| 00'29'' | Case presentation
I can start immediately with this incision. I think you can see the neck; it is a lady with a long neck. We do a 1.5cm incision with a standard scalpel. I am now opening the subcutaneous tissue, you can see the electrocautery. We have no platysma because we stay right in the middle where the platysma is very poorly represented, so we try to reach the midline while avoiding any minimal bleeding. As you can see, we are using standard instruments, very small retractors designed specially for this surgery, much smaller than the ones we use as sort of Farabeuf retractors, derived from the Army-Navy retractors. You see the midline, I am going to open it to try and reach the thyroid space on the left side. You can see now the strap muscles, that means we are about to separate. It is important not to make the strap muscles bleed because otherwise it becomes impossible to see. The thyroid space is about to appear. We must retract. Now we can change the retractors and place some longer ones because the thyroid space is in view. This part of the procedure is like when preparing the access with trocars. From now on, the procedure will be completely endoscopic. You can see the carotid artery, so we are preparing the operative space. You see the strap muscles are still present, we are dissecting them completely, the nodule is in the upper part of the lobe, partly covered by the strap muscles. It is important now to move the retractors in order to put in evidence the upper pedicle. At this moment, we have reverted the angle of the endoscope. Now the view is obtained from a 30 degree angle towards the higher part of the operative field. If I revert the endoscope, I have a nice view of the thyroid space. But at this moment, I need to reach the upper pedicle. So a better view is the one that I am reaching now with a 30 degree angle looking towards the roof of the operative space. So we are dissecting the muscles just to put in evidence the upper pedicle. We are now using Ultracision to dissect the muscles, trying to get a better access to the upper pedicle. You see the spatula. The lower part of the upper pedicle is already visible. We are dissecting and this is just to avoid any contact. I put the inactive blade towards the nerve. You see the upper pedicle has been grabbed by Ultracision at a safe distance from the nerve. Just in case I put my inactive blade closer to the nerve, so there is no heat transmission. I am just dissecting the upper pedicle. You need a little bit of time. My spatula is now touching the artery, can you see it pulsating? The upper pedicle is completed now. I place an endoscope with some angle so that it looks towards the thyroid space. I have not yet used a clip and hope that I won’t be using any. The most dangerous part of any thyroidectomy procedure is the upper pole and in thyroid toxicosis, which is what you have here, there is undoubtedly increased blood flow. When would you decide to use a clip, how often do you actually clip that upper pedicle as opposed to just treating it with the Ultracision? In this case, the patient has a very mild thyroid toxicosis, the total volume of the gland is quite low, it is almost a normal gland, we don’t have big vessels into the pedicle so I decided to go through the Ultracision. Of course, Grave’s disease is not a simple indication for the use of Ultracision, in that case I would dissect every single vessel and I would put clips. But in this case, I am quite confident that the coagulation should be enough.
We are going ahead with the dissection, looking also at the parathyroids. This is the parathyroid now we are touching with the spatula, we are slowly dissecting it just to separate it a bit from the thyroid gland. Then we are searching for the recurrent nerve; the anatomical landmark is usually the inferior pedicle. Here is the nerve, it is quite a nice view because you can see the nerve and underneath some fibres of the esophagus. Therefore we are quite deep in our search for the nerve, quite posterior, the nerve will be prepared almost all along its course. Now that I am quite sure, I am looking even higher for the nerve, we are following its path until it is close to entering the larynx. This is a nice view, this is the main anatomical landmark: the inferior thyroid artery. The nerve shows in a typical way, passing underneath the thyroid artery so that we have a standard anatomical situation. We dissect the nerve a little before extracting the lobe. The nodule is not very large, from the ultrasonography it is around 1.5cm. When using the retractors, the nodule is bulging a little bit; so if the nodule is very big, it becomes very difficult to load it. We are dissecting the nodule a little bit and trying to load it with the retractors. The upper parathyroid is in this position, almost completely covered by the nodule. We are dissecting slightly the parathyroid gland, so we have seen both parathyroids and we are now ready to extract the lobe because it has been completely separated by the structures we want to preserve. We are now rotating the upper pole of the gland. At this moment, we need an extra relaxation from our anesthesiologist because otherwise the strap muscles do approach the midline and prevent us from extracting the lobe. I am dissecting on the isthmus now, I will try to show you exactly the resection of it. When using the Harmonic scalpel through very small incisions, it is important that you avoid contact with the skin edges because the contact does generate a tremendous amount of heat and you may lose your cosmetic effect if you actually burn the edge of the skin. The lobe is completely retrieved; this is the nodule, which is about 2cm, this is the lobe, and we are now going to complete the dissection. The surgeon has moved to the left as it needs to have good vision and be on the same side of the lobe that will be resected. We are now showing the inferior artery and we are now dissecting the isthmus on its lower part. There are small vessels coming from the opposite side of the isthmus, maybe arteria thyroidea ima that we are dividing with Ultracision. We will check the stage of the pyramidal lobe in the end. We are going towards the opposite side to be sure that we have removed the entire isthmus, this is a general rule of thyroid surgery but a lobectomy should be performed for benign disease, isthmus lobectomy. The neck is not hyper-extended so there will be no neck stretching; it is a completely supine position. This is the tract you see, so we are on the opposite side of the tract. Making sure that we have removed all the isthmus and now making a final check of the nerve, which is quite far away because here is the artery and the nerve is underneath. We are now dividing the small branches coming from the inferior thyroid artery so the main trunk will be completely preserved. Here is the nerve just at its entrance so we can be sure that we are not jeopardising the nerve before the final dissection of the Berry’s ligament. We have the entire lobe with its capsule entirely removed. The pyramidal lobe is right here, I am showing it with my spatula, we are going towards the highest part where it ends up, we can dissect. Also the pyramidal lobe has been completely removed. It has been removed, that’s it. We are now on the tracheal surface, we can go quite safely and quickly. The pyramidal lobe is completely removed and the operation is now completely removed. We will check the operative field endoscopically. Here is the upper pedicle, it is a 30 degree scope looking towards the high part, then I revert the angle and I can see better the artery, the upper pedicle pulsating, then I go lower. You see the parathyroids, this is the lower one. I clean and wash the operative field, once again I go in. You were right, it was the upper parathyroid, the inferior is here. Here you see the nerve all along its course. Here is the specimen, it is a 5cm long lobe, this is the nodule, which was covered by the thyroid. It is a 2cm hyper-functioning nodule. This is the lobe, and this is the pyramidal lobe.
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Video-assisted left thyroid lobectomy
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