Endo Flashcards
Thyroidectomy
Position the patient with the neck extended.
Place your incision to enable access to both the upper and lower poles.
Elevate subplatysmal flaps and separate the strap muscles.
Take the upper pole vessels first.
Mobilize the lobe anteriorly and medially to facilitate RLN identification.
Carry all dissections as close as possible to the thyroid gland.
Always identify the parathyroid glands and preserve their blood supply.
Potential Pitfalls
Nerve injury usually occurs close to the nerve insertion at the cricothyroid membrane.
Inadvertently removed or devascularized parathyroid glands should be autotransplanted and implanted in muscle tissue at the end of the case.
Postoperative expanding neck hematoma should prompt bedside wound exploration followed by return to the operating room.
Total Thyroidectomy
Low collar incision within or parallel to natural skin lines.
Raise subplatysmal flaps.
Separate the strap muscles in the midline exposing the thyroid gland.
If using an intraoperative nerve monitoring system, expose the vagus nerve in the carotid sheath and confirm function of the monitor by stimulating the vagus nerve prior to exposure of the recurrent laryngeal nerve.
Separate the lateral border of the thyroid gland from the strap muscles and carotid sheath; enter the avascular plane medial to the upper pole without damaging the cricothyroid muscle fascia; isolate and divide the upper pole vessels.
Rotate the thyroid lobe anteriorly and identify the recurrent laryngeal nerve in the tracheoesophageal groove using the nerve monitoring system if available; dissect craniad along the nerve, separating from the thyroid, up to the cricothyroid muscle.
Divide the ligament of Berry anterior to the passage of the nerve into the larynx.
Separate the thyroid posterior surface from the trachea.
Identify and inspect the parathyroid glands; reimplant them if their vascularity is in question.
If using the nerve monitor, confirm unchanged function of the vagus nerve–recurrent laryngeal nerve–vocalis muscle system by stimulating the vagus nerve.
Potential Pitfalls
Injury to the recurrent laryngeal or superior laryngeal nerves.
Injury to the parathyroid glands.
Tumor invasion into surrounding structures, such as larynx, trachea, esophagus, carotid sheath, or strap muscles.
Total Thyroidectomy with Central Neck Dissection and Modified Lateral Neck Dissection
Make a transverse incision just below the cricoid cartilage and extend laterally or make a hockey-stick incision to facilitate lateral neck dissection.
Perform total thyroidectomy.
Central neck dissection is performed by dissecting out the recurrent laryngeal nerves and removing all fibroadipose tissue between the two carotid sheaths from the hyoid bone superiorly to the brachiocephalic vessels inferiorly.
Lymph node tissue from the anterior and posterior triangles, defined as the submandibular gland superiorly, the internal jugular vein medially, trapezius muscle laterally, and clavicle inferiorly, is removed.
The medial aspect of the sternocleidomastoid muscle is reapproximated to the sternothyroid muscle, followed by the platysma, and then the skin.
Parathyroidectomy
Anesthesia: general endotracheal anesthesia or anterior cervical nerve block
Positioning: semi-Fowler’s position with neck in extension
Kocher incision and development of subplatysmal flaps
Early identification of recurrent laryngeal nerve
Identification of abnormal parathyroid gland(s); careful excision without breaching parathyroid capsule
Intraoperative rapid iPTH monitoring if available, and meeting the Miami criteria (iPTH normalization and 50% reduction in value.)
Meticulous hemostasis within operative field
Neck incision closure
Overnight hospital observation or outpatient discharge to home
Potential Pitfalls
Injury to the recurrent laryngeal nerve
Injury to normal parathyroid glands
Inability to localize or identify abnormal parathyroid gland
Not meeting the Miami criteria
Laparoscopic Left Adrenalectomy
General anesthesia induced with patient in supine position.
Place patient in lateral decubitus position, ipsilateral side up.
Obtain laparoscopic access periumbilically and place additional bilateral subcostal trocars to triangulate
Mobilize splenic flexure of colon.
Divide lateral peritoneal attachments of spleen and lienophrenic ligament.
Reflect spleen medially and mobilize pancreatic tail.
Bluntly create a plane medial to adrenal gland and lateral to aorta.
Dissect and divide the inferior phrenic vessels and central adrenal vein.
Mobilize adrenal gland by dividing inferior and lateral attachments.
Remove adrenal gland from abdomen.
Inspect suprarenal fossa for hemostasis.
Close port sites.
Potential Pitfalls
Inability to visualize the gland.
Vascular injuries.
Pancreatic injury resulting in pancreatic leak.
Laparoscopic Right Adrenalectomy
General anesthesia induced with patient in supine position.
Place patient in lateral decubitus position, ipsilateral side up.
Obtain laparoscopic access.
Retract right lobe of liver medially by dissecting triangular ligaments.
Open peritoneum overlying adrenal gland inferior to superior.
Bluntly create a plane medial to adrenal gland and lateral to vena cava.
Dissect and divide the central adrenal vein (clip or linear stapler).
Mobilize adrenal gland by dividing inferior and lateral attachments.
Remove adrenal gland from abdomen.
Inspect suprarenal fossa for hemostasis.
Close port sites.
Potential Pitfalls
Inability to visualize the gland.
Liver injury resulting in hematomas and conversion to open procedure.
Vascular injuries.
Aberrant adrenal vein draining into right renal vein.
Open Adrenalectomy
A bilateral subcostal incision typically provides the best exposure, although a midline laparotomy may be used in patients with a narrow costal angle, and a thoracoabdominal incision may be necessary for larger tumors with IVC invasion
Inspect and palpate to evaluate for metastasis
1) Right Adrenalectomy
Mobilize hepatic flexure and duodenum to expose VC
Retract liver superiorly and right kidney inferiorly
Mobilize right adrenal gland from retroperitoneal fat including a margin
Ligate and divide right adrenal vein (superomedial)
2) Left Adrenalectomy
Enter the lesser sac through gastrocolic omentum
Incise peritoneum over inferior border of pancreas
Retract pancreatic body superior and left kidney inferiorly
Mobilize left adrenal gland from retroperitoneal fat including a margin
Ligate and divide left adrenal vein (inferomedial)
Potential Pitfalls
Anticipate the need for multivisceral resection and/or IVC reconstruction preoperatively
Avoid tumor manipulation to prevent catecholamine release (PC/PGL) or capsule rupture (ACC)
Control the right adrenal vein cautiously as it is short, easily avulsed, and drains directly into the IVC
Additional blood supply to the adrenal may come from the inferior phrenic pedicle (often more apparent on the left side)
