INDICATION FOR PROCEDURE: The patient is a 29-year-old gentleman who presents with a large left thyroid goiter, visible in the neck and shifting his airway to the right. After considering his options, he elected to proceed with a left hemithyroidectomy.

DESCRIPTION OF PROCEDURE [This is an op note, what a surgeon is required to dictate after every operation for the records. I was told to write one as an exercise, but I added these bracketed asides for your entertainment.]

The patient was brought to the operating room and placed on the operating table in supine position. He had intermittent compression stockings placed for DVT prophylaxis. [This is my job as the med student!] General anesthesia was induced by the anesthesia team, and he received a dose of prophylactic Ancef antibiotic. The patient’s neck was positioned, prepped, and draped in the usual sterile fashion.

The skin and subcutaneous tissues along a skin crease were infiltrated with local anesthetic mixture, and a 10-cm horizontal skin incision was made with a #10 blade. A sub-platysmal muscle dissection was performed with electrocautery. [I can just hear the surgeon admonishing the resident: along the muscle! No, that’s thyroid, THAT is muscle. Great, now it’s bleeding, have you even learned anything?] The large left goiter was appreciated [large = freaking enormous. Why the patient waited so long for surgery I don’t know.], as well as a large anterior jugular vein laterally. The sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were bluntly freed and divided [The crux of surgery: spread stuff apart. The crux of the med student’s role: stand around and retract stuff out of the way.]; additionally it was divided superiorly to gain access to the superior pole. A major branch of the anterior jugular vein was affected [meaning blood started pouring out of his neck], but hemostasis was rapidly achieved [meaning the surgeon sewed it shut through a waterfall of blood like a boss].

The middle thyroid vein, the superior pole vessels, and the inferior thyroid vessels were, in sequence, divided between ties and using the LigaSure Vessel Sealing instrument [plastic tongs that cauterize then cut like scissors afterward. Best. Instrument. Ever.]. The thyroid isthmus was then elevated off the trachea and divided with the Ligasure. The goiter, round and regular and measuring approximately 10x7x6 cm, was elevated out of the neck into the incision. [Freaking enormous. Just measure it out. That was in his neck.]

The recurrent laryngeal nerve was appreciated along the tracheoesophageal groove and was traced from inferior to superior, and the goiter was mobilized away from the nerve. [This is invariably the scariest part. This is the nerve in charge of his voice box, so nicking it means he’ll lose most of his voice and have difficulty swallowing forever. It looms in the field, the surgeons working millimeters from it.] The left superior and inferior parathyroid glands were not preserved. [They look like fatty grains of rice, and taking out 2 of 4 is not a huge deal.] The attachments at the ligaments of Berry were divided with the Ligasure. The “left thyroid lobe” specimen was then passed off to the scrub tech with a stitch marking the superior pole [also my job!].

Hemostasis was then meticulously secured with electrocautery. A Valsalva maneuver was performed several times without evidence of bleeding. [i.e. anesthesia closed the lung outflow and squeezed the inflow balloon] A small skin incision was made on the right lower neck, a #15 round Blake drain was placed, and the drain was secured with one #3-0 silk stitch. [and the “grenade”, or plastic negative pressure bulb, just hangs out his neck]

The sternohyoid muscles were then reapproximated with a running #3-0 Vicryl suture from superior to inferior [the words “up” and “down” aren’t allowed anymore], then the platysma muscle and subcutaneous tissue was reapproximated with #3-0 Vicryl suture. The skin was closed with a running #4-0 Biosyn suture [I can just hear the surgeon scolding “in the same plane! Don’t travel between bites! No, that’s going to pleat the skin! Are you even listening!?”]. Steri-Strip dressings were applied.

The patient was then awakened, extubated, and transferred to the recovery room in stable condition, having tolerated the procedure well. [Total OR time: 2.5 hours. Med student’s primary concern: do I have time for lunch before the other three thyroid cases?]

 

 

 

image links

• https://edc2.healthtap.com/ht-staging/user_answer/avatars/2513880/large/open-uri20160428-20797-10592fj.jpeg?1461811789
• http://www.medgadget.com/wp-content/uploads/2012/09/LigaSure-small-jaw-instrument.jpg