Causes of goiter Iodine deficiency Surgery for thyroid goiter 50% - - PowerPoint PPT Presentation

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Surgery for thyroid goiter

Bhuvanesh Singh, MD, PhD

Attending Surgeon Memorial Sloan-Kettering Cancer Center

Causes of goiter

• Iodine deficiency

– 50% decrease after implementation of universal salts idealization program in mainland China (Zhao

et al. PLOS One. 2014)

• Genetic predisposition

– Autosomal dominant pattern – monozygotic vs. dizygotic twins – Linkage studies – 14q31, Xp22, others

• Tobacco use? (Knudsen , et al. Thyroid 2002)

Causes of goiter Management of goiter

• Non-Surgical
• Surgical

– Cosmesis – Fear of malignancy

• Increased risk for FTC/Anaplastic Ca
• Risk <10%

– Airway compromise

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Airway issues in goiter Airway Compromise in Goiter

lessons4medicos.blogspot.com/2009/01/what-is-this-pemberton-sign.html

Evaluation-Physical Findings

• Respiratory insufficiency/stridor
• Laryngoscopy
• Thyroid – consistency, texture,

relationship to clavicles

• Lateral neck

Evaluation Evaluation

• Chest x-ray
• Pulmonary function tests – flow volume

loop studies

• Computerized tomography/MRI
• Barium swallow

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Indications for Surgery in Substernal Goiters Indications for Surgery in Substernal Goiters

Compression effects: Up to 22% develop acute airway

• bstruction requiring emergent

intervention Fear of malignancy: Malignancy reported in 5-15% Cosmesis: The majority of cases of SSG are visible in the neck offering

• bvious cosmetic significance

Emergency airway management

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Surgical technique: Setup Surgical technique: Setup

• Non-traumatic intubation
• Discuss intubation with anesthesiologist
• ET tube well below the vocal cords
• tendency for the tube to slide up
• Paralysis during surgery
• Role of monitoring

Surgical technique: Approach Surgical technique: Approach

• A wide skin excision
• Transection of sternothyroid
• Open Joll’s triangle
• Work on surface gland
• Ligate feeding vessels
• Finger dissection

Surgical technique: key points Surgical technique: key points

• Ligate several inferior thyroid veins carefully
• Use Bipolar cautery or Ligasure
• The RLN best identified after delivering substernal

portion of gland

• In difficult cases- retrograde technique dissect

RLN near the ligament of Berry

• Parathyroids

Role of finger dissection

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Role sternotomy

• Pre-operative consent
• Median sternotomy, clam shell

thoracotomy, lateral thoracotomy

• Indications
• Recurrent/isolated mediastinal

goiter

• Superior vena cava syndrome
• Thyroid cancer
• direct extension or metastatic

disease

Management of RLN

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Perioperative management Perioperative management

• Placement of suction drain recommended
• Most of the patients can be extubated in OR
• Traceomalacia rarely an issue
• If concern- keep intubated for 24 hrs