Thyroidectomy

THYROIDECTOMY * DONALD E. Ross, M.D. ANGELES, CALIFORNIA

LOS

T

HE mortality rate for thyroidectomy in many of the Ieading cIinics in this country is Iess than I per cent. This is remarkabIy low and speaks highIy of the quaIity work done. One shouId reaIize that this does not represent the mass of surgeons throughout the land whose statistics are diffrcuIt to obtain. It goes without saying that the mortality is much higher and in some instances aIarmingIy so. My own mortality rate has been graduaIIy Iowered. The Iast one hundred cases have been done without any mortaIity, and onIy one death occurred in the previous one hundred cases. My excuse, therefore, in writing this paper is the hope that by describing a simple technic and emphasizing some points it may be heIpfu1 in Iowering mortality for others. In no other lieId of surgery is thorough knowIedge of anatomy and pathoIogy so essentia1. The surgeon shouId know where the parathyroids are Iocated normaIIy as we11 as the location of the recurrent nerve. Every surgeon can Iearn anatomy and I, therefore, urge him to do so before doing a thyroidectomy. (Figs. I to 5.) Pathologica conditions of the goiter vary greatIy in different parts of the countrv due to variation in iodine content of the soil and water and to other factors. In this locale we seIdom see a “pure” type. Practically aIways they are of the mixed variety. In the one microscopic section one may see norma aIveoli, excessive coIloid areas and even hyperpIastic areas. We beIieve that iodine benelits aImost a11 patients, also LugoI’s soIution, 15 m. three times a day and sufficient phenobarbita1 for complete rest. At Ieast two weeks’ treatment in bed is insisted upon prior to any surgery. * From the Department

Th e question of muItipIe operative stages is much debated. I believe that the age of the patient and the duration of the symptoms are of the utmost importance in making this decision. Many patients stand Iobectomy who would dre with a It prevents &lapse compIete operation. of the trachea, minimizes the postoperative tracheitis and prevents the incidence ot severe reaction. I believe, too, that Iigation operations shouId be done in severe cases. It is a very minor operation and gives exceIIent resuIts as evidenced by increased weight, reduction of genera1 nervousness and toxic symptoms. I aIso beIieve that this procedure reduces the mortalit?.. OPERATIVE

PROCEDURE

Anesthesia. The choice of anesthesia is more important than is usuahy considered. I do practically a11 operations, except on chiIdren, under loca1 anesthesia. It definiteIy minimizes the operation, ensures deIicate handling of the tissues and prevents many of the postoperative complications such as tracheitis, bronchitis, shock and genera1 reaction. Many of the Iarge clinics use intratrachea1 anesthesia. The presence of such a foreign body in the trachea over the period of operation definiteIy increases tracheitis. I cannot understand why more surgeons do not adopt IocaI anesthesia. To administer the anesthetic a whea1 is raised with a smaI1 needIe and then inliltration under the skin aIong a line encircling the operating heId. (Fig. 7.) It is usually unnecessarv to use intraderma1 infiltration. The needIe”is next inserted deepIy through the fascia every half inch along the posterior margin of the sternomastoid muscle to block the branches of the cervical plexus

of Surgery, Ross-1 .oos Medical Group 37

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incIuding the postauricuhrr, occipital, transand clavicular verse colic, acromia1 branches. (Fig. 6.) Great care should be

FIG. I. FIGS.

I AND2. Anatomica

taken to draw back on the syringe each time before injection as occasionahy a vein may be entered. FoIIowing infiItration through the fascia, the muscIes immediateIy in front of the sternomastoid are injected to bIock off the descendens hypogIossi. The Iast step is injection into the superior pole. UsuaIIy about IOO cc. of I per cent novocain are used with three drops of adrenaIin LATERAL

DtSSECTION

.JANUARY.

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incision to pull downward, and if it is too low it will uItimateIy cross the upper part of the sternum and be too conspicuous.

FIG. studies; self-explanatory.

2.

In the average case the incision need nor be too Iong and a short scar gives bettet cosmetic resuIt. However, when the thyroid gland is very large, I do not hesitate to enIarge the incision, carrying it upward toward the ear aIong the sternomastoid as this helps materiaIly in exposing the upper poIe of a Iarge goiter. The incision is carried down through the skin, superficial

COMPLETED

FTC. 3. FIGS. 3 AND 4. Anatomical

added to each ounce. Some authorities cIaim that the use of adrenalin precipitates a postoperative storm. I have found no such immediate or Iate reaction in any of my cases. After the gland is exposed, more solution is injected into the upper poIe to block off the sympathetic fibers which accompany the superior thyroid artery. Incision. The incision (Fig. 8) shouId be made about one inch above the sterna1 notch since there is a tendency for the

FIG. 4. studies; self-explanatory.

fat and pIatysma but not through the fascia. Gauze is then used to assist in stripping the fIap upward, using sharp dissection where necessary. The Iower edge of the incision is dissected downward in the same manner. This aIIows better skin approximation and better exposure. The fascia is not cut in a transverse plane. The fascia is incised in the midline with a scaIpe1 and cut with a scissors in a vertica1 direction from the thyroid cartiIage to the

cpistcrnaI notch, avoiding the anterior jugular vein. The sternohyoid muscIes are split vertically in the midIine, exposing

groove between the upper pole 01‘the ~lantl and the thyroid cartiIage to rele:rsc thcl media1 side of the pole. (Fig. IO.)

,L SUPERFICIAL

POINTS NERVE

* ‘.

FOR DEEP BLOCK

FIGS. : AND 8. Superficial block and line of incision. In Figure 7 a circular arr~ is inliltrntctl dong the line indicated. I;I(;L

5 ANll 6. Anatomical tory.

studies;

sekxplana

the gIand with the two thin sternothyroid muscles covering the Iobes on either side. (Fig. 9.) The sternothyroids are stripped off carefutly and retracted Iaterally to expose the IateraI edges of the Iobe. Steps in Resection. The steps from this point may vary greatIy in the hands of different surgeons. Each surgeon of repute has worked out details of resection to his own Iiking. A carefuIIy pIanned operation needs to be varied onIy rareIy and greatIy facititates the speed and smoothness of any operative procedure. Our technic is :is foIIows : Step I. The upper poIe is injected with novocain to anesthetize the sympathetics along the vessets. If this is not done, the patient may compIain of discomfort during the operation. Dissection is begun in the

Step 2. The IateraI aspect of the gIand is retracted by a Percy forceps and the capsuIe stripped backward. The middle thyroid vein is encountered at this point, and is doubly cIamped, cut and tied. (Fig. I I.) The vein enters the internal jugular vein directIy and if it is allowed to retract before Jigat‘ion, undesirabIe bleeding may occur. It is diffrcuIt to foIIow the proper line of capsuIe if this vein is not first secured. Gauze dissection is used to strip the capsule upward and posteriorIg until the Iateral aspect of the superior pole is cIeared. (Fig. 12.) Step 3. The upper pole is exposed by retraction and gently pulled downward, forceps. (Fig. I 3.) If the using Percy thyroid gland is unusuaIIy Iarge :lnd extends upward, the sternohyoids may be divided. This procedure is rareIg necessary but it does give good exposure in difficult

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Ross-Thyroidectomy

cases. A bIunt aneurysm needle is used to thread No. I pIain catgut under the poIe, passing the needle from within outward to

JANUARY,

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posteriorIy some distance from the poIe. The media1 branch enters the thyroid near the trachea about haIf way up. It is

II

9

IO

FIG. g. Thyrohyoids

and fascia have been divided, virtually exposing the isthmus and thyroid cartilage. FIG. IO. Dissection is begun by dissecting in the groove between the upper pole and the Iarynx. FIG. I I. Lateral side dissected securing the middle thyroid vein. FIG. 12. Shows dissection of the capsule.

prevent picking up the superior IaryngeaI nerve. (Fig. 14.) This procedure is much simpIer than using curved forceps and is accompIished with Iess trauma. The poIe is doubIy tied and divided, Ieaving enough tissue dista1 to the Iigatures to ensure their safety. Step 4. Dissection is carried around the Iower poIe and the inferior thyroid vesseIs are cIamped cIose to the gIand. It may be noted that the trunk of the main inferior thyroid artery is rareIy seen. It emerges through the fascia behind the Iower poIe and aImost immediateIy divides into three or more branches. One of these branches may have been encountered during dissection of the lower part of the IateraI aspect. Another Iarge branch enters the gland

very necessary to remember the Iocation of these branches and to Iigate them before they can retract. Grasping for them may cause injury to the recurrent nerves and parathyroids. Step 5. The isthmus is now divided. Sometimes this procedure is facilitated by undermining with a curved KeIIy forceps. (Fig. 14.) UsuaIIy, however, the isthmus is divided in smaI1 sections by doubIy cIamping and cutting. When the trachea is reached the dissection is continued IateraIIy; care is taken not to strip the trachea too cIean. UsuaIIy a Iayer of fascia is left over it. The IateraI aspect of the trachea is freed. Step 6. The whoIe Iobe is now Iifted up to decide how much tissue shouId be

allowed to remain. A smaII portion is usually left chnging to the posterior capsuIe and to the groove between the trachea

FIG. I 3. An aneurysm a ligature is passed p0k.

needle carrying under the upper

and esophagus. I 3.) The portion (Fig. between the trachea and esophagus cover the recurrent laryngea1 nerve and protects it. The amount of gland to be left is stiI1 a matter of surgica1 judgment. I believe that a small, relatively heaIthy portion

Frc;.

15. Roth

Iobes removed leaving portion of each.

a small

of the gland is rareIy found. In most cases practicaIly all of the gIand tissue is affected. If diseased tissue is aIIowed to remain, it may continue growing and cause a11 the symptoms to recur, In spite of great care there will remain a small laver of gIand tissue over the recurrent IaryngeaI nerve area and a small portion over t.he trachea. For ten years I have done almost complete thyroidectomies and have had no untoward effects. It is true that in a

few cases some thyroid tabIets are necessary postoperativeIy, but these supply all necessary thyroid secretion to the body.

FIG. r.+. After freeing the lowrr isthmus is divided.

pole tht

CarefuI follow-up with repeated basa1 metabolism tests is advisable, and I am often agreeabIy surprised to see the test very satisfactory when a \rery low metabolic rate was anticipated. After packing the area gently the isthmus is carefull\- dissected off the trachea

FIG. r 6 IIlustrates a new method of drainage. Forceps passes through the sternothyroid muscIe and is carried Iatrrally, superficial to it (along the dotted line) and through a thinned-out portion of the sternomastoid muscle. The right side of the illustration shows the tube in position.

toward the other side, clearing not onIy th e anterior aspect but a considerable portion of the lateral aspect. Resection of the Ieft lobe is then carried out by the same procedure as used on the right. making certain that Step 7. After hemostasis is satisfactory the next step is

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Ross-Thyroidectomy

to suture

the Iayers of muscIe and fascia I beheve that and to estabhsh drainage. adec quate drainage is necessary for twenty-

IateraI ends of the wound. (Figs. 16 and rg.) The tube makes its appearance behind the latera to the sternomastoid

19

FIG. 17,The

sternothyroids are sutured as a separate layer over the trachea, protecting it and preventing adhesions to the skin. Sternohyoids are next sutured. FIG. 18. Skin is closed with skin clips and a few fine dermal sutures. Drainage tubes are shown. FIG. rg. A s&sterna1 goiter is iIlustrated showing the dissection from above downward, dividing al1 the attachments shown in Figure 2. FIG. 20. Substerna goiter with all attachments divided and ready for deIivery.

four hours postoperativeIy. I am aware that certain authorities do not consider It is assuming the drainage necessary. impossibIe to state that a wide dissection shouId aIways be free from some coIIection of serum. The trachea is very sensitive to changes in pressure and if cJots occur they may cause sweIIing in the neck and collapse of the trachea. For drainage I use a soft gum-eIastic tube of smaIl size and have had no harmfu1 effects from its use. In the past, drainage has been established through the midIine. Because of this, adhesions to the trachea often deveIoped and caused a puhing in of the skin and scar whenever the patient swahowed. I now establish drainage on each side, bringing the tube out at the

muscIe. The procedure is fraught with some danger of injury to the interna juguIar vein. The foIIowing technic protects the vein: The edges of the sternothyroid muscle are heId up under shght tension, using a Percy forceps. A KeIIy forceps transfixes the sternothyroid muscIe and is carried backward and outward in the plane between this muscIe and the sternomastoid muscIe and is pushed through the fascia. The tube is then puIIed through. The drain for the opposite side is inserted in a simiIar manner. Step 8. In the next step the thin Iayers of sternothyroid muscles are brought across the trachea and sutured together in this position. (Fig. 17.) This is done to protect

the trachea and prevent postoperative adhesions. The sternohyoid muscIes and fascia are then sutured as one Iayer, using a continuous stitch. The skin, superficial fascia and platysma are brought together with large clips and to secure accurate approximation a few derma1 sutures are inserted between the chps. The drainage tubes are brought out the IateraI corners of the wound. (Fig. 19.) SUBSTEKNAL

GOITEK

It’ the attachments of the gland are well i II mind and the gland is divided from above downward, resection of a substernal goiter is quite simple. The attachments may be enumerated as follows (Figs. 2 and 18): i I) the superior pore, (2) the isthmus, (3) the Iateral aspect of the trachea, (4) the capsule of gIand posteriorIy and IateraIIy, (5) the middIe thyroid vein, (6) the branches of the inferior thyroid artery entering the gIand on the posterior surface, (7) the fascia-over the lower pole anteriorI) in the neck and (8) the inferior thyroid veins. If dissection is carried out in the order given from above downward, the intrathoracic portion usuaIIy can be deIivered without dilt;cuIty. (Fig. 20.) In rare instances the intrathoracic portion is very large and cannot be delivered. In this case it may be necessary to divide the gland into several portions and deIiver it in sections. This procedure can be carried out safeIy since the blood supply has been cut off previously. This procedure is much preferable to drvision of the sternum which, in my opinion, shouId never be done in these cases. TWO-STAGE

OPEKATION

The question arises as to which cases shouId be subjected to a two-stage operation. It is here that exceIIent surgica1 judgment is so valuable. There are no definite rules or tests to evaluate properly a patient’s ability to stand surgery. In cases of old, long-standing goiter with cardiac decompensation, the operation should be performed in two stages or even three or

four stages. In borderline cases it is more difficult to decide. The best criterion is the age of the patient. If the patient is past fifty years of age, the danger of the operation IS magnilied. I prefer a two-stage operation and a low mortaIit\: to ;I onestage operation and a high mortality. I do not hesitate to do Iigations as a Preliminar! procedure and am convinced of their value. Preoperative preparation of these patients is important. P ro I onged rest in bed uith phenobarbital gr. I 1i three times a da\-, and Lugol’s solution~is essential. llc+talization for a few days preoperativel~ i\ advisabIe in a11 cases. Edema of the Iegs does not always mean cardiacdecompensation and ma!- be cleared up in many cases by blood transfusion. Adherence to the above principles has enabled me to do the last one hundred cases without a death. KECURKENT

GOITEKS

Cases of recurrence of the enlargement of the thyroid gIand present a most serious problem since the gland is adherent ever>where and there are no natural planes of dissection, The only advice offered is to stag cIose to the gland and dissect slowly and carefuIIy, as otherwise the parathyroids or the nerves may be damaged. SUMMARY I. Low mortality may be obtained by (a) careful selection of patients and vaIuation of their abiIity to toTerate operation, (b) carefu1 and adequate preparation of the patient, (c) a simpIe and we11 planned operative technic, emphasizing the deIicate handling of tissue and hemostasis, (d) use of 1ocaI anesthesia is urged and the technic is described and (e) multiple operations are used in bad risks and definitely saves many Iives. 2. A radical operation is carried out as a routine, Iowering the incidence of recurrence. 3. My operative technic is described, showing a new method of closure and drainage.