Gemsenjäger Atlas of Thyroid Surgery

Principles, Practice, and Clinical Cases
1. Auflage 2008
ISBN: 978-3-13-258115-9
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 192 Seiten, ePub

An outstanding reference for performing successful thyroid operations

Atlas of Thyroid Surgery: Principles, Practice, and Clinical Cases is a concise guide for the surgical management of thyroid disease.

Highlights:

Descriptions of endocrine pathophysiology and the pathogenesis of nodular goiter and thyroid neoplasms
Thorough discussion of the capsular dissection technique and its essential advantages as a minimally invasive approach with low morbidity
Numerous clinical cases with step-by-step demonstrations of surgical procedures and concise comments on management, helping clinicians prepare for range of scenarios encountered in everyday practice
More than 100 clear line drawings and full-color photographs that illustrate key concepts
Surgical videos on an accompanying DVD present detailed surgical technique in five clinical cases with cross references to the text
Atlas of Thyroid Surgery: Principles, Practice, and Clinical Cases is a superb guide for general surgeons and endocrine and ENT surgeons operating on the thyroid. Endocrinologists, oncologists, pathologists, and residents in these specialties will also greatly benefit from the wealth of information provided in the text.

Zielgruppe

Ärzte

Autoren/Hrsg.

Gemsenjäger, Ernst

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Chirurgische Techniken
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Endokrinologie

Inhaltsverzeichnis

Part 1 Surgical Anatomy and Surgical Technique
1 Notes on Positioning the Patient
2 Basic Surgical Anatomy
3 Incisions: Thyroid Exposure
4 Capsular Dissection
5 Thyroid Hilus: Suspensory Ligament of Berry; Inferior (Recurrent) Laryngeal Nerve; Parathyroids; Posterior Thyroid Process (Tubercle of Zuckerkandl)
6 Further Case Records with Demonstrations of the Technique of Capsular Dissection
Part 2 Thyroid Nodules—Modern Concepts
7 Basic Remarks
8 Proliferation, Clonality, and Autonomy of Thyroid Lesions
9 Molecular Genetic Diagnosis. Gene Profiling
10 Follicular Neoplasia
11 Thyroid Nodules in Surgical Practice. Strategy of Adequate Excision
12 Case Records: Hyperplastic and Neoplastic Nodules; Functional Anatomy; Follicular Thyroid Carcinoma
13 Embryological Thyroid Development and Developmental Anomalies: Clinical Aspects
14 Total Thyroidectomy for Benign Nodular Goiter
15 Long-Standing Solitary Nodule
16 Further Clinical Considerations
17 Nodules in Graves Disease
18 Nodules in Chronic Autoimmune Thyroiditis (Hashimoto Thyroiditis, Hashimoto Disease, Lymphocytic Thyroiditis
Part 3 Malignant Tumors
19 Papillary Thyroid Carcinoma
20 Anaplastic (Undifferentiated) Thyroid Carcinoma
21 Medullary Thyroid Carcinoma (C-Cell Carcinoma)
Part 4 Concluding Remarks
22 Basic Tools

Leseproben

3
Incisions; Thyroid Exposure 3.1
Skin and Platysma ? Fig. 3.1 The Kocher incision (1 in Fig. 3.1) is centered over the isthmus of the thyroid, which lies just caudad to the cricoid cartilage. This placement is preferred to a more caudal one.215 If the neck is hyperextended the incision will lie more caudally once the patient is in the erect position. The level of the suprasternal notch should be avoided because of the risk of unfavorable scar formation since the platysma is lacking in the midline at that level. Symmetry of length and height of the slightly curved incision, placed in a normal neck line or skin fold, is important. The length depends on neck configuration, goiter size, and planned surgical procedure. The planned incision line is marked preoperatively with the patient in the erect position, and on the operating table with the neck hyperextended. The laryngotracheal axis, the anterior border of the sternocleidomastoid muscles (SCM), and the sternal notch are also outlined with a marking pen. In selected patients an additional vertical midline (T-)incision of the skin (and of the SF and MF) extending down to the manubrium (2 in Fig. 3.1) may be essential for mobilization of large mediastinal and thoracic inlet goiters. There is a risk of scar enlargement or contraction, which may later necessitate a Z-plastic correction. The Kocher incision may be extended laterally to the posterior margin of the SCM (McFee incision) or to the trapezius muscle (3 in Fig. 3.1) if excisions of large goiters or lateral nodal dissection are planned. For these indications a longitudinal incision along the anterior border of the SCM may also be used (4 in Fig. 3.1), with or without a simultaneous Kocher incision. Hemostasis of these incisions is effected for the most part by pressure on a gauze for a short time. 3.2
Transverse Division of the Superficial Fascia and Middle Fascia ? Fig. 3.2 Superficial fascia (SF). No mobilization of skin platysma flaps is carried out. After transection of the platysma a very shallow scalpel incision will denude the superficial veins, which may turn out to be rather large. They are not dissected free, but simply cut between perpendicularly placed clamps and ligated or secured with suture ligatures (a later sudden flooding bleeding may originate from a reopened superficial vein). The SF encompasses the SCM and may be incised on its medial border, freeing the muscle for lateral retraction (Fig. 3.2 a, b). Middle fascia (MF, strap muscles). The underlying sternohyoid muscles, incorporated in a thin fascia, are cut transversely with a scalpel or with blunt scissors from the midline laterally; the fine fascia encompassing the more laterally situated sternothyroid muscles is then lifted off the thyroid surface in the midline and carefully transected transversely with the scissors together with the muscle (? Case 5). No muscle crushing clamps are placed across the strap muscles; minor bleeding ceases spontaneously or with diathermy. Laterally the fascial incision may be extended toward the jugular–carotid bundle; care is taken not to injure the ansa cervicalis (which innervates the strap muscles) and the internal jugular vein. At the lateral edge the MF may be incised in a longitudinal direction over a short distance (a few centimeters), thus opening a “back door approach” (see Fig. 4.9 a, b). The MF is gently lifted or pushed away and dissected free as one layer from the thyroid capsule in a cephalad, caudad, and lateral direction, with traction exerted to the cut muscles and the SCM on one side and to the thyroid gland on the other side. As middle and inferior (pretracheal) veins are encountered, they are individually dissected free, ligated, and divided near the thyroid capsule. Fig. 3.1 a, b Incisions of skin and platysma. 1, Kocher incision; 2, midline incision extending to the manubrium; 3, Kocher incision extended laterally to the posterior margin of the SCM; 4, longitudinal incision along the anterior border of the SCM. Fig. 3.2 a–g Transverse division of the superficial fascia (SF) and middle fascia (MF). a, b Superficial fascia divided, MF exposed. The sheath of the sternocleidomastoid muscle (SCM) is opened on the left side. c       Sternohyoid muscle divided. The thin fascia of the more laterally situated sternothyroid muscles is exposed. d       Strap muscles (MF) divided. e, f  MF transected. Exposure of the capsula propria with enlarged vessels beneath. g       Incision of the MF at the lateral edge.   The more lateral and posterior mobilization of the thyroid will then be achieved by capsular dissection (see Figs. 4.1–4.3). 3.3
Longitudinal Median Division of the Superficial Fascia and Middle Fascia ? Fig. 3.3 For this approach, a skin–platysma flap must be mobilized from the Kocher incision, cephalad to the level of the thyroid notch, and caudad down to the level of the sternal notch. The flap dissection is carried out with curved blunt scissors in the avascular plane between the platysma and the SF. The flap is held tautly vertically by fine hooks or between the surgeon's left thumb and fingers away from the SF, which is pulled downward, permitting proper blunt and sharp dissection. For mobilization of the inferior flap, the surgeon changes his place, moving to the top of the operating table. The exposed SF, a rather strong fascial layer, is then incised in the midline and divided longitudinally in its entire length; care must be taken not to harm the superficial veins that are running parallel. With slight retraction of the cut SF, the midline of the MF is defined, picked up with two toothed pincers, and opened longitudinally. Successively, the layer of the sternohyoid and the underlying thin fascia of the sternothyroid muscles are incised in their full length. The SF and the MF are retracted from the thyroid capsule laterally in one layer. At that stage the capsular dissection (laterodorsal skeletization of the thyroid gland) will be started. Fig. 3.3 a–c Median longitudinal division of the superficial and middle fascia. a    Mobilization of skin platysma flaps. Exposure of the superficial fascia (SF) with superficial veins. b    Incision of the superficial fascia. c    Incision and retraction of the fascia of the sternohyoid and sternothyroid muscles.   A longitudinal fascial division (Fig. 3.3) (with or without transection of the sternothyroid muscle) is very satisfactory for small goiters. A liberal fascial division throughout the entire length is important. Postoperative transient edema formation is less frequently seen than after transverse division; there is a risk (albeit very low) of hematoma or abscess formation in the large subcutaneous space. This access is insufficient for large goiters and for goiters with high extension of the upper poles. For wound closure, all layers are sutured separately, using atraumatic absorbable suture material, by a running suture for transverse incisions, and by single stitches for longitudinal incisions. Larger spaces are drained with a fine suction drain for 12–24 hours. The platysma is sutured by a 5–0 thread. The skin is reapproximated with intracutaneous single stitches, and then compressed with gauze for a short time. Adhesive skin closures (e. g., Steri Strips) are then applied in a vertical direction on the incision line. The operative field is compressed with both hands during extubation, if there is coughing, and in a state of excitation of the patient. A skin stitch is placed and left for 12 hours if there is bleeding from the skin margins. 3.4
Modifications Separation of the strap muscles (blunt dissection between the sternohyoid and the sternothyroid muscles) (Fig. 3.4) has been recommended for better exposure,35 for posterior digital exploration without interfering with dorsal vessels,215 and to avoid postexploratory scar formation in the surgical space in case of an eventual reoperation. Intraoperative contralateral exploration has now widely been replaced by preoperative ultrasound. With a longitudinal midline incision of the SF and MF the access may be improved by transverse transection of the sternothyroid muscle. We reapproximate transected strap muscles by a running suture when the wound is closed. Fig. 3.4 a, b Modifications of fascial incision I. a    Separation of the strap muscles (according to reference 35). b    Digital exploration in the avascular space (according to...