Subtotal resection of the thyroid gland, considered the most effective method of therapy of thyrotoxicosis( a condition caused by an elevated level of thyroid hormones) has been performed for almost six decades.
Its implementation helps to significantly improve the quality of life of the operated patient.
The concept of
Subtotal resection of the thyroid gland is called a surgical procedure, during which most of this organ is removed, but a small amount( from four to six grams) of its tissues is left on the lateral surfaces of the parathyroid glands, trachea and laryngeal nerve.
After this operation, L-thyroxine replacement therapy is necessary.
Indications
The operation of subtotal resection of the thyroid gland is indicated by the detection of:
- of different stages of cancer of this organ;
- malignant growths of unclear etiology;
- adenoma;
- of Hashimoto's disease is a chronic ailment, most often diagnosed in women, in which the immune system produces antibodies to cells of the thyroid gland;
- diffuse goiter( referred to as Graves 'disease or Graves' disease);
- of nodal formations that occur in men on the background of diffuse-toxic goiter;
- high probability of malignancy of small benign tumors;
- tumor nodes, whose diameter exceeds 3.5 cm;
- nodular goiter, resulting in squeezing adjacent tissue and fraught with the development of suffocation;
- disturbing dynamics, characterized by a high( more than 0.5 cm for six months) rate of increase in the tumor node.
Preparing for operation
The operation of subtotal resection of the thyroid gland requires a sufficiently long preoperative preparation.
- At least three months before the doctor appoints the patient thyreostatics - drugs that help reduce hyperthyroidism by inhibiting the production of thyroid hormones.
- Two weeks before the surgery, the patient starts taking beta-blockers and iodine-containing medications , suppressing the thyroid gland's ability to produce thyroid hormones. Another goal of medical preparatory therapy is to reduce the blood supply of the thyroid gland. Thanks to this measure, it is possible to reduce the intensity of bleeding accompanying the operation and the likelihood of postoperative blood loss.
- If there are indications for urgent surgery, the patient is prescribed iodine-containing drugs, thyrostatics and glucocorticosteroids in a higher dosage: , this avoids the onset of thyrotoxic crisis.
- Assignment of beta-blockers is shown both before and after surgery.
During the preoperative period, the patient must undergo a series of standard laboratory tests:
- urine analysis;
- coagulogram;
- blood test for the presence of antibodies to HIV, hepatitis, syphilis.
Among the laboratory tests of particular importance are:
- indices, which characterize the level of thyroid hormones in the blood;
- results of pathomorphological diagnosis, obtained by performing fine needle puncture biopsy of tumor nodes.
The list of hardware studies is quite impressive. Patient must pass:
- Ultrasound examination of the thyroid and cervical lymph nodes. With its help, it is possible to determine the location and size of nodes and tumor neoplasms, as well as the anatomical features of the zone of future surgical intervention.
- Laryngoscopy is a diagnostic procedure that allows visual assessment of the condition of the vocal cords and larynx.
- Procedure for computed tomography of the neck.
- Radionuclide diagnostic examination( scintigraphy), which allows a visual assessment of the degree of hormonal activity of tumor foci and unchanged thyroid tissue.
- Fluorography.
During the medical examination the patient should visit the therapist's office. Analyzing the data obtained in the above studies, a team of specialists, consisting of a treating surgeon and an anesthesiologist, appoints the date of the future operation.
The patient is then instructed to stop using any liquids and food fourteen hours before surgery.
Operation of
- The operation of subtotal resection begins with the marking: edges and the middle of the future seam are marked with vertical lines;The cut line can only be horizontal. At the time of marking on the skin, the patient is in a wakeful state, in a standing or sitting position. A reclining position is not suitable for this, since there is a possibility of asymmetric line deposition.
- During an operation performed under general anesthesia, the patient is placed on the back of the , laying the roller under the shoulder blades, so that his head is thrown back.
- The cut is performed in exact accordance with the lines of preliminary marking. Its length, depending on the extent of the surgical intervention, can range from two to fifteen centimeters.
- To obtain access to the thyroid gland, the layered dissection of tissues is consistently performed: of skin, fatty tissue, broad neck muscle. The flap from the superficial fascia is pulled upward.
- After longitudinal cutting of the second and third cervical fascia, dissection( or separation) of the muscles covering the thyroid gland located in the fascial capsule is performed.
- After bandaging, the thyroid vessels are cut off, carefully moving and separating the recurrent laryngeal nerve all along its length( starting from the bottom and ending with the site of its attachment to the larynx).
- Pass to the separation of parathyroid glands , keeping a thin layer of thyroid tissue so as not to disturb the blood flow.
- Depending on the indications, a resection( its different variants) is performed either by one or both of the thyroid glands.
- In the presence of malignant tumors and their metastasis, lymphadenectomy begins - the removal of closely located lymph nodes.
- After resection, perform layer-by-layer stitching of tissues, doing this in the reverse order of , taking care of the drainage. It is carried out with the help of the Blake system - a flexible silicone tubing connected to a vacuum suction and allowing the removal of the remains of blood from the wound. With this system, the process of draining the operating cavity is much faster and less painful.
- After removing the drainage, cosmetic seams of are applied, using catgut, special glue or synthetic material.
- In the presence of positive dynamics, the patient's discharge is performed on the third day of after the operation is performed.
Subtotal, subfascial thyroid resection by Nikolaev
This type of surgical intervention, developed by the famous Soviet surgeon-endocrinologist OV Nikolaev, is an operation almost unrelated to the risk of damage to the parathyroid glands and recurrent laryngeal nerve.
Gentle( in relation to parathyroid glands and recurrent laryngeal nerve), the nature of this surgical intervention is due to the topography of the thyroid gland. Since parathyroid glands are located under the fascial capsule, and the recurrent laryngeal nerve is outside, surgical manipulations performed inside this capsule do not pose a threat to the above nerve.
Immunity of the parathyroid glands is due to the preservation of a thin layer of tissue on the posterior surface of the thyroid gland.
Starting the operation, the surgeon makes a transversal arcuate incision located just above( no more than 1.5 cm) of the jugular notch of the sternum. To gain access to the thyroid gland, it dissects the skin, subcutaneous tissue and superficial muscle of the neck( with the capture of the superficial fascia).
After pulling the formed flap to the upper edge of the thyroid cartilage, the specialist performs the dissection of the second and third fascia of the neck, having a longitudinal incision exactly in the middle: between the sternum-thyroid and the sternum-hyoid muscle.
To expose the thyroid gland, the surgeon produces a transverse dissection of the sternum-hyoid muscle( sometimes it is necessary to dissect the sternum-thyroid muscle in a similar way).
To block the nerve plexus of the fascial capsule and facilitate the removal of the thyroid from the thyroid gland, a solution( 0.25%) of novocaine is injected under the fascial capsule. The thyroid gland, withdrawn from the capsule, is resected, and bleeding is stopped with special clips.
Having ascertained the reliability of hemostasis, they begin to stitch the edges of the fascial capsule by applying a continuous catgut suture. For stitching of the sternum-hyoid muscle, catgut n-shaped sutures are used;for stitching the edges of the fascia - catgut nodal seams. Sewing of skin edges is carried out using nodal synthetic or silk sutures.
Video shows the course of subtotal resection of the thyroid:
Distal and proximal subtotal resection of the stomach according to Billroth
Subtotal resection is performed on the stomach. Resection of the stomach is called surgical intervention, aimed at removing a large part of it with the subsequent restoration of the continuity of the digestive tract.
By distal gastric resection is meant the removal of its lower part. The category of distal resections of the stomach includes:
- operation consisting in removal of its antral part( located in the lower part of the stomach and engaged in rubbing, mixing and pushing the food lump through the sphincter);
- is a subtotal resection consisting in removing most of the stomach and leaving only a small portion of it in the upper part of the digestive organ.
With proximal resection of the stomach, the entire upper part of the stomach is removed along with the cardiac sphincter separating the stomach and esophagus;the lower part of the digestive organ( to a greater or lesser extent) is retained.
In the presence of an exophytic malignant neoplasm of small size localized in the lower third of the stomach, subtotal resection of the stomach can be performed by one of the methods proposed by the German surgeon Theodor Bielrot:
- The first variant of the restoration of gastrointestinal continuity, called Billroth I, begins with the removal of two thirds of the stomach. After this, a partial suture of its central stump is made. The dimensions of the lumen to be left must correspond to the diameter of the duodenum, since in the next stage of the operation between the duodenum and the stump of the stomach an end-to-end anastomosis is formed. After resection, performed in this way, the possibility of anatomical and physiological progression of the food lump together with bile remains. The main advantage of this type of operation is the speed of execution and their technical simplicity. This technique has two drawbacks: the presence of a joint of three joints at once and the probability of tissue tension in the upper part of the anastomosis. Each of these deficiencies can provoke sore throat, making the anastomosis insolvent. Avoid this complication can be, flawlessly owning the technique of performing the operation.
- The second version of this technique( Billroth II) involves the formation of a broad gastroenteroanastomosis between the onset of the jejunum and stomach stumps superimposed "side-to-side". This method is used in the event that it is not possible to form an anastomosis with the above-described method.
On the video, laparoscopic distal subtotal resection of the stomach:
Advantages and risks of
The operation of subtotal resection of the thyroid gland is fraught with the development of a number of complications involving the risk:
- of profuse internal bleeding( in case of blood vessel damage), dangerous development of suffocation when breathing in the respiratory tract;
- air embolism resulting from damage to the cervical veins;
- is purulent( the most dangerous is the phlegmon of the neck) complications;
- accidental removal of parathyroid glands, fraught with the development of metabolic disorders( the brightest of them is hypoparathyroidism - a disease caused by a lack of parathyroid hormone);
- serious damage to the recurrent laryngeal nerve, responsible for the innervation of the vocal apparatus and capable of causing aphonia( loss of voice sonority) and hoarseness of voice;
- paralysis of the vocal cords that occurs when bilateral injury of the laryngeal nerve;
- airway obstruction;
- development of postoperative thyrotoxicosis, the main manifestations of which are: severe tachycardia, tremor of hands, a state of anxiety, severe fatigue. This condition can develop due to improper selection of hormonal treatment;
- probable( in every fifth case) occurrence of relapse.
In addition, after surgery:
- There is no need for frequent delivery of expensive tests for hormones.
- The patient gets rid of a debilitating condition, characterized by a frequent change of hypothyroidism by hyperthyroidism.
- After getting rid of the need to take toxic thyreostatic drugs, women can bear and give birth to children.
Restorative therapy
After subtotal resection of the thyroid gland, the patient is prescribed synthetic hormone replacement drugs( eutirox and L-thyroxine are the most sought after ones), designed to fill the temporary shortage of thyroid hormones and normalize the course of vegetative processes.
To timely identify and prevent the emergence of all kinds of pathologies, the patient should regularly( at least twice a year) visit his treating endocrinologist. The control of its condition is carried out by:
- of the passage of ultrasound examination;
- performing scintigraphy;
- blood test for hormones.
In the presence of indications, the endocrinologist will correct the daily dosage of hormonal preparations.
The cost of
Citizens of the Russian Federation who have certain indications for resection of the thyroid gland can use the compulsory insurance policy that gives the right to perform a free operation.
In clinics in Moscow, the cost of surgical treatment consists of several components. It is affected by:
- level of complexity of surgical intervention;
- the amount of resection to be performed;
- qualification of the specialist performing the operation;
- length of stay of the patient in the hospital;
- rating of the medical institution.
Thus, the cost of resection of the thyroid gland in conditions of paid Moscow clinics varies very widely: from 12 000 to 103 000 rubles.