THYROIDECTOMYThyroid gland surgical anatomy

Location: Thyroid is situated in the neck in relation to 2nd 3rd and 4th tracheal rings

Two lobes: Right and left, joined by an ‘isthmus’ Arteries: Supplied by superior and inferior thyroid arteries Veins: Drained by superior, middle and inferior thyroid veins

Important nerves in relation to thyroid

– External laryngeal nerve: Close to superior pole of thyroid. • Injury produces voice weakness

– Recurrent laryngeal nerve: Related to lower pole of gland as it runs upwards in the tracheo-esophageal groove.

• Injury produces vocal cord paralysis. • From superficial to deep:

– Skin– Platysma (a muscle in superficial fascia of neck)– Investing layer of deep cervical fascia– Pre-tracheal layer of deep cervical fascia– Strap muscles of neck (thin flat muscles)

Thyroidectomy – Indications

• Goitre (any non-neoplastic swelling of the thyroid gland is classified as a goitre)– Single swelling (Solitary nodular goitre)– Multiple swellings (Multi-nodular goitre)

• Carcinoma– Follicular carcinoma– Papillary carcinoma– Rare varieties

Thyroidectomy – Types

• Hemi-thyroidectomy: Removal of half of thyroid gland (Hemi = Half)• Lobectomy: Removal of either right of left lobe of thyroid gland

Both these are done in solitary goitre

• Total thyroidectomy: Removal of whole thyroid gland

This is done in cases of malignancy

• Subtotal thyroidectomy: Removal of a little less than total; done in multi-nodular goitre

• Near-total thyroidectomy: Almost same as total, but a little thyroid tissue around one parathyroid gland is preserved

• Isthmusectomy: Dividing the isthmus

Pre-operative investigations

• Full blood count (CBC)• Serum Urea, Electrolytes, Creatinine

• Thyroid Profile: T3, T4, TSH• Ultrasound thyroid gland• Radio-iodine (99mTc / 131I) scan of thyroid• X-ray neck • X-ray chest

• (Both AP / lateral)• Fine Needle Aspiration Cytology (FNAC) of thyroid nodule, if any

palpable• Indirect laryngoscopy to assess pre-operative function of both vocal

cords.

*INFORMED CONSENT FOR THE SURGERY IS ESSENTIAL

Thyroidectomy Steps 1 – The preliminaries

• Position of patient: – Supine position, – Neck slightly extended, – Sand bag under shoulder – Foot end slightly down

• Preparing the part:

– The entire front of neck, from jaw line to nipples, is cleaned with Cholorhexidine, surgical spirit and Betadine.

• Draping: – Sterile sheets are draped above, below and on either sides of

neck, keeping only neck portion visible. – Some surgeons cover this area with self-adhesive Opsite to

enhance sterility.

Thyroidectomy Steps 2– Incision and raising flaps

• Incision: – Size 22 blade on Bard-Parker handle– Curvilinear skin incision along neck crease, from one sterno-

mastoid to other, 1.5 cm above manubrium notch – Incision is deepened through skin, subcutaneous tissue,

superficial fascia and platysma

• Skin flaps: – Two skin flaps raised; one above and below. – Held in place with Joll’s retractor.

• Strict haemostasis (control of bleeding)– Essential during entire procedure – Achieved by coagulating diathermy and/or ligation using 2-0 Vicryl

sutures.

Thyroidectomy steps 3 – Exposing the gland

• Investing deep cervical fascia is split open• Strap muscles of neck divided between clamps• This exposes the thyroid gland enclosed in pre-tracheal layer of deep

cervical fascia.• This layer of fascia is also opened and thyroid exposed, with the nodule

(or any pathology) visible.

Thyroidectomy steps 4 – Dealing with vessels

• Arteries before veins (to prevent venous engorgement) • Vessels clamped, divided and ligated with 2-0 vicryl • Superior thyroid artery ligated close to the upper pole of the gland. • This is to prevent damage to external laryngeal nerve.• Inferior thyroid artery is similarly dealt with far away from the lower pole

of the gland.• This is to safeguard recurrent laryngeal nerve.• Then superior, middle and inferior thyroid veins are dealt with in a

similar manner.

Thyroidectomy steps 5 – Removing the gland proper

• Multiple artery forceps are applied around the thyroid gland • Appropriate portion (hemi-, subtotal, total thyroidectomy, lobectomy etc)

is removed.• Be sure to preserve the excised specimen in Formalin solution for

biopsy.• Cut edge of the gland usually bleeds profusely. • This is stopped by under-running with multiple continuous 2-0 Vicryl

sutures.• Accurate haemostasis is essential, at all times, now more than ever.

Thyroidectomy Steps 6 – Winding up process

• Redivac (suction) drain is inserted in the cavity left by the excised thyroid gland,

• Brought out through a separate stab incision at the side of the neck, • Sutured to the skin with 2-0 Silk sutures.• Strap muscles are sutured with 2-0 Vicryl.• Cut edges of deep cervical fascia are also sutured with 2-0 Vicryl.• Again, haemostasis is minutely checked.• Joll’s retractor, which was holding the skin-platysma flaps open, is

removed.

Thyroidectomy steps 7 – Closure

• Platysma and subcutaneous tissues are closed with 2-0 Vicryl interrupted sutures.

• Skin closed with 3-0 Nylon, horizontal mattress sutures or subcuticular sutures.

• The latter gives a finer scar, but it requires more technical expertise, finesse and time.

Post-operative management

• Patient is kept NPO/NBM (Nil Per Oral / Nil By Mouth) on the day of surgery.

• Supplemental IV fluid usually given on day of surgery; usually between 2.5 to 3 litres.

• Compatible blood may be transfused if there had been excessive blood loss during surgery.

• Oral intake initiated from next day, starting with ‘clear fluids’, going on to ‘free fluids’, then to soft diet and finally to normal diet

• Analgesics essential in post-operative period; there is invariably severe pain during first night.

• Antibiotics avoided in clean elective surgeries• Daily vital (PTR, BP) chart is maintained. • Rise of temperature after 3rd post-operative day indicates infection.

• This may require inspection of suture line.• Careful note is made of daily output from Redivac drain. • Drain removed after 48 hours or when drainage falls to few ml during

last 24-hour period, whichever is earlier.• Initial dressing changed after 48-72 hours (to inspect for infection of

suture line),

• Unless there is soakage, when it should be removed earlier. • Dry dressings sufficient every alternate day, if suture line is clean and

dry.• Sutures usually removed on 5th post-operative day.

• This gives minimum scarring.

Thyroidectomy – Possible complications

• Hemorrhage• Respiratory distress or stridor • Hoarseness of voice• Total vocal cord paralysis – aphonia • Hypocalcemic tetany (due to accidental removal of parathyroid glands

during total thyroidectomy)• Wound infection: This may manifest after 48 hours of surgery

CHOLECYSTECTOMY

NURSING MANAGEMENT OF THE PERIOPERATIVE PATIENT

Perioperative Nursing:

• Includes the preoperative (before), intraoperative (during) and postoperative (after) periods.

Preoperative period:

• This is an important time to address issues that may come up during surgery (Screening)

o i.e. assess for bleeding problems, don't want to find out that someone has a bleeding problem as they exsanguinate on the operating table

• Also can teach patients and family about what to expect before, during and after a procedure

o in an emergency, we can prepare the family if the patient isn't alert

Types of Surgeries

1. Diagnostic-Determination of the presence and or extent of the pathology

i.e. lymph node bx, bronchoscopy, exploratory laparatomy

2. Therapeutic -Elimination or repair of the pathology

Removal of the appendix when it's inflammed, removal of a localized cancer

3. Palliative -Alleviation of symptoms without curing the underlying disease

Rhizotomy (cutting of a nerve root) to decrease pain, colostomy placement to bypass an obstructing colon tumor

4. Preventive - Surgery to remove tissue that has the potential to become pathologic (may not already express a pathologic problem)

Total Colectomy in patients with FAP

5. Cosmetic-The surgery is performed for aesthetic reasons

Repair of scars from burns or injuries, minor cleft palate repairs, face lifts, breast augmentation

Further Descriptors of Surgery

Elective:

• Carefully planned event • Advanced assessments are usually attained and pre-operative

checks are in place o blood draws o physical exam o other necessary studies

• Can be scheduled in some cases as an outpatient or in an ambulatory surgery center

Emergency:

• arises unexpectedly • can also occur in a wide variety of settings

o ER o OR o Battlefield/Trauma scene

• Needed within minutes to hours

Urgent:

• delay could be detrimental • usually within 24-48 hours

Types of Elective Admissions for Surgery

Ambulatory Surgery:

• Usually outside a hospital setting • Special prescreening • Don't use in patient's with multiple problems

Same-Day Surgery:

• Outpatient, can be in the hospital • Go home the day of the surgery

Early Hospital Admission:

• Patient comes in early (night before or earlier) • Usually patients with complex medical issues, and increased risk

for poor surgical outcomes

Preoperative Nursing Assessment

1. Age 2. Allergies 3. Vital Sign Trend 4. Nutritional Status 5. Habits affecting tolerance to anesthesia 6. Presence of Infections 7. Use of drugs that are contraindicated prior to surgery 8. Physiological Status 9. Psychological state of the patient

Preoperative Nursing AssessmentAge:

• Elderly are at risk • >65 years of age • obtain a detailed medical history and health assessment • assess for sensory deficits • assess for overall functional status • understand that there is a decreased physiological reserve

Allergies: • assess for known drug, food and substance allergies • assess what the reaction to the drug or substance is (is it a true

allergy, hives or anaphylaxis?) • allergies must be clearly noted on the chart, and other steps are

usually taken per hospital/institutional protocol

Vital Signs Trends: • What is normal for that patient, and are V/S in the preoperative

period in line with the norms or deviating? Nutritional Status:

• This can be a situation of deficit or excess • assess for individuals who are prone to general nutritional

deficiencies: o Aged o Cancer patients o Gastrointestinal problems o Chronic illness/Chronic steriod use o Alcoholics/Drug Addicts

• Also assess for excess (Obesity): o Poor wound healing because of decreased blood supply o Hard to access surgical site o Decreased lung capacity o Anesthesia meds are stored in fat cells

Habits affecting tolerance to anesthesia: • Smoking:

o alters platelet function...hypercoagulable o reduces the amount of functional hemoglobin

carboxyhemoglobin o cilia in the lung are damaged, more difficult to mobilize

secretions in the patient that smokes o retards wound healing (especially because of the decreased

functional hemoglobin) • Alcoholism:

o can have impaired liver function o B-vitamin deficiencies

• Opioid Addiction o have a high tolerance for pain meds

Presence of Infections: • Biggest indicator is the presence of fever above 101 degrees F (38C) • If infection is present, likely surgery will need to be delayed because

the risks to the patient are too great.

• Goal will be to find and treat the infection, and then reattempt surgery once the infection is cleared

Use of drugs that are contraindicated prior to surgery: • Drugs like aspirin, heparin, warfarin (Coumadin) should be stopped

prior to surgery o affect bleeding time

ASA is 2 weeks because of the permanent platelet affects

heparin, and low molecular weight heparins are usually stopped 24 preop, unless there are problems with the liver

warfarin is usually 7 days, but the PT/INR is rechecked either the day of or the day before the surgery to check for bleeding

Use of drugs that are contraindicated prior to surgery: • current use of medications, over the counter agents and herbal

remedies should be assessed and documented • some drugs/herbs can interact with the anesthesia • check about antihypertensives the morning of surgery • need to be clear about home meds (dose, frequency, timing) so that

any necessary meds are in the postoperative order as per the MD o can check with the MD if certain meds should be restarted

• want to reinforce that if the patient is to take meds the morning of surgery, they should be taken with sips of water

Physiological Status: • Need to ensure as a preoperative nurse that all labs, xrays, EKGs and

necessary tests are done and in the chart • Need to notify the physician if there is anything abnormal, shouldn't

assume that they've already seen it• Common behaviors are fear and anxiety • fear = pt. knows what they are scared of • anxiety = don't tangibly know what is scaring you

Psychological States: Common Fears:

1. Fear of death 2. Fear of pain and discomfort 3. Fear of mutilation or alteration in body image

4. Fear of anesthesia 5. Fear of disruption of life functioning or patterns 6. Fear due to lack of knowledge regarding the proposed surgery 7. Fear related to previous surgical expriences 8. Fear due to the influence of significant others

Remember, for our patients, surgery presents a major lack of control.

Preoperative fear and anxiety can lead to: 1. Need for increased anesthesia 2. Need for increased postoperative pain management 3. Speed of recovery is decreased

Preoperative education of what to expect in clear, common english can alleviate some fear and anxiety Remember the role of HOPE for our patients, it is often the most common coping strategy

Patient Preparation for Surgery1. Operative consent 2. Preoperative learning needs 3. Interventions the day or evening prior to surgery 4. Interventions the day of surgery

Operative ConsentThis is part of the legal preparation for surgery. Informed consent: an active, shared decision making process between the provider and recipient of care. Has 3 components to make it valid:

1. Adequate Disclosure: of the diagnosis, nature and purpose of the proposed treatment, probability of successful outcome, risks and consequences of moving forward with treatment or alternatives, the prognosis if treatment is not instituted, and if treatment is deviating from standard for their condition.

2. Understanding and Comprehension of above: this has to be assessed before sedating meds can be given (minors can't give consent, severely mentally ill or severely developmentally challenged).

3. Voluntary Consent: Can't be coerced into going through with a procedure. This consent can be revoked at any point leading up to a surgical procedure.

Who can give consent? o the patient o next of kin (in order of kinship): Spouse, Adult Child, Parent, Sibling o Can be designated with a durable power of attorney in case of

medical incapacitation

Who has the legal responsiblity of obtaining consent?

The Physician • The nurse is not legally required to obtain consent • however, the nurse must make sure the consent was signed

o nurse has a primary role as a patient advocate. • nurse can "witness" the consent, and sign it as such • if the patient has questions that you can answer to clarify things, you

can do that • if the patient continues to have questions, or there is a question that

they are not voluntarily giving consent, the doctor needs to come and speak with them again.

• Very important that patient is consenting voluntarily and with knowledge of the situation

What about emergency treatment?A true medical emergency may override the need to obtain consent.

When medical care is needed to protect the life of an individual, the next of kin/POA (Power of Attorney) can give consent. Also, if there is a known and available Advanced Directive with healthcare decision making instructions, that can be used to assist in justifying consent. If they are not available, and the doctor deems the procedure necessary for life, the doctor can chart that it was necessary, and go ahead with the procedure.

• The nurse may need to write up an incident report and state that the emergency caused a deviation in the normal policy to obtain consent on everyone.

Patient preparation: preoperative learning needs• Deep breathing (incentive spirometer), coughing, leg exercises,

ambulation • Pain control and medications • Cognitive control to decrease anxiety and enhance relaxation (deep

breathing) • Recovery room orientation • Probable postoperative therapies • Directions for the family

Patient preparation: interventions the day or evening prior to the surgery• Diet Restrictions

o Historical guidelines to prevent aspiration were NPO after midnight the night before

o Educating the patient about the reason for NPO status may help with adherence

• Information of what to wear to the surgery • Patient will likely need to be there 1 to 2 hours prior to scheduled

procedure

Patient preparation: interventions the day of surgery

This varies based on whether the person is inpatient or outpatient. • Encourage the patient to void (empty their bladder) before

they get any sedative medications

• Final preoperative teaching • Final Assessment and communication of findings to MD • Ensuring that all preoperative orders have been completed • Check to chart to make sure that there is:

o a signed consent for the procedure o laboratory data, Xray reports, EKG o H&P, and necessary consults o Baseline vitals o Nursing notes up until that point

• Remove any jewerly, hair pins, clothes (except gown) o May be able to wear a wedding band taped firmly to

the finger • Remove contact lens • No dentures or partial dentures • If the hearing aides need to be removed, please not that on

the front of the chart. o glasses or hearing aides need to be returned to the

patient as soon as possible after the procedure • No makeup or dark nail polish • Give any preoperative medications • Note the time the patient leaves the floor • ID band should be placed, or checked depending on patient

status, and an allergy band per institution protocol

Preoperative Checklist

Preoperative Medications

• Benzodiazepines/Barbituates: used for their sedative and amnesic properties

• Anticholinergics: reduce secretions, and can reduce cramping

• Opioids: decrease need for intraoperative analgesics and decrease pain

• Antiemetics: decrease N/V

• Antibiotics: to prevent infective endocarditis, or where wound contamination is a risk (GI surgery) or where wound infection would cause significant postoperative morbidity o usually given IV

• Eyedrops: especially with eye surgery (lasik, cataract surgery)