Video-assisted thyroidectomy

This video demonstrates the technique of video-assisted thyroid lobectomy in a patient with nodules. The surgeon uses a 1.5 cm skin crease incision in the middle of the neck to gain access to the thyroid space and under video-assisted vision to identify the key structures including the thyroid vascular pedicles and the recurrent laryngeal nerve. The vascular pedicles are divided using ultrasonic scissors and the thyroid nodule is delivered after division of the isthmus.

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Video-assisted   thyroidectomy

Authors
P Miccoli
Abstract
This video demonstrates the technique of video-assisted thyroid lobectomy in a patient with nodules. The surgeon uses a 1.5 cm skin crease incision in the middle of the neck to gain access to the thyroid space and under video-assisted vision to identify the key structures including the thyroid vascular pedicles and the recurrent laryngeal nerve. The vascular pedicles are divided using ultrasonic scissors and the thyroid nodule is delivered after division of the isthmus.
Classification
basic techniques
Keywords
thyroid lobectomy, nodule, recurrent laryngeal nerve, video-assisted
Media type
Duration
15'00''
Publication
2005-05
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1271e.htm

Video-assisted   thyroidectomy

4. Case presentation 00'01''
It’s very important to make the incision right in the middle, exactly in the midline because we need a bloodless plane to incise. As you can see, we use this very small Army-navy retractor to accomplish this. The electrocautery is isolated and just the tip of the blade is active so that the coagulation is minimalised. You can see the fat plane is completely retracted and we should now be in a bloodless plane incising on the linea alba. This will allow us to enter the thyroid space, which constitutes the operative space for both thyroid and parathyroid procedures. You can see that not a single drop of blood is visible; this is very important because otherwise the visibility wouldn’t be possible. The Army-navys are now retracting the external layers of the strap muscles. So you can see the thyroid space here. The carotid artery is here. It is very well visualized. There’s its white layer here. Now you can see the nodule. We’re now coagulating the small veins and now we’re going straight on to the upper pedicle of the thyroid. We’re preparing the upper pedicle of the thyroid now and we’re searching for the external branch of the superior laryngeal nerve, which is shown just here. I’m not sure I have enough room but I’ll try. There are 2 blades in this instrument. This part you see with the white part is not active. The other jaws are active so it’s important to avoid the heat on the nerve. Always keep the inactive blade against the structures you want to protect. You can see even the small vessels pulsating. This is the side on the thyroid lobe and this is the side on the carotid artery. You see 2 small clips put on a small vessel, which is bleeding a little bit and it escaped the Ultracision coagulation. Now we go down searching for the recurrent nerve. You see we’re working with the small spatulas. We need very small instruments of course. Here you can see quite clearly the inferior pedicle of the thyroid. So we know from anatomy that the recurrent nerve should be lying exactly under the inferior pedicle of the thyroid. We suspend the artery a bit and the assistant is dissecting and the nerve should appear on the screen. You see the inferior pedicle here and we’re now touching the nerve and dissecting it away from the thyroid nodule a little bit. This is the parathyroid. We’re going ahead with the dissection of the thyroid and we’re now under the inferior pedicle. This is the best view of the nerve. We had seen it previously from the other side. Now I’m coagulating the second middle thyroid vein. The nerve is best seen from this side. We’re dissecting it and placing it away from the thyroid. You can see the nerve, which lies underneath the artery so it’s a very correct anatomical presentation without any sign of variation. We’re also checking the upper pedicle. You can see the external branch of the superior laryngeal nerve, the inferior pedicle with the artery and the vein. Of course, it should not be ligated. This is our position. Beneath the inferior pedicle, the recurrent laryngeal nerve is very well visualized. You can see the nerve almost completely prepared and separated from the gland. We’ll have a second good view when the thyroid lobe has been extracted. Right now, we’re trying to extract the thyroid lobe. You can see the upper pole of the thyroid, which has been completely ligated with its upper pedicle. So we’re now extracting all the upper part of the thyroid. It’s completely freed. Now the problem is extracting the lower pole because it contains a nodule. We’re preparing the last capsular vessels and this is the lobe of Zuckerkandl. We’re now dissecting the isthmus from the right lobe of the thyroid, and I can now show you the entire lobe. You see the 2 nodules. The inferior nodule, which is the largest as probably 22mm and the other nodule is posterior. Now what remains is to prepare the small inferior vessels and check the nerve once again. This is the ligament of Berry. We check the nerve underneath and I always keep the inactive blade of the Ultracision posterior so as not to jeopardize the structures. Now you can see the trachea is completely free. So what we can say is that we were able to perform absolutely a radical thyroid lobectomy. This is the last part of the isthmus and as you remember, we had prepared it already. Now I’m right on the plane of the trachea and I keep the inactive blade against the trachea so it’s not injured. These are some small veins coming from the inferior pedicle toward the capsule: we dissect them. Now you can see the opposite side of the thyroid. This is the left lobe of the thyroid, so it can be said that a complete lobe isthmusectomy has been performed. If there is a cancer, or if we need a total thyroidectomy, it’s not difficult from the central access to go to the opposite side, in this case the left lobe, and perform the same operation and end up with a total thyroidectomy. I have to say that the use of the Harmonic scalpel allows a large amount of time to be saved. And here’s the final look. We’re checking on the upper pedicle. Hemostasis is good. We can look down now. We close the midline of the single stitch. No drain is used and in fact no skin stitches either just Thermabond.