Chapters Transcript Total thyroidectomy with central neck dissection Mayo Clinic otolaryngologist Daniel L. Price, M.D. demonstrates a total thyroidectomy and central (level 6) neck dissection. Daniel L. Price, M.D. My name is Dan Price. I'm gonna take you through a total thyroidectomy with the central neck dissection performed on a 66 year old male with a biopsy. Proven papyri thyroid carcinoma tumor was measured at greater than four centimeters in size with ultrasound evidence of extra capsular extension. And for that reason, the central nec dissection was planned. Linse prep is used to avoid inadvertent uptake of iodine from a beta dine prep decision is made approximately 6 to 7 centimeters in length. The horizontal skin crease flaps can be elevated in the plane just above the strap muscles, preserving the an interior jugular veins, flaps should be elevated to the hyoid bone superiorly and to the sternum, inferiorly, strap muscles are divided in the midline, retracted laterally off of the thyroid. Gland. Joel's J O L L S triangle is dissected out along the medial surface of the super pull of the thyroid gland to preserve the superior laryngeal nerve and dissect out the superior thyroid peta. Those vessels are then isolated, ligated and divided. In this case, I use the thunder beat 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 N M tube throughout the procedure as well. For nerve monitoring, little thyroid vein is divided, ligated gland rotated immediately and the super parathyroid gland is usually then visualized vessels 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 immediately 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 dissection, the entire length of it in the neck will need to be skeletonized has continued to be rotated immediately. Vascular church coming from inferiorly is divided. Recur lal 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. Nema artery is divided. Careful dissection, performed a berry's ligament, a cuff of which can be left around the nerve to protect it or very carefully divided and ligated to maximize removal of thyroid tissue. The thyroids then elevated off of the trachea. The parameter lobe should be dissected out and can extend all the way up to the hyoid bone. The right lobe is now completely mobilized. You repeat the same process. On the left side, the strap muscles are elevated off the gland. You haven't done so already. Joel's triangle dissected out suire thyroid vessels, isolated ligated, divided middle thyroid vein, isolated ligated divided parathyroid glands, both superior and inferior dissected away from the gland, preserving the blood supply from the infero thyroid artery. And then the recurrent laryngeal nerve identified again most reliably near the cricothyroid joint in the tracheoesophageal groove there. His ligament is carefully divided and then it's elevated off of the trachea. Total thyroidectomy is complete. Frozen section isn't really necessary if it's not going to change the plan, superior and infero parathyroid glands are preserved. We perform an ipsilateral central nec dissection. Key components to 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 th thyroid artery dissecting that out and to remove the lymphatic tissue from the trachea immediately to the Caro 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 fibro fatty tissue. We similarly identify and preserve the blood supply to the parathyroid glands and divide the fibro 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 or central neck dissection. We would routinely admit the patient postoperatively monitor postoperative calcium and dismiss after a one night hospitalization. Certainly outpatient management is an option as well. Skin is closed with dissolvable sutures that concludes the total thyroidectomy and central nexus section. Key points to remember our first adequate preoperative evaluation with good ultrasonography, fine needle aspiration, biopsy and planning whether that's for hemi thyroidectomy, total thyroidectomy thyroidectomy with nectar section. Next is identification and preservation of the superior laryngeal nerve uh and good control of superior pull 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 barry's ligament to avoid injury to the recurrent laryngeal nerve and manage bleeding. Thank you for watching. Published February 15, 2021 Created by Related Presenters Daniel Price, MD Otolaryngologist Oral Cavity Cancer and Reconstruction Clinic in Minnesota View full profile
