoid. Oh I see, yeah. It gives you better retraction, great. So hold on one sec, let me get this buzzed right here. Good, now right here. Good, another buzz, good. And once again you can divide, can I have a baby abdominal retractor? A small portion of this sternothyroid muscle, where it inserts into the thyroid cartilage, in order to access the upper pole, if you need to. Now I haven't yet done that in her, because we're able to retract it effectively at this point. A little buzz, we are now dissecting free the lateral and medial edges of the upper pole. Don't buzz in there, 'cause that's where the superior laryngeal nerve is. You can pick up right here, Rich. Okay, relax on that. So under Matt's retractor here is the, no no no, no. Not yet, just because it's... So in younger people, the medial edge, can I have a second forcep? The medial edge of the upper pole is way more adherent to the cricothyroid muscle, making the superior laryngeal nerve dissection more difficult. Remember in the last patient, this separated out really nicely. Do you remember that, guys? Yeah I do, yeah. And this one was a little more challenging. See how stuck it is? It's because she's healthy and young. Can I have a regular size Kelly? I use a regular size Kelly to retract the upper pole downwards towards the feet. And as soon as we put this Kelly on, is when we wanna listen for or watch for, I'm sorry, the twitch of the cricothyroid muscle, there it is. So the superior laryngeal nerve, the external branch, is traveling just medial and above, just medial and superior, to the medial edge of the upper pole. All right, right angle please to Dr. Guyer. Here it is, okay. Just right here. Medium clips please. And I close and move down. So once again I do a double ligation of the upper pole vessels, with either clip, ties, or both. Harmonic. Suction please. Okay. Rich, you can come under that little bit right there. We're taking down the upper pole, a little bit more of the upper pole. We've already ligated with the two clips the main vessels, some additional attachments at the upper pole. And we are now below and lateral to the external branch of the superior laryngeal nerve, and we're above and lateral to the insertion point of the recurrent laryngeal nerve. Good, so what you don't wanna do at this point Rich, is go too much under there, 'cause that's where the recurrent can insert. So you can take this bite right here. We're gonna just clean up the isthmus a little bit, so that when we flip the thyroid over, it's not stuck to the trachea. We're retracting upwards now on the left thyroid - forcep. So it's just this, a little bit of the superficial stuff here Rich, good. We're not gonna spend too much time there, 'cause now we go to the lateral attachments, which is where we usually see the middle vein. Peanut, please. So now what we're gonna do, is we're actually gonna connect the dots with our pretracheal lymph node dissection down here, forcep, once we get to the lower pole. Right here. Good. So these are some lateral and inferior, or lower pole attachments. Great, and actually if you want to go down below Rich, hold that gently there. Can you turn the Bovie down to 15? So I'm a little curious right now, forcep please, about what this is here. That white thing right there? If that's a lymph node, or is it a parathyroid gland? Oh I see. Yeah, yeah, yeah, yeah. Para like. It looks like, very para like, I have to agree with you, Rich. So I think what we're gonna do, is we're gonna save that, right? Thank you, and so you wanna gently pick this up. And remember we're removing all this. So this is tricky, when we're trying to preserve an inferior parathyroid gland, and remove the pretracheal lymph nodes. Oops sorry, let's just try this. You have to carefully dissect between the two, in order to effectively remove the lymph nodes without devascularizing, or removing the lower parathyroid gland. Right - forcep please. So we have the inferior parathyroid gland here, you can see, do you see that there Matt? Yes. Right here. So we wanna preserve that, so we'll do a little more work, but we're taking all this out. So hold this up, Rich. And actually I'm gonna hold here, and then you're gonna come between the parathyroid and the lymph node packet, great. So this is how during a central neck dissection you can preserve the inferior parathyroid gland. Forcep. Hold that towards you Rich, nice and gentle. Rich has the parathyroid gland right now. Okay, so your last bite is gonna be along there. This is where you have to be very careful not to pull the recurrent laryngeal nerve up. So we'll test for that, nerve monitor please. And what's the nerve monitor set at right now? It's at two. Okay. You can put it up to three. Okay, it's at three. Thank you. Forcep please. So, you see what you're doing here? You wanna leave that kind of alone, yes, yep. Nerve monitor, please. So you can see how you could have inadvertently, I don't think you're doing that, 'cause I think you're in the right spot, but you could, yep, you have to do that. Okay, yes please. Forcep, there you go. So there's the pretracheal or central neck lymph nodes right here, that are gonna come out with the specimen. The trachea is right underneath, and just lateral and right next to it is the inferior parathyroid gland that we're now gonna save. Bovie please, to Rich. So before you start coming under with it, we're gonna do the capsule just a little bit. So this is how you peel down or save a parathyroid gland. It's attached to the lower pole, give me a buzz, of the thyroid gland, and we wanna make sure it saves its blood supply. Right angle to Rich, please. Forcep please. Great. And I would come way up here, maybe a little, yeah, I think that's actually right in that space right there. So the challenge here, 2-0 tie, is to make sure we maintain a blood supply to that lower parathyroid gland, as we dissect between the parathyroid and the left lower pole of the thyroid. Good. It's there, it's good. So you see the difference here, Rich, between going next to the parathyroid here, and coming up here? Yeah. I think that'll be a better, we'll do a better job saving the blood supply. And you're still on top of the trachea. I'll take a medium clip, thanks. Right angle to Rich. Slide and move that way. Knife, please. Metz please, peanut. Can I have the nerve monitor please? So I'm curious to know how far lateral the nerve is, which is right here. So you can finish up taking, no, right angle. Good, you see where you wanna go there, Rich? Right here. So finish up, yep. So Dr. Guyer's staying very, very, very close to the thyroid gland here, because the parathyroid is close by, and we wanna preserve that. The parathyroid is right here. This is a vessel at the lower pole of the thyroid. Okay, I'm just gonna hook you Matthew, right there. Right angle to Rich, please. A medium clip. And once again, none of these medium clips are left inside the patient, 'cause they come out with the specimen, only the tie. Small clip please, let me reinforce that Rich, please. All right, so Matt you're gonna come above. So we're at that point in the case that I like to talk about, where we're about to start dissecting the nerve insertion point. Take this little bite right here, or actually buzz, yep. Okay, now this, I'm gonna push that muscle up there, okay. A lot of the blood you're seeing is back bleeding from the thyroid gland. Let's see if we can find that little, yep right there. And we don't mind a little back bleeding, but we mind it when it obscures our vision, our visualization of the nerve. Can I have a fine Kelly please, Rich is gonna take the nerve monitor. So here's the trachea here, and here's the tracheoesophageal groove, where Dr. Guyer is about to detect the nerve signal. And here's the peduncle of thyroid, under which the nerve reliably inserts. Take your forcep there please Rich, and just pick up that. Okay, I think it's right in here. See it in there? It's that white thing, yeah. That's it. Can you turn it down to two please? So it's inserting right under the peduncle of the thyroid. Peanut? You can let go of that Rick, for a second. Forcep. So we're now gonna work on our final nerve dissection. Hold this up here, don't buzz it. Hold up right here Rich, but just no buzzing right now. Hold on, see if we can get good exposure of the nerve. Wait a second, fine Kelly. Scissors please, to Rich. You see the nerve right there? It's right... Right behind us there? Yes, good. Peanut. I see it clearly now. Yep. So now we can clearly see the recurrent laryngeal nerve, as it's ascending to insert to the larynx. It's coming right up underneath the thyroid peduncle, as we discussed previously, right angle please. 2-0 tie to Rich. So we're just gonna take this little bit up here, which is well away from the nerve, to start. And I'm gonna obscure your vision for one second Rich, while I slide Matthew up there, okay great. Peanut please, nerve monitor, Rich is gonna take the right angle. And I'll take the knife. You want that? Actually you know what? Let me, yeah the clip, I'll take the clip. Close and move out. Knife please. Scissors. Great. So let's review what we have here thus far. We have, forcep, we have the recurrent laryngeal nerve, this white structure right here, coming, ascending up to enter the larynx. This is the trachea here, the lower parathyroid gland here. I haven't yet seen the upper parathyroid gland, and this is the thyroid peduncle that we've talked about. Can I have a fine Kelly, please? So right now I'm actually inspecting for the superior parathyroid. What if that's it right in this area here? I bet it's right there Rich, I totally agree. So trying to carefully separate the nerve, right angle please. And once again we have one of those pesky little vessels that runs right over the nerve. Tie please to Dr. Guyer, yes please. So nerve is down, we're approaching the spot where the nerve enters right into the larynx, which once again is the most critical part, because that's where the nerve is most likely to get injured, and that's where the nerve is closest to the thyroid gland. Peanut. Nerve is right under where Dr. Guyer is tying right now. Right angle to Dr. Guyer. Just tighten that up please, thank you. Small clip please, let me put a clip underneath it, just to make sure. Peanut. So this is... Take that right back. A very critical part here. I'd get a 3-0. Right angle? So I don't like, what I don't like here, is I don't like how the nerve is moving while I'm dissecting this vessel. That means I'm a little closer to the vessel than I would like to be, fine Kelly. That being said, this is a very young patient, and so I would prefer not to leave a significant amount of thyroid tissue in place, 'cause she has a diagnosis of cancer, and it would be good to do as complete a resection as is reasonable. Can I borrow the right angle? Thanks, suction. There we go, 2-0 tie please. I have a 3-0, do you want a 2-0? 2-0, 2-0, yep, this ended up being a larger bite than we had expected. Let's hope that nerve still works, suction. Do you see how I had to kinda work my way under there, Rich? That's when you can get some traction stuff going on. Luckily we don't, right angle to Rich please, when he's done tying. Just be very careful not to hook the nerve from above. And Matthew, I'm gonna just kinda straighten you out a bit, like that, perfect, knife please. Okay, so now we have the entire course of the nerve, peanut, dissected free, just the nerve again. That's why I didn't... Nerve again. See, this is a little quiet now, right? I don't think it's anything but, because remember how we pulled a little bit there? Right angle, please. We're gonna take the tissue below the nerve. 2-0. Suction. Just be careful about pulling the sort of nerve up and down, right angle to Rich. I think you need to go a little more superficially, or higher, higher, yep. There you go, perfect. Knife please. So right now we're just medial to the nerve. Scissor please, and we'll figure out where the bleeding's coming from, but we're a little close to the nerve right there. Suction please, good, forcep. And try putting a medium clip, but just be careful that the nerve is just lateral. I'm not sure that's gonna do it though, so we'll see. Peanut. So we're now dissecting up where the nerve inserts into the larynx. Can I have a fine Kelly please? Right there, stitch please, do a little suctioning right there. Actually, right angle first. Trying to get beneath that vein? Trying to get this stuff right here, which is right above the nerve, there we go. 2-0 tie to Rich, please. Okay, and keep that high up there Rich, don't push it down towards the nerve insertion, good. Oh, I see where it's bleeding out, right angle. Knife. Can I get two more 15 blades please? Scissors. And Matthew, pull just a little bit, please. There you go, perfect. Good. All right so now, hold that right there. Peanut to me, please. This is where the nerve is inserting into the larynx, right there. And then the thyroid is all up here, so we're probably gonna end up leaving a slightly smaller remnant than we did on that other side. In the last case you mean? Yep in the, sorry. In the last case, yep. Forcep, please. Are you stimulating there? Yeah, so I'm gonna actually just talk a little bit about what we just noticed, which was that at one point we didn't have a beep on the nerve. So when I looked over at the numbers here, which is the first thing I did, when the number there drops below 100, do you know about this Rich, or no? No I don't. It stops beeping. But if the number's like 80 or 70, you know you haven't seriously injured the nerve, because it would be much lower than that. So I knew it was traction. Remember that bite took, where I had to move the nerve around a lot? That's when it went below 100, but they often do recover quite quickly, so it went all the way back up, the 13 is when you were not testing the nerve, back to 106. So sometimes if you just give it a little time, if we had not had a beep and the number that stayed below 100, we likely would've modified the procedure. On the other side. On the other side. We would've come around the isthmic tumor, and we would've left the right lobe in place. So we'll decide that in a minute. But I knew the nerve was intact, and I knew exactly how it became injured, which was a traction injury, and now it's recovered or recovering. Okay, can I have the Bovie please? But she's put me on high alert that her nerves are sensitive to dissection. But as we just did an ultrasound right before the procedure, she has absolutely no nodules in either lobe. Right, right. So you could easily leave... And spare her some thyroidal tissue. Oh, well she has Hashimoto's. Oh you're right. Yeah, that's right. So moot point. Nerve monitor. So now we're 120. So when you're right on a very healthy nerve at a high stim, you'll get 500, just to kind of context. Okay, forcep please. So now gently either dab or suction right here, we're not gonna Bovie there. There's a little bleeder right next to the nerve in this medial, see that right there? Small clip please to Dr. Guyer. And I would say just come right under what I'm holding, and then down a little deeper there. Yep good, you have a little room there. Yep good, all right. Can I have a stitch please? See how the nerve's getting pulled over there? That's what you have to be very careful of. So you're gonna put it like right across there. Exactly. But I'm not gonna go there. So these are the ligating figure-of-eight stitches we did on the last one, to ligate the thyroid tissue right next to where the nerve inserts. And be very careful tying this Rich, 'cause that nerve does not like to be pulled. Yeah. And I don't wanna get into the trachea on these stitches, I wanna be right on top of it. Okay, just be very careful that doesn't crimp where the nerve is inserting, see that right there? So very gentle tying there. So, good. But do you see that? Just make sure that's tight. Yep. Okay. Yep, so now we're up to 180. So, isn't that cool? You can actually see a traction and then a recovery. Scissors please. One time I actually left the OR for like 15 minutes, and came back and it was beeping again, forcep, and so we did the other side, knife please. The real moral of the story is take a lunch break whenever that happens. Right. Here's a knife. So now we're just cutting through the thyroid tissue towards the specimen from the figure of eight, leaving a very tiny remnant of non-cancerous thyroid, where the nerve inserts into the larynx. There's a little vessel right there, see that? Can we have, do you have a 2-0 silk stitch again? Just suture ligate that vessel right on the trachea there please, Rich. Peanut. Yep. Where's that what you speak of. Forcep. Right here? Exactly, see that right there? Good, a little deeper, good. And I would just, see the nerve is all the way over here, and there's a little oozing here, so I would take your next one towards the remnant, does that make sense? Yeah, kinda like right... Exactly, so we can get a little hemostasis on that. Good, perfect, just a little hemostasis for a little section that had that vessel in it. Good, now make sure that's sort of - scissors. Needle, and just tighten that first, by pulling. Yeah, thank you. Good, suction please. Is that Kelly? Yeah. Hi Kelly. Hi Dr. Stephen. Scissors, Metz? Metz, yeah. Knife please. Mm-hmm. Bovie please, to Dr. Guyer. Forcep to me. And we're able to Bovie here, 'cause we're far away from the nerve. One more little buzz right there please, good. And you can come here. Okay, now we're taking the attachments of the thyroid to the trachea right over the midline. Be careful of that, give me a buzz. Give me a buzz. Another buzz. Buzz me here. Good. Just be careful of the trachea, Rich. Okay. All right, now we're gonna elevate up these central neck lymph nodes that will remain connected to the thyroid, right? And we're getting ready to proceed to the other side. This is all done, right here Is the last little bit of those nodes, good, okay great.

CHAPTER 8

So we're gonna take a peek at our side here on the left. Make sure the nerve is stimming. Make sure we're happy with our parathyroid glands. Check for hemostasis. Good, now we're back up to the 260 range. Forcep please. I'm also going to inspect in the central neck area for any additional lymph nodes that would connect up. So if you thought there might be some lymph nodes here, Rich, that you were concerned about, you would dissect this nerve free here, and get all the tissue under here. I think we're already reasonably exposed there, and we already have the pretracheal, so I think we're good on that, okay? Bovie, give me a buzz. Great. All righty, so now we're gonna proceed to the other side. We've documented the integrity and the stimulation of the left recurrent laryngeal nerve, and the viability of the parathyroid gland on that side. All right, so Matt, you're gonna come over here. Had we not regained the signal on the left-sided nerve, we would not be proceeding at this point to the right.

CHAPTER 9

All right, now we're removing the sternothyroid gland once again, now on this side, sternothyroid muscle from the thyroid gland. The most important thing here is to not get into the thyroid gland with the Bovie, 'cause it will bleed, good. Can we have the baby abdominal please? To provide retraction to proceed to the upper pole. Once again, sternothyroid muscle, thyroid gland. So that same vessel, yep. Can I have a small, go ahead, yep. Small clip please. Take that up towards you. Pull just a little bit more Rich, and stay very, very high on the muscle. One of the things you might hear me saying to Dr. Guyer is to stay high up on the muscle. So when you're removing the sternothyroid gland from the thyroid, it's important to stay towards the muscle side, not towards the thyroid side, or you can cause bleeding in the thyroid. Just divide those fibers there. Yep, good. And now we're proceeding to expose the upper pole. Relax for one second, there. Buzz. Can I have the Kelly, please? So once again the Kelly is used to retract the upper pole down towards the feet. One second. Nerve monitor, so if you wanna test right up in here, Rich, for that external branch, here's our cricothyroid muscle right there. Little deeper, little high, there you go. See he just found, there's the external branch. Do that again for the cameras. There it is, there's the twitch. Medial superior to the upper pole is the external branch of the superior laryngeal nerve. Not super deep there, just take that muscle first, and then we'll see what's underneath it for the upper pole. Great. Okay, forcep please. So a little bit of muscle, there's a good, there's a more better view of the upper pole. So we're gonna get Matthew hooked on the muscle there, and there's the upper fold of the thyroid right there. Nerve monitor, so I'm testing once again for the external branch, which actually you can see it. But Rich and Matthew, there's a little white thing, a little white loop there. There is the nerve, that is the external branch of the superior laryngeal nerve. Right there, see it? So touch that with the stimulator so we can see the twitch. Thank you. Mm-hmm. Yep, no question. So then what's important here, is that Dr. Guyer is gonna take this bite at the upper pole well below that. Good, you see your nerve up there? Relax for a second. Yep, okay. Medium clip, please. Medium clip. Pull just a little bit there Matthew please, so we can get the clips in. Spread. Oh I see, sorry. I thought you were trying... The third one, the third option. The one I wasn't doing. Yeah, right. Take another clip, please. So double ligation down near the thyroid gland, so we don't interfere with what we just visualized, which is the external branch of the superior laryngeal nerve. That's probably the best you've ever seen it, right Rich? I think so, yeah. Come on out, suction please. Oh come on. We're sort of snagged here. Here pass it to me, there you go. You just couldn't get far, you know what I'm saying? Have leverage, yeah. Right. So now we're gonna finish the upper pole, as we did on the last case, with some direct harmonic stimulation once again, or direct harmonic use, care with the external branch of the superior laryngeal nerve, and the carotid artery, which is lateral. Open wide, there you go. Forcep and Bovie please. So we're gonna do a few more little isthmic attachments before we proceed to the lateral aspect of this. So I would say come up here. That actually could be the true pyramidal lobe right there, see it? It kinda goes up here a little more. Yep, so you wanna pick this up, well, is that muscle? Hmm. I think it's muscle up there. Yeah I do too, give me a buzz. I think it ends right in here somewhere. Yeah stay right, right here. Good, and then you wanna just take that, sort of off the trachea. Yep, that is quite a little inflammatory pyramidal lobe there. So we're in the upper midline, and we see a little bit of what we call the pyramidal lobe up here. Buzz me. Good. Okay, so now we're gonna come out laterally to where the middle vein is located. So hold that over there Rich, right angle to Dr. Guyer. I see it right here I think. Yep. So these are lateral muscular attachments to the thyroid gland. We're well lateral to the nerve, the recurrent laryngeal nerve, at this point. More lateral attachments here, suction please. Peanut please. The key is the peanut there. Yeah. Lean that up, there we go. So a few tough attachments at the lower pole. After we take this bite we'll inspect for the lower parathyroid gland. Good. Okay, let's replace this. This right here, right here. Forcep please. So here is our lymph node packet. So we need to finish that up and connect the dots here. So I take, right here Rich. So we're kind of back over the trachea again, now towards the right side as opposed to the left side. And now we're done on the trachea there, perfect. Bovie, please. This packet, fatty packet once again is the level six, the pretracheal or central neck lymph nodes. Okay, so we finish that dissection, and you can come right here, mm-hmm, good. And this is where we start to think a little bit more about the right recurrent laryngeal nerve. We're still slightly medial and superficial to that nerve right now, good. Clean dry gauze, nerve monitor please. Can you turn the nerve monitor up to four please? Four. Thanks, Tim. So that is the stimulation of the right recurrent laryngeal nerve. So I would finish off this lymph node packet right here, right angle Rich, stay right, maybe a little higher, right here. Go down to the trachea, which is behind it. Good. Good. Forcep to me, Bovie to Rich. Again. Good, okay, so now we've gotten back to that point where we're gonna start looking at that peduncle and where the nerve inserts, so we can do our nerve dissection. So the first thing we're gonna do is check to make sure we have the whole upper pole down. We might be able to do a little bit more there. Right angle to Rich, please. We're gonna take out a little bit of the isthmus right here. We're starting to see increasing evidence of her inflammation, her Hashimoto's. Good, suction please. Another Kelly please. Suction right there Rich, for a second. So now we're pulling down a little bit more of the right upper pole, nerve monitor. You wanna come right under this stuff right here. Yeah, don't grab anything medial. There you go. Perfect. 2-0 tie please, and a forcep, got it. Yep. Right angle please, to Rich. Just right underneath here. Knife please. Tie those up, Rich please. There you go, spread again. Scissors, yep forcep. Do we not forcep? Do we not have that tied? All right, let's go with that. Maybe the vessel's not in the tie. I don't know. Yeah, I know. Medium clip to Rich, please. Just put a clip behind your tie. Pull the suction back please, Kat. You want it back? Back, yep. There you go. Good, interesting. Still bleeding. Something's weird here. Have another clip please. Forcep please. Forcep. Here. You want the clip? There you go. Hold on. Do you know what? Hold this up Rich, I'll come from the bottom. Yeah There we go. Suction, scissors. We don't wanna go any farther down here, because that's where the recurrent can cut in. All right, can we have a little squirt please? Hold that over, Rich please. Good, and this should be coming up here, good. And nerve monitor, please. Good, right angle please to Rich, let's dry that up. You might wanna hold this Rich, either with your hand or with a peanut, 'cause that Kelly's not helping you as much as it could. So we're gonna come right here, finish up the lower pole, great. Exclude that, there you go. Suction please. Give me a little buzz here, Rich please. Keep holding this thyroid. Not with that, peanut or gauze. And back that up just a tad, there you go. Right angle please, pull up with your peanut, and now take this. Harmonic, we're still slightly medial to the recurrent laryngeal nerve at this point. Bovie, please. And nerve monitor, please. Suction, that's exactly right. Very nice, Rich. There's a little something here that's bleeding. Can I have a small clip, please? Okay, all right, so right now I know the recurrent laryngeal nerve, second forcep please, is coming up right underneath the peduncle of thyroid, here. Here, right on outside the peduncle is the superior... Para? Parathyroid gland, exactly. So Bovie please, to Rich. So just be very careful just to do the surface here Rich, because the nerve is right underneath us. So we're just gonna release the capsule of the thyroid to drop that parathyroid down. Just tight. Yeah, exactly. Don't go in there, 'cause that's where the nerve is. All right, nerve monitor. There's the parathyroid gland. Do you see that there, Matt? Yes. Fine Kelly, please. You can pull on those just a tad there. Thank you so much. So now we are dissecting just medial to the parathyroid gland, going right under the thyroid peduncle for the recurrent laryngeal nerve. Turn the nerve monitor, is it down to two? I'll check, it's on four still. Oh, you can turn it down to two. Can I have the fine Kelly please? And there, the white there, I believe that's the recurrent laryngeal nerve, on the right. I see that. Right angle please. Harmonic to Rich please. That will drop down that para, just with the tip there. Just the tip, just the tip. There you go, perfect. Too slow? Good. Okay, so what we did with that bite is we just dissected the parathyroid gland out. and here is the recurrent laryngeal nerve right there. Can I have the right angle, please. And a 2-0 tie, please. Great, thank you guys for holding so nicely. So we're just above and lateral to the nerve at this point, but we're close. Rich is gonna take the right angle. Pull just a little bit Matthew please. Medium clip, please. Once again, the medium clip does not stay in the patient. Just the tie does. Try what you, yeah try that. Knife please, spread. Gotcha. There you go. Good, thank you. And then another clip please. Don't trust your tie? You know what? It's too close. I know it's not tight Rich, right? It's not tight. Scissors. Forcep. There's our recurrent laryngeal nerve right there. Peanut please. Do you see that there, Matthew? That white structure right there. Yeah. Suction. Forcep. Rich, hold this over for me. Thank you, put that right there. Right angle please. And a 2-0 tie up please, Kelly. 2-0 tie. Thanks. Pull with that peanut just a tad there, please Rich, and I'll put this on this side of the tie, and nerve monitor please to Dr. Guyer. Okay, suction. Right up there, see it, right here. Good, right angle to Rich please. Perfect, knife please. Here's the peduncle of thyroid, just hanging over the nerve as we elevate it up and away. Scissors please, forcep and suction. Bovie please. Okay, fine Kelly. So now we're gonna trace the nerve up to its insertion in the larynx. Scissors please. We're cutting a little bit of tissue right above the nerve so we can visualize it. So there's the nerve, and once again, this is the third or fourth time today we have a little vessel right on top of the nerve here. Right here, right? Yep. Let me go from below there, I should, can I have a fine Kelly? So first we're gonna separate that tissue from the nerve, and then we're gonna ligate it. This is exactly where we got the loss of the signal on the other side, right Rich? Very tight there, right? Right angle, nerve monitor. 2-0 tie up please, nerve monitor fist. So this one was a little more robust, or a little less stuck, or both, okay. Rich, just take your forcep and tilt the, there you go. You don't wanna pull that down, you wanna pull it that way, yeah there, right there, perfect. And right angle please, to Dr. Guyer. Suction, right underneath that silk. Yeah, I found a little gap. Well, I think you need to go a little medial. Well, now you're too medial. Good, perfect. Knife please, to me. Scissors please. Actually a small clip, please. And pull up on that please, Rich. Thank you. Forcep, okay. So now we have this last little piece, where the nerve is really attached to the thyroid. This is always the hardest, especially when patients have inflammatory thyroid disease. Peanut please, see it right there, going right, the nerve here is going right into the thyroid gland. There's actually some thyroid even lateral to it, which makes it even more difficult. And there's bleeding from the inflamed thyroid gland. So do me a favor here Rich, just hold that over right there. Did it go all the way down? Yeah, it fell down. Okay. Hold this right here please, Rich. We need just a new cord. Can I have a fine Kelly please? Rich, if you can hold this over here, even with a peanut. Oh yep, all this stuff here. Suction please. So in this particular patient, which is not unusual in Hashimoto's, the nerve is completely plastered. Yeah. Yeah. To the thyroid right here. So here Rich, I'm gonna have you come here as well. Suction. Thank you. And I don't think trying to separate it from the thyroid is gonna be a good idea. So we're gonna leave it right down there. Nerve monitor please. So let us know when the red cord is up. We got a red cord here. Great. Okay, so we're gonna pass this to you Dan. And if you could replace... Stand right here? Yeah, we're gonna towel clip this in place, so take that one out. And Dan, if you don't mind actually just pulling the old one just out towards you. Yep. Suction. Clean dry gauze, up please. Okay, right here Matthew. Just watch your fingers there, Rich. Forcep, can I have another forcep? Yep, I got it right here. Thanks. That's our nerve monitor. So if you talk to the laryngologists, who deal with recurrent laryngeal nerve palsies after thyroidectomy, they will tell you that the most common cause of a permanent recurrent laryngeal nerve palsy when you have not divided or sacrificed the nerve, so pure traction, is in patients with Hashimoto's, and we saw how that could be the case, and we're seeing it right now too. Because the thyroid is very adherent to the nerve, at the point where the nerve inserts into the larynx, which is the point where it's most vulnerable to injury, traction injury. I'm just gonna put one more throw on it, Rich. Suction. Mm-hmm, knife, please. Can you reload this please, Kelly? Just watch your fingers there, please Matt. Oh yeah, sure. And a forcep. And a forcep. So this is just a little bit of remnant thyroid tissue well away from the tumor, that we're leaving in place where the nerve is adherent to the thyroid tissue. Stitch please. So I'm just looking at where the nerve is coursing there. So the nerve is inserting into the larynx right there. We are gonna try to pull as much of this thyroid tissue over as we can, so that we get a good complete resection. And take a forcep, or you can even take mine Rich, and hold that thyroid tissue over, so that when we tie it, and here is our nerve. Don't you love my contraption? Do you love it? It's pretty nifty No it's like, you don't miss a beat, right? You're not like standing around there waiting for the hemostat, they're opening up six new kits. They're calling people like down in the other end of the OR, right? You're like, "I just need a cord." Middle school electricity, right? Yep. Something that conducts. Well it was funny, the reason this happened, is because one time that happened, and of course I was doing the thing I just described, like just complaining and calling for it, and the neurosurgery intern who was helping me just put that together, started stimulating the nerve. And you were like, okay. I'm like, oh thank you. Like you're a brain surgeon. Yeah, exactly. And I'm not. Okay, here's a needle back. Thank you. General surgeon. Yes. Can I please have a forcep? And before we cut this, what is this? Oh my God, wow. I know. That is like record time. A knife please. Knife, yeah. So in this last picture here, here's the nerve inserting into the larynx. We've sutured with a figure-of-eight 2-0 silk suture, the thyroid tissue just medial to the nerve where it's stuck, and then we're just gonna divide this, and leave that ligated thyroid tissue behind, right where the nerve inserts into the larynx. And if we need another stitch down here on this thyroid tissue, we can do that too. The knife is back. Bovie, please. Rich, you can take it, and then just way up here, see? Pull that over. This up here? Yeah, the nerve is here, so be careful not to come down here. Good, give me a buzz. And then you can sort of very carefully separate, actually stitch please. Let me put a stitch there, 'cause it's bleeding so much. There's a 2-0. That might be mostly... And we're putting a final little figure of eight for hemostasis on this thyroid remnant. I think I'm locked, no I'm not. Scissor. Needle's coming back. Thank you. Okay, hang on there Rich, suction. So you do have to release this last little bit. Go down to the trachea, make sure you go down to the trachea. Good, just don't get into the trachea. Good, good. Give a buzz here. Buzz me. So now we're dividing the final attachments of the thyroid to the trachea. We're well away from the recurrent laryngeal nerve. Give me a buzz, so we're able to use heat from the Bovie to do this. And as you can see, we've left a tiny little remnant of thyroid tissue where the nerve inserts into the larynx. Give me a little buzz. And just come a little bit away from the trachea Rich, there you go, okay. And this specimen's gonna look slightly different than the last one, because we have the attached pretracheal and central neck lymph nodes with it.

CHAPTER 10

Okay, so let's put this right here. So, there's the thyroid gland, the clamp here is at the right upper pole- And these are the attached pretracheal or central neck lymph nodes that we resected with the thyroid, because they're just adjacent to the tumor, which is right here. These are the lymph nodes here, tumor here. Left thyroid lobe, right thyroid lobe, right upper pole. So we're gonna have you mark that. Thank you, great. Bovie - get hemostasis?

CHAPTER 11

Yeah, start with your side. Hold that right there. Can we get some Tisseel please, or Vistaseal? Vistaseal Yeah. What would you like to call the specimen? It's a total thyroid with attached central neck lymph nodes, stitch at right upper pole. Irrigation, clean up some of that clot with the... So we got a good look at the left inferior... You know what would be great to do, Dan? Before she wakes up, anytime, can you draw 3 cc of blood for a PTH level? PTH, yeah. That way, she doesn't have to get stuck when we wake up. So we're gonna check a parathyroid level on her after surgery, because we didn't have a great view of all of her parathyroid glands. And we wanna know how hypocalcemic she's likely to get after the surgery. There's one right there, and that looks nice and viable. See that? Yeah, yeah. So we have at least one which is good, but would like to see what her PTH is after surgery. Nerve monitor. Testing the left recurrent laryngeal nerve function. I'll take another round of irrigation, please. Yeah, I don't see anything bleeding. I'm not convinced. Can we have a Valsalva please? A Valsalva please. Looks good. Checking for hemostasis under a Valsalva, with a little bit of water in there. Are you up Dan? Yep. Great, thank you. You can breathe. That looks good. Now let's check the other side. Right upper pole. So now we're checking for hemostasis and petite, yep. Forcep, or Bovie to me. I think you made it worse. Just make sure you don't make a hole in the trachea. Good, okay peanut, irrigation. Attached central neck lymph nodes, forcep. Let us know when you're up Dan, you up? Yep. Great. You can breathe, looks great. Are you thawing the Vistaseal? Yes, it's thawing. Okay. So in this particular patient, 'cause she was more inflamed and has a little more ooziness, we're gonna put an extra sealant in called Vistaseal, along with the Surgicel, peanut please. And if I can just, ooh where's that from? Oh, the other side. Hold this right here. So just to show you a few things here while we're waiting for the Vistaseal this is the little remnant of thyroid we left in place. That's the recurrent laryngeal nerve, right down there. And out here is the right superior parathyroid gland, just lateral to the nerve where it inserts into the larynx. Give me a little buzz here, please. Good, just wanna make sure this isn't bleeding here. That looks good, we're checking the upper pole. Let's check this little thing, remember that little thing that was bleeding? I think that looks okay. Let's just check this other side, 'cause we just saw a little, hold that right there. I think it's very important at the end of the thyroidectomy procedure to spend a little time checking for hemostasis, because you don't wanna get a neck hematoma and have to come back. Can I have the Bovie, please? It's just at the edge of this remnant, I think. Rich, right here, see? Good, and there's our lower, left lower parathyroid gland. Forcep. I'll take the Surgicel to start then. Yeah, that's just one side still frozen. Great, so we're gonna place the Surgicel right on top of the remnant piece at the upper pole. Another piece at the lower pole, right over the inferior parathyroid gland. Actually I'm gonna put an extra piece in here, down where we did that central neck dissection, and then one over the parathyroid. You can stay in there, 'cause we'll put the Vistaseal in there in two secs there, Rich. How's it look? I think it looks good. So this is fibrin, and it helps seal that, create a little bit of hemostasis, we're gonna do it on each side. Okay, so just gently hold that over, Rich. I know that's the trachea. I actually think it's probably fine. I got it in here. We're good, we're good. So piece of Surgicel on the remnant, piece of the upper pole, and a little piece at the lower pole as well. I'll take the Tisseel please, what's left of it, and then the remainder of the Tisseel, which once again is a very effective hemostatic agent. Forcep please. And we'll take 4-0 Vicryls. Thank you. A little extra Surgicel down where we did the central neck, or the pretracheal lymph node dissection.

CHAPTER 12

Here's the sternohyoid. There, I think that's what we want. So really small bites, and watch out for the AJ, which is right there. You can get a little bit of muscle there first. No, none of that. Just a little, yeah, that's perfect. Thank you, see I got a little bit of the edge of the vein there myself. Once again, very important not to get too big bites on the sternohyoid, you can put one above there, Rich, because then the patient will have a sensation of catching when they swallow. Cut please. Can I have a baby abdominal please? Can you reload that for me Kat, please? Probably one more above here. Forcep please. Let's see here Rich, maybe just like a little edge of the fascia here, see? Like that to, good. Cut please, great. Can we let the thyroid back down please? And we'll each take Addison's, and Dan, if you can just sort of tip her chin down to her chest and make sure her chin is straight, so we can close this symmetrically, great. I'll take a Vicryl please. Bag's down. Great, and then if you don't mind, oh hi. Actually I'll take one. By just tipping her chin down to her chest a tad. So I always make sure I don't pucker the skin when I take a platysmal stitch, because that means you're tacking the dermis to the muscle, and then the scar won't heal as well. So you absolutely just want muscle. Let's debrief on that, guys. It's a total thyroid with attached central neck lymph nodes. Stitch at right upper pole. Cut please. You can cut this needle off here, needle back, Kat. And you can see how much tension this would be under, if you didn't put the extra layer of deep dermal sutures between the platysma and the skin. And what's interesting about putting in several layers, is that sometimes it looks a little bumpier at first, but that all goes away as the stitches dissolve and the swelling goes down, and it just looks so much better. So I would put... One more in there? Yeah, and maybe even like one here. Do you know what I mean? Like I think we need one more superficial one in the midline and one here, okay. The needle is coming back. I see it, I got it. Don't worry. All right. Any other questions for me? Everybody good? We're good. Great, thank you very much.

CHAPTER 13

So in this patient we did do the pretracheal lymph node dissection. The lymph nodes that were located in this region looked very slightly abnormal, which could have been consistent with inflammation, or possibly consistent with malignancy. Those lymph nodes were resected and sent to pathology for analysis, but it's not unusual for patients with Hashimoto's to have some enlarged lymph nodes in this region. The patient was noted to have inflammation and vascularity of the thyroid gland, which is once again consistent with the diagnosis of Hashimoto's. And in this particular case, we did choose to leave small remnants of thyroid tissue where the nerve inserted into the larynx, to avoid injury to the recurrent laryngeal nerve when it inserts into the larynx. I would also say that we noted that the tumor itself appeared well contained within the thyroid with no muscle or tracheal invasion that we could tell.