A Patient with a
Facilitating Learning Session
Participants (mostly surgical trainees with some
certified general surgeons)
Postgraduate Course of the Department of
Surgery, Philippine General Hospital
September 6, 1999
Drs. Randy Abdulla, Janice Maddela, Marlo Rendon, Merceditha Althea
Luis Serafin C. Dabao, Romulo Barrameda, Jr., Arlean, and others
(from Laguna, Polymedic Medical Center, Iloilo,
Bacolod, Tondo Medical Center)
Facilitator: Reynaldo O.
How I Did It and What
the orientation of the participants in the Estrada Hall, my group and
I proceded to the operating room at 10:30 am.
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
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
the thyroid problem was that of a
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
process on the thyroid nodule ran like
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
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.At this point, I asked the question:
Do you need a paraclinical diagnostic
procedure? The consensus was
The paraclinical diagnostic process on
the indication ran like this:
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.
At this point, I asked the question:
Considering the primary and secondary
diagnoses, what is the most cost-effective paraclinical diagnostic
procedure for this patient? The
consensus was a needle biopsy.
The resident-in-charge was asked whether
a needle biopsy was done. YES, it was done and the result showed
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).
The next question was: What will you
do next? Go for another paraclinical
diagnostic procedure? Proceed to treatment?
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
Justifications for nonoperative
treatment consisted of the following:
Justifications for operative
treatment consisted of the
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.
The givens at this point in time
were: The primary diagnosis was colloid
adenomatous nodule and the secondary diagnosis was follicular
adenoma-carcinoma. The patient chose an operative
treatment. The patient was in the
operating room ready to be operated by me (the
During this time, I had asked the
resident to prep the patient's neck and then draped the operative
At this point I asked the question:
What is our goal in the operative
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
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
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
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
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
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
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
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
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
Closure and Breaking the Neck
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
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
subcutaneous-platysmal layer and then subcuticular
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