DANIEL PRICE: My name is Dan Price. I'm going to take you through a total thyroidectomy with a central neck dissection. This is performed on a 66-year-old male with a biopsy proven papillary thyroid carcinoma. Tumor was measured at greater than 4 centimeters in size, with ultrasound evidence of extracapsular extension, and for that reason, central neck dissection was planned.
Hibiclense prep is used to avoid inadvertent uptake of iodine from a betadine prep. Incision is made approximately 6 to 7 centimeters in length in the horizontal skin crease. Some flaps can be elevated in the plane just above the strap muscles, preserving the anterior jugular veins. Flaps should be elevated to the hyoid bone superiorly, into the sternum inferiorly.
Strap muscles are divided in the midline-- retracted laterally off of the thyroid gland. Joll's-- J-O-L-L-S-- triangle is dissected out along the medial surface of the superior pole of the thyroid gland to preserve the superior laryngeal nerve and dissect out the superior thyroid pedicle. Those vessels are then isolated, litigated, and divided.
In this case, I used the thunder bead clips, or silk suture ligatures are equally effective. The closer you divide the vessels to the superior pole, the less risk of injury you will have to the superior laryngeal nerve. As a matter of standard, we use a NIM tube throughout the procedure as well for nerve monitoring.
The thyroid vein is divided, ligated. Gland rotated medially, and the superior parathyroid gland is usually then visualized. Muscles are divided from the lower pole as well, dividing these superficially to avoid inadvertent damage to the recurrent laryngeal nerve, which is much deeper into the dissection.
The gland is rotated medially, and the recurrent laryngeal nerve then identified in the tracheoesophageal groove. Its most reliable landmark, being near the cricothyroid joint. Very little dissection of the recurrent laryngeal nerve is required for a thyroidectomy alone, but in a central neck section, the entire length of it in the neck will need to be skeletonized.
Gland is continued to be rotated medially. Vasculature coming from inferior leaves divided. Recurrent laryngeal nerve is traced inferiorly in the tracheoesophageal groove. Vasculature to the parathyroids, which both will be coming from the inferior thyroid artery, have to be preserved. The renal artery is divided.
Careful dissection performed at various ligament, a cuff of which can be left around the nerve to protect it or very carefully divided and litigated to maximize removal of thyroid tissue. The thyroid is then elevated off of the trachea. The pyramidal lobe should be dissected out and can extend all the way up to the hyoid bone.
The right lobe is now completely mobilized. And we repeat the same process on the left side. The strap muscles are elevated off the gland if you haven't done so already. Joll's triangle dissected out.
Superior thyroid vessels isolated, ligated, divided. Little thyroid vein, isolated, litigated, divided. Parathyroid glands, both superior and inferior, dissected away from the gland, preserving the blood supply from the inferior thyroid artery. And then the recurrent laryngeal nerve identified-- again, most reliably near the cricothyroid joint in the tracheoesophageal groove.
Berry's ligament is carefully divided, and then it's elevated off of the trachea. Total thyroidectomy is complete. Resection isn't really necessary. If it's not going to change the plan, superior and inferior parathyroid glands are preserved.
I'm going to perform an ipsilateral central neck dissection. Key components of the central neck dissection are to preserve the recurrent laryngeal nerve along its entire length to preserve both the superior and inferior parathyroid glands as well as their blood supply from the inferior thyroid artery, dissecting that out, and to remove the lymphatic tissue from the trachea medially to the carotid sheath laterally from the sternum inferiorly to the hyoid bone superiorly.
We start by dissecting out the recurrent laryngeal nerve down to the thoracic inlet, dividing the fiber of fatty tissue. We similarly identify and preserve the blood supply to the parathyroid glands and divide the fibrous fatty attachments of that lymphatic packet.
Hemostasis is assured. A drain isn't required, but used in many cases. The strap muscles should really just be loosely approximated and do not need to be closed in a watertight fashion. For central neck dissection, we would routinely admit the patient post-operatively, monitor postoperative calcium, and dismiss after a one night hospitalization, though, certainly outpatient management is an option as well.
Skin is closed with dissolvable sutures. That concludes the total thyroidectomy in central neck dissection. Key points to remember are, first, adequate preoperative evaluation with good ultrasonography, fine needle aspiration biopsy, and planning, whether that's for heavy thyroidectomy, total thyroidectomy, thyroidectomy with neck dissection.
Next is identification and preservation of superior laryngeal nerve and good control of superior pole vessels. Identification of the superior and inferior parathyroid glands and preservation of their blood supply. Identification of the recurrent laryngeal nerve and the tracheoesophageal groove, and careful division of Berry's ligament to avoid injury to the recurrent laryngeal nerve and manage bleeding. Thank you for watching.
