bumkin81
Guest
Would anyone be able to help me? I do not know if the neuroplasty is inclusive. nerve repair has me so stumped.
ESCRIPTION OF PROCEDURE: Informed consent process was performed with the patient which included discussion regarding the indications of procedure as well as the risks of bleeding, infection, transient versus permanent hypoparathyroidism and hypocalcemia, injury to recurrent laryngeal nerves or external branch of the superior laryngeal nerves bilaterally. The patient was taken to the operating room and placed in supine position on operating room table. Sequential compression devices were placed on the lower extremities bilaterally. After adequate IV sedation was given, the patient underwent an uncomplicated endotracheal tube intubation by anesthesia. This was performed using GlideScope assist. Leads positioned on the distal end of the endotracheal tube were placed abutting the vocal cords in anticipation of nerve monitoring. The patient's arms were tucked to her sides with all pressure points padded. An IV pressure bag wrapped in a blue towel was then positioned beneath her shoulder blades and insufflated to provide gentle hyperextension of her neck. Full head support was provided on a gel donut. Her earlobes, mandible chin, neck and upper chest were prepped with chlorhexidine solution and draped in standard fashion. A formal timeout was performed. Using a 15 blade, a transverse 4 cm neck incision was made along the natural skin crease. This was taken down sharply through the dermis. Subcutaneous tissue and platysma were divided using the Bovie electrocautery. Subplatysmal flaps were created superiorly to the thyroid cartilage and inferiorly to the sternal notch. The midline raphe was also well identified and divided along a right angle clamp using Bovie electrocautery. The right strap muscles inclusive of the sternohyoid and sternothyroid muscles were dissected off of the thyroid capsule using both blunt dissection with a Kittner as well as dividing more dense adhesions along a right angle clamp using Bovie electrocautery. Moderate amount of perithyroidal inflammation and fibrotic change were noted. These were carefully dissected using a right angle clamp, divided using the Bovie electrocautery or bipolar. The right middle thyroid vein was well identified, ligated and divided using a clamp and tie technique with 2-0 silk ties. The right thyroid lobe was quite large, dense multinodular with retroesophageal extension. An esophageal probe was placed in order to be able to palpate the location of the structure of the esophagus. Superiorly, the gland extended up towards the hyoid bone. The superior thyroidal vessels were individually ligated and divided using a clamp and tie technique with 2-0 silk ties. Nerve function of the external branch of the right superior laryngeal nerve was monitored throughout and viable. Both the right superior and inferior parathyroid glands were visualized and dissected off of the thyroid capsule. They were grossly viable at the end of the procedure. Significant fibrosis was noted posteriorly to this along the right thyroid lobe. The right recurrent laryngeal nerve was identified, it was tracking up into the tracheoesophageal groove and followed medially towards the thyroid. The nerve was completely adherent to a portion of the tubercle of Zuckerkandl. Using a fine tonsil, a portion of the nerve was dissected off the thyroid tissue, but at one point seemed completely fused. To this regard, a small portion of the thyroid tissue was left in place along the nerve. The inferior thyroidal vessels were ligated and divided at the junction with the thyroid parenchyma using a clamp and tie technique with 2-0 silk ties. Posterior attachments of the right thyroid lobe to the underlying trachea were divided carefully using Bovie electrocautery as well as bipolar. Nerve function of both the right external branch of superior laryngeal nerve and right recurrent laryngeal nerve were confirmed on dissection and mobilization of the right thyroid lobe. The posterior attachments of the isthmus were then dissected off of the trachea also using Bovie electrocautery. At this point, the dissection of the left thyroid lobe was performed. This was performed in a similar fashion including dissection of the left strap muscles off of the left thyroid lobe, the left middle thyroid vein was not well identified in that the lobe had significant posterior extension behind in the retroesophageal plane. The left superior thyroidal vessels were ligated and divided using the clamp and tie technique with 2-0 silk ties. Nerve function of the external branch of the left superior laryngeal nerve was confirmed. The left inferior thyroidal vessels ligated and divided using a clamp and tie technique as described. Left inferior parathyroid gland was well identified anterior to the left recurrent laryngeal nerves. Similarly, the left recurrent laryngeal nerve was seen tracking up into the tracheoesophageal space into an area of fibrosis at the ligament of Berry. The nerve was followed carefully with a fine tonsil. The left superior parathyroid gland was noted in a subcapsular position adjacent to the nerve. This was resected en bloc with the thyroid tissue. A biopsy of this tissue was then sent to confirm parathyroid tissue on frozen section analysis. As this was parathyroid tissue, the remaining left superior parathyroid gland was preserved in cold sterile normal saline back table in anticipation of a parathyroid autoimplantation. Although careful dissection using the tonsil was performed to try to separate out the recurrent laryngeal nerve from the fibrotic tissue at the ligament of Berry, there was nerve injury acutely. Using the neuro monitoring, there was loss of signal. The decision at this point was made to fully transect the nerve in order to create viable ends and proceed with a primary repair of the nerve. Small tenotomy scissors were used to biopsy the ends of the nerves, both proximally and distally. Nerve was confirmed with frozen section analysis. Using the nerve monitor, the proximal limb of the nerves demonstrated function. The nerve was reapproximated without tension and closed with a horizontal mattress 6-0 Prolene suture using a BV needle. The alignment of the nerve was quite acceptable. Following repair of the left recurrent laryngeal nerve, the right and left paratracheal wound beds were irrigated with water, suctioned over Ray-Tec gauze. A Valsalva technique to 40 mmHg was performed with no evidence of active bleeding in either side. Once again, the function of the right recurrent laryngeal nerve was confirmed prior to closing. To optimize hemostasis, Arista was placed in the wound bed. For closure, the strap muscles were reapproximated along the midline and closed with a running 3-0 Vicryl with an approximately 1 cm opening inferiorly. The IV pressure bag beneath the patient's shoulders was then desufflated to provide better reapproximation of platysma and skin. Platysma was reapproximated and closed with running 3-0 Vicryl. The skin was closed with a running subcuticular 5-0 Monocryl. Prior to skin closure, the skin edges were excised with tenotomy scissors due to some mild retraction injury. The wounds were reinforced with half inch Steri-Strips placed longitudinally and dressed with a strip of Telfa secured with Steri-Strips. All counts for sponges, instruments and needles were correct at the end of the case. The patient was slowly extubated and taken to the recovery room in stable condition. She was vocalizing quite well at that time. Intraoperative interventions and findings were shared with both the patient as we
ESCRIPTION OF PROCEDURE: Informed consent process was performed with the patient which included discussion regarding the indications of procedure as well as the risks of bleeding, infection, transient versus permanent hypoparathyroidism and hypocalcemia, injury to recurrent laryngeal nerves or external branch of the superior laryngeal nerves bilaterally. The patient was taken to the operating room and placed in supine position on operating room table. Sequential compression devices were placed on the lower extremities bilaterally. After adequate IV sedation was given, the patient underwent an uncomplicated endotracheal tube intubation by anesthesia. This was performed using GlideScope assist. Leads positioned on the distal end of the endotracheal tube were placed abutting the vocal cords in anticipation of nerve monitoring. The patient's arms were tucked to her sides with all pressure points padded. An IV pressure bag wrapped in a blue towel was then positioned beneath her shoulder blades and insufflated to provide gentle hyperextension of her neck. Full head support was provided on a gel donut. Her earlobes, mandible chin, neck and upper chest were prepped with chlorhexidine solution and draped in standard fashion. A formal timeout was performed. Using a 15 blade, a transverse 4 cm neck incision was made along the natural skin crease. This was taken down sharply through the dermis. Subcutaneous tissue and platysma were divided using the Bovie electrocautery. Subplatysmal flaps were created superiorly to the thyroid cartilage and inferiorly to the sternal notch. The midline raphe was also well identified and divided along a right angle clamp using Bovie electrocautery. The right strap muscles inclusive of the sternohyoid and sternothyroid muscles were dissected off of the thyroid capsule using both blunt dissection with a Kittner as well as dividing more dense adhesions along a right angle clamp using Bovie electrocautery. Moderate amount of perithyroidal inflammation and fibrotic change were noted. These were carefully dissected using a right angle clamp, divided using the Bovie electrocautery or bipolar. The right middle thyroid vein was well identified, ligated and divided using a clamp and tie technique with 2-0 silk ties. The right thyroid lobe was quite large, dense multinodular with retroesophageal extension. An esophageal probe was placed in order to be able to palpate the location of the structure of the esophagus. Superiorly, the gland extended up towards the hyoid bone. The superior thyroidal vessels were individually ligated and divided using a clamp and tie technique with 2-0 silk ties. Nerve function of the external branch of the right superior laryngeal nerve was monitored throughout and viable. Both the right superior and inferior parathyroid glands were visualized and dissected off of the thyroid capsule. They were grossly viable at the end of the procedure. Significant fibrosis was noted posteriorly to this along the right thyroid lobe. The right recurrent laryngeal nerve was identified, it was tracking up into the tracheoesophageal groove and followed medially towards the thyroid. The nerve was completely adherent to a portion of the tubercle of Zuckerkandl. Using a fine tonsil, a portion of the nerve was dissected off the thyroid tissue, but at one point seemed completely fused. To this regard, a small portion of the thyroid tissue was left in place along the nerve. The inferior thyroidal vessels were ligated and divided at the junction with the thyroid parenchyma using a clamp and tie technique with 2-0 silk ties. Posterior attachments of the right thyroid lobe to the underlying trachea were divided carefully using Bovie electrocautery as well as bipolar. Nerve function of both the right external branch of superior laryngeal nerve and right recurrent laryngeal nerve were confirmed on dissection and mobilization of the right thyroid lobe. The posterior attachments of the isthmus were then dissected off of the trachea also using Bovie electrocautery. At this point, the dissection of the left thyroid lobe was performed. This was performed in a similar fashion including dissection of the left strap muscles off of the left thyroid lobe, the left middle thyroid vein was not well identified in that the lobe had significant posterior extension behind in the retroesophageal plane. The left superior thyroidal vessels were ligated and divided using the clamp and tie technique with 2-0 silk ties. Nerve function of the external branch of the left superior laryngeal nerve was confirmed. The left inferior thyroidal vessels ligated and divided using a clamp and tie technique as described. Left inferior parathyroid gland was well identified anterior to the left recurrent laryngeal nerves. Similarly, the left recurrent laryngeal nerve was seen tracking up into the tracheoesophageal space into an area of fibrosis at the ligament of Berry. The nerve was followed carefully with a fine tonsil. The left superior parathyroid gland was noted in a subcapsular position adjacent to the nerve. This was resected en bloc with the thyroid tissue. A biopsy of this tissue was then sent to confirm parathyroid tissue on frozen section analysis. As this was parathyroid tissue, the remaining left superior parathyroid gland was preserved in cold sterile normal saline back table in anticipation of a parathyroid autoimplantation. Although careful dissection using the tonsil was performed to try to separate out the recurrent laryngeal nerve from the fibrotic tissue at the ligament of Berry, there was nerve injury acutely. Using the neuro monitoring, there was loss of signal. The decision at this point was made to fully transect the nerve in order to create viable ends and proceed with a primary repair of the nerve. Small tenotomy scissors were used to biopsy the ends of the nerves, both proximally and distally. Nerve was confirmed with frozen section analysis. Using the nerve monitor, the proximal limb of the nerves demonstrated function. The nerve was reapproximated without tension and closed with a horizontal mattress 6-0 Prolene suture using a BV needle. The alignment of the nerve was quite acceptable. Following repair of the left recurrent laryngeal nerve, the right and left paratracheal wound beds were irrigated with water, suctioned over Ray-Tec gauze. A Valsalva technique to 40 mmHg was performed with no evidence of active bleeding in either side. Once again, the function of the right recurrent laryngeal nerve was confirmed prior to closing. To optimize hemostasis, Arista was placed in the wound bed. For closure, the strap muscles were reapproximated along the midline and closed with a running 3-0 Vicryl with an approximately 1 cm opening inferiorly. The IV pressure bag beneath the patient's shoulders was then desufflated to provide better reapproximation of platysma and skin. Platysma was reapproximated and closed with running 3-0 Vicryl. The skin was closed with a running subcuticular 5-0 Monocryl. Prior to skin closure, the skin edges were excised with tenotomy scissors due to some mild retraction injury. The wounds were reinforced with half inch Steri-Strips placed longitudinally and dressed with a strip of Telfa secured with Steri-Strips. All counts for sponges, instruments and needles were correct at the end of the case. The patient was slowly extubated and taken to the recovery room in stable condition. She was vocalizing quite well at that time. Intraoperative interventions and findings were shared with both the patient as we