THYROIDECTOMY

Thyroid gland surgical anatomy

Location: Thyroid is situated in the neck in relation to 2
nd
3
rd
and 4
th

tracheal rings
Two lobes: Right and left, joined by an isthmus
Arteries: Supplied by superior and inferior thyroid arteries
Veins: Drained by superior, middle and inferior thyroid veins

Important nerves in relation to thyroid
External laryngeal nerve: Close to superior pole of thyroid.
Injury produces voice weakness
Recurrent laryngeal nerve: Related to lower pole of gland as it
runs upwards in the tracheo-esophageal groove.
Injury produces vocal cord paralysis.
From superficial to deep:
Skin
Platysma (a muscle in superficial fascia of neck)
Investing layer of deep cervical fascia
Pre-tracheal layer of deep cervical fascia
Strap muscles of neck (thin flat muscles)
Thyroidectomy Indications
Goitre (any non-neoplastic swelling of the thyroid gland is classified as a
goitre)
Single swelling (Solitary nodular goitre)
Multiple swellings (Multi-nodular goitre)
Carcinoma
Follicular carcinoma
Papillary carcinoma
Rare varieties
Thyroidectomy Types
Hemi-thyroidectomy: Removal of half of thyroid gland (Hemi = Half)
Lobectomy: Removal of either right of left lobe of thyroid gland
Both these are done in solitary goitre
Total thyroidectomy: Removal of whole thyroid gland
This is done in cases of malignancy
Subtotal thyroidectomy: Removal of a little less than total; done in
multi-nodular goitre
Near-total thyroidectomy: Almost same as total, but a little thyroid
tissue around one parathyroid gland is preserved
Isthmusectomy: Dividing the isthmus

Pre-operative investigations
Full blood count (CBC)
Serum Urea, Electrolytes, Creatinine
Thyroid Profile: T3, T4, TSH
Ultrasound thyroid gland
Radio-iodine (
99m
Tc /
131
I) scan of thyroid
X-ray neck
X-ray chest
(Both AP / lateral)
Fine Needle Aspiration Cytology (FNAC) of thyroid nodule, if any
palpable
Indirect laryngoscopy to assess pre-operative function of both vocal
cords.

*INFORMED CONSENT FOR THE SURGERY IS ESSENTIAL
Thyroidectomy Steps 1 The preliminaries
Position of patient:
Supine position,
Neck slightly extended,
Sand bag under shoulder
Foot end slightly down
Preparing the part:
The entire front of neck, from jaw line to nipples, is cleaned with
Cholorhexidine, surgical spirit and Betadine.
Draping:
Sterile sheets are draped above, below and on either sides of
neck, keeping only neck portion visible.
Some surgeons cover this area with self-adhesive Opsite to
enhance sterility.
Thyroidectomy Steps 2 Incision and raising flaps
Incision:
Size 22 blade on Bard-Parker handle
Curvilinear skin incision along neck crease, from one sterno-
mastoid to other, 1.5 cm above manubrium notch
Incision is deepened through skin, subcutaneous tissue,
superficial fascia and platysma

Skin flaps:
Two skin flaps raised; one above and below.
Held in place with Jolls retractor.
Strict haemostasis (control of bleeding)
Essential during entire procedure
Achieved by coagulating diathermy and/or ligation using 2-0 Vicryl
sutures.
Thyroidectomy steps 3 Exposing the gland
Investing deep cervical fascia is split open
Strap muscles of neck divided between clamps
This exposes the thyroid gland enclosed in pre-tracheal layer of deep
cervical fascia.
This layer of fascia is also opened and thyroid exposed, with the nodule
(or any pathology) visible.
Thyroidectomy steps 4 Dealing with vessels
Arteries before veins (to prevent venous engorgement)
Vessels clamped, divided and ligated with 2-0 vicryl
Superior thyroid artery ligated close to the upper pole of the gland.
This is to prevent damage to external laryngeal nerve.
Inferior thyroid artery is similarly dealt with far away from the lower pole
of the gland.
This is to safeguard recurrent laryngeal nerve.
Then superior, middle and inferior thyroid veins are dealt with in a
similar manner.
Thyroidectomy steps 5 Removing the gland proper
Multiple artery forceps are applied around the thyroid gland
Appropriate portion (hemi-, subtotal, total thyroidectomy, lobectomy etc)
is removed.
Be sure to preserve the excised specimen in Formalin solution for
biopsy.
Cut edge of the gland usually bleeds profusely.
This is stopped by under-running with multiple continuous 2-0 Vicryl
sutures.
Accurate haemostasis is essential, at all times, now more than ever.
Thyroidectomy Steps 6 Winding up process
Redivac (suction) drain is inserted in the cavity left by the excised
thyroid gland,
Brought out through a separate stab incision at the side of the neck,
Sutured to the skin with 2-0 Silk sutures.
Strap muscles are sutured with 2-0 Vicryl.
Cut edges of deep cervical fascia are also sutured with 2-0 Vicryl.
Again, haemostasis is minutely checked.
Jolls retractor, which was holding the skin-platysma flaps open, is
removed.
Thyroidectomy steps 7 Closure
Platysma and subcutaneous tissues are closed with 2-0 Vicryl
interrupted sutures.
Skin closed with 3-0 Nylon, horizontal mattress sutures or subcuticular
sutures.
The latter gives a finer scar, but it requires more technical expertise,
finesse and time.
Post-operative management
Patient is kept NPO/NBM (Nil Per Oral / Nil By Mouth) on the day of
surgery.
Supplemental IV fluid usually given on day of surgery; usually between
2.5 to 3 litres.
Compatible blood may be transfused if there had been excessive blood
loss during surgery.
Oral intake initiated from next day, starting with clear fluids, going on to
free fluids, then to soft diet and finally to normal diet
Analgesics essential in post-operative period; there is invariably severe
pain during first night.
Antibiotics avoided in clean elective surgeries
Daily vital (PTR, BP) chart is maintained.
Rise of temperature after 3
rd
post-operative day indicates infection.
This may require inspection of suture line.
Careful note is made of daily output from Redivac drain.
Drain removed after 48 hours or when drainage falls to few ml during
last 24-hour period, whichever is earlier.
Initial dressing changed after 48-72 hours (to inspect for infection of
suture line),
Unless there is soakage, when it should be removed earlier.
Dry dressings sufficient every alternate day, if suture line is clean and
dry.
Sutures usually removed on 5
th
post-operative day.
This gives minimum scarring.
Thyroidectomy Possible complications
Hemorrhage
Respiratory distress or stridor
Hoarseness of voice
Total vocal cord paralysis aphonia
Hypocalcemic tetany (due to accidental removal of parathyroid glands
during total thyroidectomy)
Wound infection: This may manifest after 48 hours of surgery














CHOLECYSTECTOMY










NURSING MANAGEMENT OF THE PERIOPERATIVE PATIENT
Perioperative Nursing:
Includes the preoperative (before), intraoperative (during) and
postoperative (after) periods.
Preoperative period:
This is an important time to address issues that may come up
during surgery (Screening)
o i.e. assess for bleeding problems, don't want to find out that
someone has a bleeding problem as they exsanguinate on
the operating table
Also can teach patients and family about what to expect before,
during and after a procedure
o in an emergency, we can prepare the family if the patient
isn't alert

Types of Surgeries
1. Diagnostic-Determination of the presence and or extent of the
pathology
i.e. lymph node bx, bronchoscopy, exploratory laparatomy
2. Therapeutic -Elimination or repair of the pathology
Removal of the appendix when it's inflammed, removal of a
localized cancer
3. Palliative -Alleviation of symptoms without curing the underlying
disease
Rhizotomy (cutting of a nerve root) to decrease pain,
colostomy placement to bypass an obstructing colon tumor
4. Preventive - Surgery to remove tissue that has the potential to
become pathologic (may not already express a pathologic
problem)
Total Colectomy in patients with FAP
5. Cosmetic-The surgery is performed for aesthetic reasons
Repair of scars from burns or injuries, minor cleft palate
repairs, face lifts, breast augmentation
Further Descriptors of Surgery
Elective:
Carefully planned event
Advanced assessments are usually attained and pre-operative
checks are in place
o blood draws
o physical exam
o other necessary studies
Can be scheduled in some cases as an outpatient or in an
ambulatory surgery center
Emergency:
arises unexpectedly
can also occur in a wide variety of settings
o ER
o OR
o Battlefield/Trauma scene
Needed within minutes to hours
Urgent:
delay could be detrimental
usually within 24-48 hours
Types of Elective Admissions for Surgery
Ambulatory Surgery:
Usually outside a hospital setting
Special prescreening
Don't use in patient's with multiple problems
Same-Day Surgery:
Outpatient, can be in the hospital
Go home the day of the surgery
Early Hospital Admission:
Patient comes in early (night before or earlier)
Usually patients with complex medical issues, and increased risk
for poor surgical outcomes

Preoperative Nursing Assessment
1. Age
2. Allergies
3. Vital Sign Trend
4. Nutritional Status
5. Habits affecting tolerance to anesthesia
6. Presence of Infections
7. Use of drugs that are contraindicated prior to surgery
8. Physiological Status
9. Psychological state of the patient

Preoperative Nursing Assessment
Age:
Elderly are at risk
>65 years of age
obtain a detailed medical history and health assessment
assess for sensory deficits
assess for overall functional status
understand that there is a decreased physiological reserve

Allergies:
assess for known drug, food and substance allergies
assess what the reaction to the drug or substance is (is it a true
allergy, hives or anaphylaxis?)
allergies must be clearly noted on the chart, and other steps are
usually taken per hospital/institutional protocol

Vital Signs Trends:
What is normal for that patient, and are V/S in the preoperative
period in line with the norms or deviating?
Nutritional Status:
This can be a situation of deficit or excess
assess for individuals who are prone to general nutritional
deficiencies:
o Aged
o Cancer patients
o Gastrointestinal problems
o Chronic illness/Chronic steriod use
o Alcoholics/Drug Addicts
Also assess for excess (Obesity):
o Poor wound healing because of decreased blood supply
o Hard to access surgical site
o Decreased lung capacity
o Anesthesia meds are stored in fat cells
Habits affecting tolerance to anesthesia:
Smoking:
o alters platelet function...hypercoagulable
o reduces the amount of functional hemoglobin
carboxyhemoglobin
o cilia in the lung are damaged, more difficult to mobilize
secretions in the patient that smokes
o retards wound healing (especially because of the decreased
functional hemoglobin)
Alcoholism:
o can have impaired liver function
o B-vitamin deficiencies
Opioid Addiction
o have a high tolerance for pain meds
Presence of Infections:
Biggest indicator is the presence of fever above 101 degrees F (38C)
If infection is present, likely surgery will need to be delayed because
the risks to the patient are too great.
Goal will be to find and treat the infection, and then reattempt
surgery once the infection is cleared
Use of drugs that are contraindicated prior to surgery:
Drugs like aspirin, heparin, warfarin (Coumadin) should be stopped
prior to surgery
o affect bleeding time
ASA is 2 weeks because of the permanent platelet
affects
heparin, and low molecular weight heparins are usually
stopped 24 preop, unless there are problems with the
liver
warfarin is usually 7 days, but the PT/INR is rechecked
either the day of or the day before the surgery to check
for bleeding
Use of drugs that are contraindicated prior to surgery:
current use of medications, over the counter agents and herbal
remedies should be assessed and documented
some drugs/herbs can interact with the anesthesia
check about antihypertensives the morning of surgery
need to be clear about home meds (dose, frequency, timing) so that
any necessary meds are in the postoperative order as per the MD
o can check with the MD if certain meds should be restarted
want to reinforce that if the patient is to take meds the morning of
surgery, they should be taken with sips of water
Physiological Status:
Need to ensure as a preoperative nurse that all labs, xrays, EKGs and
necessary tests are done and in the chart
Need to notify the physician if there is anything abnormal, shouldn't
assume that they've already seen it
Common behaviors are fear and anxiety
fear = pt. knows what they are scared of
anxiety = don't tangibly know what is scaring you
Psychological States:
Common Fears:
1. Fear of death
2. Fear of pain and discomfort
3. Fear of mutilation or alteration in body image
4. Fear of anesthesia
5. Fear of disruption of life functioning or patterns
6. Fear due to lack of knowledge regarding the proposed surgery
7. Fear related to previous surgical expriences
8. Fear due to the influence of significant others

Remember, for our patients, surgery presents a major lack of control.

Preoperative fear and anxiety can lead to:
1. Need for increased anesthesia
2. Need for increased postoperative pain management
3. Speed of recovery is decreased


Preoperative education of what to expect in clear, common english can alleviate
some fear and anxiety

Remember the role of HOPE for our patients, it is often the most common
coping strategy

Patient Preparation for Surgery
1. Operative consent
2. Preoperative learning needs
3. Interventions the day or evening prior to surgery
4. Interventions the day of surgery

Operative Consent
This is part of the legal preparation for surgery.
Informed consent: an active, shared decision making process between the
provider and recipient of care. Has 3 components to make it valid:
1. Adequate Disclosure: of the diagnosis, nature and purpose of the
proposed treatment, probability of successful outcome, risks and
consequences of moving forward with treatment or alternatives, the
prognosis if treatment is not instituted, and if treatment is deviating
from standard for their condition.
2. Understanding and Comprehension of above: this has to be assessed
before sedating meds can be given (minors can't give consent,
severely mentally ill or severely developmentally challenged).
3. Voluntary Consent: Can't be coerced into going through with a
procedure. This consent can be revoked at any point leading up to a
surgical procedure.
Who can give consent?
o the patient
o next of kin (in order of kinship): Spouse, Adult Child, Parent, Sibling
o Can be designated with a durable power of attorney in case of
medical incapacitation


Who has the legal responsiblity of obtaining consent?

The Physician

The nurse is not legally required to obtain consent
however, the nurse must make sure the consent was signed
o nurse has a primary role as a patient advocate.
nurse can "witness" the consent, and sign it as such
if the patient has questions that you can answer to clarify things, you
can do that
if the patient continues to have questions, or there is a question that
they are not voluntarily giving consent, the doctor needs to come
and speak with them again.
Very important that patient is consenting voluntarily and with
knowledge of the situation

What about emergency treatment?
A true medical emergency may override the need to obtain consent.
When medical care is needed to protect the life of an individual, the next of
kin/POA (Power of Attorney) can give consent. Also, if there is a known and
available Advanced Directive with healthcare decision making instructions,
that can be used to assist in justifying consent. If they are not available, and
the doctor deems the procedure necessary for life, the doctor can chart that it
was necessary, and go ahead with the procedure.
The nurse may need to write up an incident report and state that the
emergency caused a deviation in the normal policy to obtain consent
on everyone.


Patient preparation: preoperative learning needs
Deep breathing (incentive spirometer), coughing, leg exercises,
ambulation
Pain control and medications
Cognitive control to decrease anxiety and enhance relaxation (deep
breathing)
Recovery room orientation
Probable postoperative therapies
Directions for the family





Patient preparation: interventions the day or evening prior to the surgery
Diet Restrictions
o Historical guidelines to prevent aspiration were NPO after
midnight the night before
o Educating the patient about the reason for NPO status may
help with adherence
Information of what to wear to the surgery
Patient will likely need to be there 1 to 2 hours prior to scheduled
procedure




Patient preparation: interventions the day of surgery

This varies based on whether the person is inpatient or outpatient.
Encourage the patient to void (empty their bladder) before
they get any sedative medications
Final preoperative teaching
Final Assessment and communication of findings to MD
Ensuring that all preoperative orders have been completed
Check to chart to make sure that there is:
o a signed consent for the procedure
o laboratory data, Xray reports, EKG
o H&P, and necessary consults
o Baseline vitals
o Nursing notes up until that point

Remove any jewerly, hair pins, clothes (except gown)
o May be able to wear a wedding band taped firmly to
the finger
Remove contact lens
No dentures or partial dentures
If the hearing aides need to be removed, please not that on
the front of the chart.
o glasses or hearing aides need to be returned to the
patient as soon as possible after the procedure
No makeup or dark nail polish
Give any preoperative medications
Note the time the patient leaves the floor
ID band should be placed, or checked depending on patient
status, and an allergy band per institution protocol







Preoperative Checklist


Preoperative Medications
Benzodiazepines/Barbituates: used for their sedative and
amnesic properties
Anticholinergics: reduce secretions, and can reduce
cramping
Opioids: decrease need for intraoperative analgesics and
decrease pain
Antiemetics: decrease N/V
Antibiotics: to prevent infective endocarditis, or where
wound contamination is a risk (GI surgery) or where wound
infection would cause significant postoperative morbidity
o usually given IV
Eyedrops: especially with eye surgery (lasik, cataract
surgery)