Isu Umat & Thyroidectomy

“Sesiapa yang tidak peduli urusan umat Islam, dia bukan dari kalangan mereka” (Hadis)

Operative (9/12/2010): thyroidectomy

(sepatutnya tgk video, tp dr ajar cam kuliah je. xpe).ni apa yg dpt masa dia ajar, xrujuk buku mana2 pn. tak sempat. insyaAllah bila ada rujukn nnti blh tmbah/edit.

INDICATIONS:

1. toxic multinodular goiter

there are 2 types of multinodular goiter, simple and toxic. simple means non-toxic and non-malignant. the type that requires thyroidectomy is the toxic one

2. toxic nodular goiter

it is nodular and hyperfunctioned

3. cancer thyroid or malignancy

STEPS ( E D E) :

1. Exposure

2. Devascularization

3. Excision

1) Exposure

1st we need to know the anatomy of the thyroid gland. some points to consider:

(1) anatomical position of the thyroid gland

i. in front of the neck, lower part

ii. 2-4 tracheal rings

iii. above suprasternal notch

(2)  layers, superficial to deep (SSSIIP):

1. skin

2. subcutaneous fat

3. superficial fascia

4. investing layer of deep fascia

5. infrahyoid muscle

6. pretracheal fascia

steps in short:

(remember the patient must be in supine position and the  neck  hyperextended to help exposure)

1. incise horizantally  (see picture) of the 1st 3 layers (skin, subcutaneous fat and superficial fascia) . this is called low collar incision

2. elevate the upper flap till it reaches the thyroid cartilage

3. the lower flap is pulled down but to a lesser extent than the upper flap

4. then vertical midline incision of the investing layer of the deep fascia

5. followed by lateral retraction  of  infrahyoid muscle and pretracheal fascia. in case of huge thyroid gland, the muscle and the fascia is cut. but TAKE CARE of the nerve supply

2) Devascularization

in short it  means stopping of blood flow of the thyroid. 1st we need to know the blood supply of the thyroid gland . maybe this picture on the right will help.

there are 2 main blood supplies of the thyroid gland:

1. superior thyroid artery (coming from external carotid)

2. inferior thyroid artery (from thyrocervical trunk)

steps:

1. ligate the arteries. TAKE HEED!:

– ligation of the superior thyroid artery must be made as near as possible to the gland to prevent injury on the external laryngeal nerve. (note in the picture, the nerve is away from the entrance of the artery to the gland) injury of this nerve can lead to repeated choking because this nerve supplies the epiglottis, which closes during drinking.

-ligation of the inferior thyroid artery must be made as far near as possible to the gland to prevent injury on the recurrent laryngeal nerve . (note in the picture, the nerve is in close approximation to the entrance of the artery into the gland) unilateral injury of this nerve will lead to change of voice, because this nerve supplies the vocal cord while bilateral injury may cause stridor. the reason the artery is ligated as close as possible to the gland, not as far (like before) is to preserve the blood supply of the parathyroid glands since the superior and inferior parathyroid arteries are both branches of the inferior thyroid artery (thanx to yassir for this info). so the ligation must be made after the branches. however take care not to injure the recurrent laryngeal nerve . (note in the picture, the nerve is in close approximation to the entrance of the artery into the gland) unilateral injury of this nerve will lead to change of voice, while bilateral injury causes stridor because this nerve supplies the vocal cord.

2. stricture (not sure if this is the right term)

before severing the blood vessels, the vessels need to be clamped at both sides of the site of cut. this is a safety measure to prevent excessive bleeding just in case there is defect in the ligature

3. Excision

there are 3 types (more types can be found in the internet):

1. total thyroidectomy (preferred in malignancy)

removes the entire gland. it is used in malignancy because if a person  develops cancer, chances are both lobes of the thyroid are affected.

2. subtotal/near-total thyroidectomy (in cases of non-malignant goiter)

3.thyroid lobectomy

NOTE: the reason thyroidectomy of smallest part of the gland is preferred is not to maintain its function (this is done by medication). the aim is to protect important related  structures especially the nerves thus avoiding complications. so if given the option to do total thyroidectomy or not, consider some points:

1. there is more chance to injure the related nerves especially recurrent laryngeal nerve

2. removing the whole thyroid will also remove the parathyroid gland in it. this can lead to hypoparathyroidism

however, to avoid hypoparathyroidism, the surgeon can take the parathyroid glands (if unaffected by the disease) and planted in other part of the body, where it can still function. (details about this procedure maybe can be discussed in another post)

further reading: http://www.endocrineweb.com/surthyroid.html

thanx for reading. any comments/corrections are highly welcomed

what? oh. no, surely this is not the issue i mentioned in the topic. this is just merely an introduction for me to start studying before doing anything. and actually it’s a good way for me to stay focus (and awake!) during classes, having this mindset that ‘i’m going to share this with everyone, so i have to get as many good knowledge as possible from this session’

i know there are many issues out there that need our attention, but right now  BIG ISSUEs that in my opinion currently requires our utmost attention are two:

1)penggunaan kalimah Allah dlm akhbar mingguan org kristian serta peristiwa bakar gereja di Malaysia. untuk pembacaan lanjut sila rujuk link berikut:

1.ust Zaharuddin

2. Dr. MAZA

3. Ust Halim

4. Tuan Guru Haji Hadi

5. (dari aspek politik) Harakahdaily.com

2) pembinaan tembok besi oleh kerajaan mesir di sempadan Mesir-Palestin serta kisah  convoy viva palestina di alA’rish. boleh baca di link berikut:

1. palestinkini.info

2. viva palestina

insyaAllah further discussion regarding the issues in coming posts

wallahua’lam.

4 Responses so far »

  1. 1

    Dati said,

    salam wbt

    good one! this help me to recall my understanding on thyroid diseases heh

  2. 2

    yasir said,

    salam,
    ligation of the inferior thyroid artery must be made as NEAR as possible to the thyroid gland to preserve the branches supplying the parathyroid gland.
    kalu ligate jauh nnt mati parathyroid, sbb superior n inferior parathyroid glands are supplied by inferior thyroid artery.
    ni teknik yg latest, bleh rujuk head n neck dept.

    • 3

      muhammad3011 said,

      wa’alaikumussalam wbt.
      jazakallahukhair yasir for the info. got it right

      • 4

        yasir said,

        mad, aku bukak balik page ni, baca balik komen aku kt atas tu, rasa mcm, “eh, bila pulak aku tau info mcm tu? bila aku blj psl bnda ni?”.. lol. tak ingat langsung dah.
        Allahul musta’aan.


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