A Patient with a Thyroid Problem

Facilitating Learning Session
with

Participants (mostly surgical trainees with some certified general surgeons)
in the
Postgraduate Course of the Department of Surgery, Philippine General Hospital
Manila

September 6, 1999

12 Participants
Drs. Randy Abdulla, Janice Maddela, Marlo Rendon, Merceditha Althea Quinon,
Luis Serafin C. Dabao, Romulo Barrameda, Jr., Arlean, and others

(from Laguna, Polymedic Medical Center, Iloilo, Bacolod, Tondo Medical Center)

Facilitator: Reynaldo O. Joson, MD

Notes:

• This was the first day of the postgraduate course.
• A group of 12 participants was assigned to me in the operating room.
• My residents prepared a patient for thyroidectomy.
• I did not know the details of the problems of the patient nor did the participants.

How I Did It and What Transpired

• I used the framework of a "Management of a (Surgical) Patient."
• I focused on problem-solving and decision-making.
• I used inquiry approach and promoted interactions.

The patient had been anesthesized (general - endotracheal).

I told the participants that the patient was a 36 year old female presenting with a thyroid problem. The thyroid problem could be anything from nodule to hyperplasia, from nonmalignant to malignant disease.

I asked the participants to palpate the patient's neck which was not prepped yet.

After all had palpated the neck of the patient, I asked for the findings. Consensus was there was a 2-cm nodule on the right thyroid lobe, not hard, well-defined, movable with no nodes palpated. So the thyroid problem was that of a nodule.

At this point, I asked the resident in charge when was the onset. Two years was the answer. Other data: no other associated symptoms and signs.

Then, I asked the participants what could be the diagnosis based on the data on hand.

After some discussion, the consensus on the diagnosis was: 1) colloid adenomatous nodule, 2) follicular adenoma, 3) thyroid cancer.

There were no signs of inflammation. Therefore, most likely, the nodule was not an inflammatory tumor. The differentials at this point were malignant vs nonmalignant tumor. In the absence of signs of malignancy (hard, fixation, nodes, and distant mass), most likely the nodule was non-malignant. If it were non-malignant, the initial considerations given were colloid cyst, colloid adenomatous nodule, and follicular adenoma. Since the nodule was not cystic, it was then a toss-up between colloid adenomatous nodule and follicular adenoma. Since there were no clinical parameters (pattern recognition) that could discriminate the two, the prevalence process was utilized. Since colloid adenomatous nodule was definitely more common than adenoma, therefore, the primary diagnosis at this point was colloid adenomatous nodule and the secondary diagnosis was follicular adenoma.

The paraclinical diagnostic process on the indication ran like this:

The degree of certainty on the primary diagnosis was quantified as not certain since the diagnosis was gotten mainly on the absence of signs of malignancy and prevalence. There were no direct evidences. As a rule, if the primary diagnosis is not certain, a paraclinical diagnostic procedure is indicated.

The plan of treatment of colloid adenomatous nodule was a trial of medical therapy or at least there was this option, not outright operation. The plan of treatment of follicular adenoma (and carcinoma) was surgery. Thus, there was a difference in the plan of management for the primary and secondary diagnoses. As a rule, if there is marked difference in the plan of management for the primary and secondary diagnoses, a paraclinical diagnostic procedure is indicated.

The resident-in-charge was asked whether a needle biopsy was done. YES, it was done and the result showed follicular tumor.

At this point I asked: How do you interpret the result? Some said "follicular tumor" was a toss-up between follicular adenoma and carcinoma. Some said it was non-informative for it could be anything, malignant and nonmalignant, colloid adenomatous goiter, chronic thyroiditis, papillary cancer, follicular adenoma, follicular carcinoma, etc.

After some discussion, the consensus was that "follicular tumor" was non-informative. Thus, the diagnosis was still 1) colloid adenomatous nodule 2) follicular adenoma-carcinoma ( it was decided to lump these two together since it was hard to differentiate the two).

Some said go for another paraclinical diagnostic procedure such as repeat the biopsy and diagnostic therapy (if the patient responds to medical suppressive therapy, then most likely, colloid adenomatous nodule is the diagnosis). Most said proceed to operative treatment. Some justified the operation using the possibility that the nodule could be cancer. This viewpoint / tendency was counteracted by the argument that if we adopt this attitude, then all patients with a thyroid nodule would have to be operated since there is always the possibility that the nodule could be cancer. Nobody is ever absolutely certain of the diagnosis clinically.

Justifications for nonoperative treatment consisted of the following:

• The primary diagnosis was colloid adenomatous nodule, with an 80 to 85% probabibility.
• A trial of medical therapy could be done without unduly or dangerously comprising the life of the patient if the nodule turned out to be malignant. An operative treatment in the future was not excluded.

Justifications for operative treatment consisted of the following:

• Failure of trial of medical therapy and after being informed of the probabilities of the different possible diagnoses, the benefits and risks of operative and observation-monitoring treatment options, the patient chose to have an operation for one reason or another (such as could not live with sword of Damocles on top of her head and bothered by the palpable and/or visible nodule on her neck).
• After being informed of the probabilities of the different possible diagnoses, the benefits and risks of operative, medicinal, and observation-monitoring treatment options, the patient chose to have an operation for one reason or another (such as could not live with sword of Damocles on top of her head and bothered by the palpable and/or visible nodule on her neck).

For this patient, according to the resident-in-charge, the reason was the 2nd one stated under justifications for operative treatment. There was no trial of medical therapy. The patient wanted to have the operation.

During this time, I had asked the resident to prep the patient's neck and then draped the operative field.

At this point I asked the question: What is our goal in the operative treatment?

The consensus was to extirpate the tumor as completely and cleanly as possible (whatever it might be) in such a way that there would be no complications (particularly, hoarseness of voice and tetany) and in such a manner that the patient would be satisfied (particularly, in terms of health restoration and promotion of quality of life).

The first step in the operation proper was the incision. Considerations consisted of adequate exposure and cosmesis. The incision should be long enough (not excessively or unnecessarily long) to enable adequate exposure for intraoperative evaluation of the tumor as well as to facilitate adequate extirpation of the tumor. The incision should be placed not only in an area where exposure of the tumor could be facilitated but also in consideration of the cosmetic factor. A participant suggested placing it in the lower skin crease on the neck if there is. If not, 2-finger breaths above the sternum.

In this patient, there was no evident skin crease in the lower neck. So, I had to use an arbitrary 2-finger breaths above the sternum.

As to the length, all participants suggested to me that it should be from the right to the left sternomastoid muscles. I countered with a suggestion: Why not shorter and more on the right and just crossing the midline? Some participants said it would not be symmetrical and would, therefore, go against the cosmetic objective.

In this patient, considering the primary diagnosis was 2-cm colloid adenomatous goiter (80-85% certain) in which the plan was to do at most a right lobectomy, I made an incision starting from the anterior border of the right sternomastoid muscle to just passed the midline. With this incision, I can adequately palpate the left lobe to check intraoperatively for any abnormality (preoperatively, there was none). I felt I could do my right lobectomy without difficulty with such a length of incision. Bringing the incision to the left sternomastoid muscle would be unnecessary, exposure wise and extirpation wise. Incision is an intentional injury to a patient. Avoiding an unnecessarily long incision is synonymous to avoiding intentional injury to a patient. Remember, the dictum: DO NO HARM, I told the participants.

Going to the cosmetic considerations, making a scar symmetrical on the neck does not really promote cosmesis. A long scar is more evident than a short scar. If the incision is placed along a skin crease and if there is no hypertrophic scar formation, then a short scar is as good as a long scar, cosmetic wise. Since we cannot predict hypertrophic scar formation, a long hypertrophic scar resulting from an unnecessarily long incision will be more evident.

The other disadvantages of an unnessarily long incision would consist of more edema and more numbness postop on the neck.

In the operation, as mentioned earlier, I decided to utilize an incision starting from the anterior border of the right sternocleidomastoid muscle and just passed the midline. I was able to demonstrate to the participants that the exposure was adequate to evaluate the entire thyroid gland and to perform the subtotal thyroidectomy (isthmectomy, pyramidalectomy, and subtotal right lobectomy) without undue difficulty.

After the flap formation and splitting the midline to separate the two pairs of strap muscles (sternothyroid and sternohyoid) to expose the thyroid gland, the next step was to do intraoperative evaluation.

I asked the three participants who scrubbed in to evaluate the thyroid gland. Consensus: the left lobe was grossly normal and there was a 2-cm soft nodule on the lower pole of the right thyroid lobe. The nodule felt cystic and there was an area on the surface of the nodule that was a little bit transparent to suggest fluid inside. Thus, the intraoperative diagnosis was colloid adenomatous nodule on the lower pole of the right thyroid lobe.

When asked what would be the extent of thyroidectomy, the participants said as conservative as possible, since the nodule is benign; adequate tumor removal with an adequate margin, at least a subtotal lobectomy, at most a total lobectomy, with isthmectomy, and pyramidalectomy. I fully agreed with them and I said that would be our plan at the moment. Let us mobilize the gland some more.

The question asked of me at this time: Sir, where do you usually start when you mobilize the gland? My answer was no defnite routine. Anywhere is an answer. The rule to remember is wherever is easier. If there are difficult and easy areas of dissection, start with the easier areas first. If there are no differential difficult areas of dissection, you could start anywhere, midline or lateral, upper pole or lower pole.

In the patient whom I am operating on, there was no differential areas of difficulty of dissection. The mass was inside the right thyroid lobe and not adherent to the adjacent structures. So, I asked the participants scrubbing with me. Where do you want me to start? They said "midline." So, I started to split the midline isthmus using an electrocautery, then remove the pyramidal lobe, then mobilized the lower pole of the right lobe. After mobilizing the areas around the nodule and knowing that I could do a subtotal lobectomy with an adequate margin about 1 cm, I decided to do such that.

During the dissection, I reminded the participants of the other objectives of the operation, that of not incurring complications. When I was cutting through the isthmus with the cautery, I said I had to be careful not to burn or create a hole in the trachea. When I was dissecting the right lobe of the gland, I said I had to be careful not to injure the right recurrent laryngeal nerve which was nearby. A manuever which I used if I have not seen the nerve was to make sure anything that I cut in that area is not a nerve or does not look like a nerve. Another maneuver was to be constantly aware that the nerve is nearby and could be injured if I am not careful.

After the subtotal right lobectomy, I cut the specimen and asked the participants to look and make a diagnosis.

On cut section of the specimen, there was a 1.5 cm discrete mass with a white capsule surrounding a uniformly soft, pinkish parenchymatous substance with no cystic areas.

The consensus was most likely the nodule was benign because of the distinct capsule. If it were benign, most likely it was a colloid adenomatous nodule with no cystic formation yet. If it were not a colloid adenomatous nodule, most likely, it was a follicular adenoma. The third differential was a follicular carcinoma.

Then there was a discussion on the need to do a frozen section. Since the management would be the same even if the nodule turned out to be follicular adenoma or carcinoma, a frozen-section was not needed anymore. Somebody then asked why not a total lobectomy at least or a total lobectomy and partial contralateral lobectomy, or even a total thyroidectomy if the nodule turned out to be a follicular carcinoma? The answer was: the survival results are the same for the four procedures (the 4th being the subtotal lobectomy on the involved side as long as the tumor was adequately removed.)

A question was asked: Why not do a total thyroidectomy to facilitate radioactive iodine studies postop if the tumor turns out to be follicular carcinoma? The answers consisted of: how often do we get a positive screening total body iodine scan post-total thyroidectomy for follicular carcinoma postop? Not often. In this patient, suppose it turned out to follicular carcinoma, chances of getting a positive total body scan would most likely be 1%, considering the size of the primary tumor. Why subject this patient to unnecessary risks for operative complications like hoarseness of voice and hypoparathyroidectomy when you do a total thyroidectomy? Furthermore, why make this patient permanently hypothyroid with the total thyroidectomy which may be not be needed after all?

So, whatever the final diagnosis would turn out to be, the extent of operation would be a subtotal lobectomy that had a good margin of extirpation. If the paraffin-section report would show colloid adenomatous nodule or follicular adenoma, subtotal lobectomy was adequate. If the parafiin-section report would show follicular carcinoma, there would not be a reoperation to add more thyroidectomy or to go for a total thyroidectomy. The present extent of thyroidectomy would be sufficient.

There was a question whether I should suture the raw areas of the thyroid gland to the tracheal fascia on the isthmic side as well as on the right lobe after a subtotal lobectomy to prevent bleeding. In this particular instance, I said NO NEED. Why? There was no evidence of active bleeding or any bleeding for that matter and I had ligated the major vessels while doing the subtotal lobectomy and isthmectomy.

There was a question of drain. All the participants said they routinely placed drains. I said with adequate and secured hemostasis, there was no need to place drains. Drain is not routine. Indication for placing a drain consists of a situation in which there are oozers near the recurrent laryngeal nerve that attempting to control them would risk injuring the nerve. Considering that oozers would eventually stop after some time, a drain could be used to drain out the accumulating blood before the oozing stops.

Since I had adequate hemostasis and there were no oozers, I decided not to place a drain.

A lot of the participants removed the shoulder pad (breaking the neck) prior to wound closure. The reason given was to decrease the tension between the wound edges so as to facilitate closure. I did not break the neck. I asked them where is the difficulty in wound closure because of tension. There was none. The main reason why I do not break the neck because it would facilitate wound closure. Breaking the neck will constrict the space where I would be doing my wound closure.

As to wound closure, considerations consisted of promotion of wound healing and patient satisfaction (cosmesis and minimal discomfort postop). Proper apposition of wound edges would promote wound healing. What type of sutures to used? Absorbable vs nonabsorbable? If patient's comfort was to be considered, absorbable sutures would be preferred. There would be no pain of nonabsorbable suture removal. Does absorbable sutures produce hypertrophic scar? This has not been proven. Hypertrophic scar in the thyroid incision is mainly due to inherent body or tissue healing process, not due to the absorbable sutures.

Thus, I used absorbable sutures, subcutaneous-platysmal layer and then subcuticular appositions.

• Diet as tolerated when fully awake.
• Analgesics.
• NO need for antibiotics.
• Patient can be discharged the day after the operation.

• One week after, to check wound and to advice patient on the histopath result.
• Long-term follow-up care would be dependent on the histopath result.

Questions and Comments from Readers

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you can email me your questions and comments.)

rjoson@pacific.net.ph

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