DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left thyroid mass.
POSTOPERATIVE DIAGNOSIS: Left thyroid mass.
OPERATION PERFORMED: Left hemithyroidectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This is a patient with a left thyroid mass. The patient had a needle aspirate that suggested a benign lesion; however, because of family history and concerns about cancer, the patient has requested surgical removal. Left hemithyroidectomy with possible total based on frozen section has been recommended. The risks and benefits have been discussed. The patient was interviewed preoperatively in the holding area prior to sedatives. All questions were answered and consent was signed.
DESCRIPTION OF OPERATION: The patient was placed in the supine position under general anesthesia by endotracheal tube. Xylocaine 1% with epinephrine was injected in the lower neck, and the neck was prepped and draped sterilely.
A thyroid incision was then made and carried at a subplatysmal plane to the sternal and thyroid notches. Strap muscles were elevated and separated and taken off the left side with release of the sternothyroid superiorly. The superior pole vessels were suture ligatured as was the anterior thyroid and the anterior thyroid vasculature being the only major vasculature seen coming into this gland. The remaining soft tissues were taken off the outer surface of the gland, releasing the soft tissues, allowing them to fall laterally. The superior parathyroid was identified and well preserved. The inferior parathyroid was identified, was more adherent to the gland, but was taken off with the anterior thyroid artery and preserved.
As the gland was rolled medially, the nerve was seen traveling at its nerve entry zone, and the vessels and ligaments were taken using the Harmonic device, carefully clamping, using this to coagulate and separate, getting good hemostasis and division of the tissues. The large vessels were, however, suture ligated as indicated before. The isthmus was divided with the ultrasonic device, and this was then oversewn with 2-0 chromic to assure hemostasis in the isthmus. The wound was irrigated with antibiotic solution. It was a very dry wound. Both parathyroids and nerve were again visualized and were well preserved. The drain was brought out through a separate opening and sutured to the skin and allowed to lie from the lower wound under the strap muscle to drain the thyroid inferior and lateral portions of the wound.
The strap muscles were closed with 3-0 chromic. The platysma was closed with 3-0 chromic and the skin was closed with 5-0 Vicryl. Steri-Strips were applied. The patient tolerated the procedure well and was taken to the recovery room in good condition with no complications. Estimated blood loss was 30 mL.
