Bilateral levels IIA, IIB, III, IV and VB lateral neck dissection

Title of Operation:

Total thyroidectomy with prelaryngeal, pretracheal and bilateral paratracheal nodal basin resections.

Transposition of the right recurrent laryngeal nerve and bilateral accessory nerves/cranial nerve XI.福建省立医院基本外科黄东航

Level IA lymph node dissection.

Bilateral levels IIA, IIB, III, IV and VB lateral neck dissection.

Indications for Surgery:

A 68-year-old woman with fine-needle aspiration confirmed papillary thyroid cancer with spread to multiple cervical lymph nodes.  Risks, benefits, and alternatives of the procedure were discussed in detail with the patient.  The risks included but not limited to anesthesia, bleeding, infection, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, scar, cosmetic deformity, tumor recurrence, injury to nerves including lower lip weakness, tongue weakness, tongue numbness, neck numbness, shoulder weakness, neck weakness, arm weakness, intractable pain neck and shoulder, eyelid weakness, diaphragmatic paralysis, weakness of the diaphragm, Horner syndrome, need for additional therapy, and other.
The patient understood all these issues and did wish to proceed.

Preoperative Diagnosis:

Papillary thyroid cancer.

Postoperative Diagnosis:

Papillary thyroid cancer.

Anesthesia:

Specimen (Bacteriological, Pathological or other):

Prosthetic Device/Implant:

Surgeons Narrative:

There was no qualified resident or fellow available for the case.

    The patient was identified as medical record 4884658 and placed supine on the operating room table.  General anesthesia was established via orotracheal intubation with a #6 nerve integrity monitoring system endotracheal tube.  The eyes were protected with Tegaderm. 
    The incision was planned in the neck to allow for resection of the thyroid and regional lymph nodes.  A 15-blade was used to make the incision once the patient was prepped and draped in a sterile fashion.  Skin flaps were elevated superiorly and inferiorly.  The strap muscles were separated in the midline and then elevated over the right and left thyroid lobes. 
    The left thyroid lobe was dissected first.  In the isthmus, there was a nodule that was appreciated to be approximately 2 cm.  The capsule dissection ensued on the left side and then the fascia was dissected free from the carotid artery.  The inferior thyroid veins were ligated with harmonic focus dissector.  The cricothyroid muscle was appreciated.  The superior pole vessels were taken down with harmonic focus dissector once the external branch of the superior laryngeal nerve was protected.  The recurrent laryngeal nerve was isolated in the tracheoesophageal groove.  The superior parathyroid gland was reflected away from the thyroid capsule and the left thyroid lobe was dissected over the trachea leaving no thyroid tissue approximating the recurrent laryngeal nerve.  The inferior parathyroid gland also had been reflected. 
    On the right side, again a capsular dissection ensued from the inferior to superior aspect.  The inferior thyroid veins were ligated with harmonic focus dissector.  The recurrent laryngeal nerve was isolated in the tracheoesophageal groove. This branched into an anterior and posterior branch approximately 1 cm from the insertion into the cricothyroid region.  The superior pole vessels were taken down with harmonic focus dissector.  The recurrent laryngeal nerve was traced all way to its insertion point and the superior parathyroid gland was carefully reflected.  The right thyroid lobe was dissected over the trachea leaving no thyroid tissue approximating the recurrent laryngeal nerve.  The isthmus nodule was also incorporated. 
    The wound was then carefully inspected.  The carotid artery on the right was dissected all the way down to the level of the innominate artery then the recurrent laryngeal nerve was traced inferiorly.  The recurrent laryngeal nerve was transposed 360 degrees with a combination of dissection with a fine tip dissector and a 15-blade.  The inferior thyroid artery terminal branches were ligated.  The blood supply to the superior parathyroid gland was kept intact and all the posterior and retrocarotid lymph nodes.  Those are the lymph nodes behind the recurrent laryngeal nerve were all dissected off the esophageal muscularis and transposed underneath the recurrent laryngeal nerve.  The remainder of the lymph nodes were taken off the prevertebral fascia all the way inferiorly to the level of the innominate artery along the esophageal muscularis and trachea. The recurrent laryngeal nerve stimulated at 1 mA at the conclusion of this procedure.
    Then, on the left side, the carotid artery was traced down inferiorly to the level of the innominate artery and the clavicle.  The recurrent laryngeal nerve was traced all the way inferiorly as well.  With direct visualization, all the lymph nodes in this region were dissected over the recurrent laryngeal nerve over to the esophageal muscularis and trachea leaving no residual fibrofatty tissue in this region.  The thymus was incorporated inferiorly along with the pretracheal lymph nodes.  The specimens were labeled as right and left central neck dissection respectively. 
    Level IA dissection took place.  Next, there was a firm large mass approximately 3 cm in size in this region.  We took the fascia overlying the periosteum of the mandible then found the digastric muscle anterior bellies then dissected all the fibrofatty tissue off the mylohyoid muscle.  The mass was appreciated.  The hyoid bone was dissected and its periosteum elevated to free the mass along the thyrohyoid membrane and a cuff of strap muscle was used to keep the mass intact with the margin.  This was sent as histopathologic specimen level IA.
    Then, on the left side, lateral neck dissection was performed.  The inferior border of the submandibular gland was appreciated and dissected posteriorly.  The digastric muscle appreciated and dissected posteriorly.  The hypoglossal nerve appreciated and dissected all the way to the level of the internal jugular vein and veins in this area were ligated with harmonic focus dissector.  The accessory nerve was found as we lateralized the sternocleidomastoid muscle by dissecting along its medial border. The accessory nerve was transposed 360 degrees.  Level IIB lymph nodes were then dissected from the floor of the neck, splenius capitis and levator scapulae muscles and transposed underneath the accessory nerve.  Internal jugular vein was dissected inferiorly.  We then dissected all the cervical rootlets.  Took all the level VB lymph nodes from the floor of the neck preserving the phrenic nerve and the brachial plexus.  The thoracic duct was appreciated.  It was not injured during the procedure.  All the fibrofatty tissue along the clavicle and around the floor of the neck and over the phrenic nerve was dissected all the way back along the internal jugular vein.  All the lymph nodes were then dissected over the internal jugular vein.  These were labeled levels II, III, IV with IIA and IIB level respectively as well as level VB. 
    We then performed a similar procedure on the right side.  Please let it be known that on the left, there was a firm and enlarged level III lymph node that grossly involved level IIA lymph node and a level IV lymph node that was tucked behind the internal jugular vein at the level of the clavicle that appeared to be suspicious for disease as well.  On the right side in a similar fashion, a lateral neck dissection was performed.  Again, the inferior border of the submandibular gland was appreciated.  Digastric muscle dissected posteriorly to the sternocleidomastoid muscle.  The medial edge of the sternocleidomastoid muscle dissected and the fascia elevated.  The accessory nerve identified and then dissected 360 degrees with fine-tipped dissector.  The fibrofatty tissue along the floor of the neck was transposed underneath the accessory nerve.  Cervical rootlets were identified and then inferiorly, the transverse cervical vessels were appreciated.  All the fibrofatty tissue along this region was dissected along the clavicle.  The phrenic nerve and brachial plexus were preserved and all the lymph nodes that were dissected along the internal jugular vein from inferior to superior.  There was an enlarged level III lymph node and enlarged level IIA lymph node that we appreciated.  All these lymph nodes were dissected over the strap muscles and labeled accordingly as levels II, III, IV, and VB.
    Then, attention was turned to hemostasis. Valsalva maneuvers given.  Bleeding points controlled with bipolar cautery.  No chyle leakage was noticed in the right or left lateral neck. Surgicel was placed in the lateral necks bilaterally and also in the central neck region and fibrin glue was also placed.  A #10 JP drains were placed on either side, 2 in total, and this was secured with 3-0 nylon. The strap muscles were reapproximated with 3-0 Vicryl and then subsequently, the subcutaneous tissue closed with interrupted 3-0 Vicryl at the platysma layer and then running 4-0 Biosyn for the subcuticular closure and then tissue adhesive glue for the skin.  The patient was extubated on the operating room table and sent to the postanesthesia care unit in good condition.