Thyroid Lobectomy is an operation to remove one half (a lobe) of the thyroid gland. This simply means removal of a thyroid lobe and the isthmus (the part that connects the 2 lobes). This removes more thyroid tissue than a simple lobectomy, and is used when a larger margin of tissue is needed to assure that the “problem” has been removed. Appropriate for those indications listed under thyroid lobectomy as well as for Hurthle cell tumors, and some very small and non-aggressive thyroid cancers. Operative time: usually 45 minutes to 1 hour. Anesthesia: General anesthesia is used.
Hospital stay: usually day surgery Indications: -Thyroid cancer (non-aggressive cancer) -Goiter (an overall enlargement, unilateral non toxic goiter/ isolated to one lobe) -Hyperthyroidism (the production of too much hormone) -Thyroid Nodules (a localized enlargement, are growth of cells in the thyroid gland) Laboratory and Diagnostic exam -Physical assessment- The physical examination includes checking the thyroid gland for possible enlargement (commonly called a goiter), its adjacent lymph nodes for any pain, tenderness and swelling, and the nodule itself for consistency, size and texture.
If the nodule is soft, smooth and mobile, chances are the nodule is benign. If the nodule is firm, hard, irregular and fixed, the nodule may be malignant -Serum Ca and PH level -CT scan- to help detect and diagnose a goiter, or larger thyroid nodules. -Serum PTH- It is ordered to help diagnose the reason for a low or high calcium level and to help distinguish between parathyroid-related and non-parathyroid-related causes. It may also be ordered to monitor the effectiveness of treatment when a patient has a parathyroid-related condition.
A calcium test is almost always ordered along with a PTH test. It is not just the levels in the blood that are important, but the balance between them and the response of the parathyroid glands to changing levels of calcium. Usually doctors are concerned about either severe imbalances in calcium regulation that may require medical intervention or in persistent imbalances that indicate an underlying problem. -MRI( Magnetic Resonance Imaging) – to evaluate the size and shape of the thyroid.
* If calcium levels are low and PTH levels high, then the parathyroid glands are responding as they should and producing appropriate amounts of PTH. Depending on the degree of hypocalcemia, a doctor may investigate a low calcium level further by measuring vitamin D, phosphorus, and magnesium levels. * If calcium levels are low and PTH levels are normal or low, then PTH is not responding and the person tested probably has hypoparathyroidism. Hypoparathyroidism is a failure of the parathyroid glands to produce sufficient PTH.
It may be due to a variety of conditions and may be persistent, progressive, or transient. Causes include an autoimmune disorder, parathyroid damage or removal during surgery, a genetic condition, and severe illnesses. Those affected will generally have low PTH levels, low calcium levels, and high phosphorus levels. Nursing Consideration Before the Operation -Consent form/ “Informed Consent”- This information must be read completely before signing the surgical consent form. (regarding the risks and benefits of the procedure).
-NPO- the anesthesiologist will instruct you to have nothing per orem at least six hours before surgery, the reason why an empty stomach is required is because os Mendelsons syndrome ( aka aspiration pneumonia ) during induction of general anesthesia there is a short period where the airway is unprotected if there is reflux of gastric contents, this occurs after the patient has slept and before the trachea is intubated ( tube in airway ). -Allergy (food, medication, and those that cause skin irritation ) – It is important to disclose all known allergies prior to having surgery.
All allergies, including food, medications and those that cause skin irritation, should be included. By placing this information on your hospital chart, it will make the various departments of the hospital, including pharmacy and nutritional services, aware of the allergies. A good example is an egg allergy, which may not seem important when having surgery; however, many medications are formulated in an egg base, which could cause a serious reaction if given to the patient.
– Avoid anticoagulant – the major concern is when it is safe to perform surgery without increasing the risk of hemorrhage or increasing the risk of thromboembolism (eg, venous, arterial) after discontinuing treatment. – Answer questions, and allow time for the client to verbalize concerns. Because the incision is made at the base of the throat,clients (especially women) are often concerned about their appearance after surgery. Explain that the scar will eventually be only a thin line and that jewelry or scarves may be used to cover the scar. – Remove make-up, nail polish, jewelries.
-Assess for the vital signs. During the operation – Assess patient physical status – Consent form/ “Surgical Consent form” ( If you understand the risk and wish to proceed surgery) – Complete physical assessment record – Verify client identification, correct surgical procedure schedule. – Ensure patient safety at the OR. Procedure: Figure 1. Incision for thyroidectomy placed 1 to 2 cm inferior to lower border of cricoid cartilage Figure 2. Incision is carried through the skin, subcutaneous tissues, and platysma muscle. Figure 3. Flap elevation is performed in a subplatysmal tissue plane.
Figure 5. Incising midline of neck to expose the thyroid capsule Figure 6. Lateral retraction of strap muscles and medial retraction of thyroid lobes gives operative exposure Figure 7. Blunt dissection of the tissues between the trachea and carotid artery allows for dissection of parathyroid glands and the recurrent laryngeal nerve Figure 8. Medial upper thyroid gland dissection allows for mobilization of the superior thyroid pole. Figure 9. Medial to lateral clamping of superior thyroid pole vessels with care to avoid cricothyroid fascia allows for mobilization of the superior thyroid pole.
Figure 11. The recurrent laryngeal nerve may pass: (A) paratracheal, (B) within the thyroid parenchyma, or (C) paraesophageal. Figure 12. Separation of the lobe from the Ligament of Berry anterior to the nerve, which has been identified and exposed. Figure 13. The isthmus is clamped adjacent to the contralateral thyroid lobe and is either stapled or oversewn. Figure 14. For subtotal thyroidectomy the parathyroid glands and the recurrent laryngeal nerve are left undisturbed on an intact rim of thyroid tissue. The dotted line identifies the plane of gland transection. Figure 15.
Closure of the incision is performed with interrupted absorbable sutures in the platysma and a running intracuticular absorbable stitch in the skin. After the operation: -Keep the patient in high Fowler’s position to promote venous return from the head and neck and to decrease oozing into the incision. Check for laryngeal nerve damage by asking the patient to speak as soon as he awakens from anesthesia. -Watch for signs of respiratory distress. Tracheal collapse, tracheal mucus accumulation, laryngeal edema, and vocal cord paralysis can all cause respiratory obstruction, with sudden stridor and restlessness.
Keep a tracheotomy tray at the patient’s bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy, if necessary. -Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress. Check the patient’s dressing and palpate the back of his neck, where drainage tends to flow. Expect about 50 ml of drainage in the first 24 hours; if you find no drainage, – As ordered, administer a mild analgesic to relieve a sore neck or throat. Reassure the patient that his discomfort should resolve within a few days.
– If the patient doesn’t have a drain in place, prepare him for discharge the day following surgery as indicated. However, if a drain is in place, the doctor will usually remove it, along with half of the surgical clips, on the second day after surgery; the remaining clips, the following day, before discharge. Drainage used: Penrose drain. Discharge Instructions: Pain: For pain, take ibuprofen or Tylenol as your first measure. For more severe pain, take the narcotic pain medication as needed and according to the prescription. Incision Care: The Dermabond wound sealant is waterproof.
You may shower, use soap, and pat it dry. Do not use lotions on the incision – lotions will dissolve the coating. After several weeks, it will begin to flake off. Activity: Do not drive Diet: You may eat or drink whatever you like. Most people prefer liquids or soft foods, due to the mild sore throat which is normal for 3-7 days following surgery. Follow up check up would be after 2-4 weeks after the surgery. Complications: – Hypothyroidism – Hypoparathyroidism -Painful swallowing -Infection – Surgical scar/ keloid -Voice changes.