(especially after radiotherapy). Latissimus dorsi flap Indications (cid:142)(cid:3) Immediate or delayed breast reconstructi on \200\224may be autologous or accompanied by a tissue expander/implant. (cid:142)(cid:3) Salvage procedures such as failed streetcar flap, locoregional recurrence and radionecrosis of the chest wall. Contraindications (cid:142)(cid:3) Smoking, obesity and diabetes mellitus (relative) (cid:1 42)(cid:3) Thoracotomy (cid:142)(cid:3) Transection of thoracodorsal pedicle. Consent Infor m the patient of possible partial or complete flap loss. Explain any complications specific ally related to an implant. Preoperative preparation (cid:142)(cid:3) Determine the size of the skin and tissue compone nts of the flap preoperatively (cid:142)(cid:3) Mark the skin ellipse and borders of latissimus dorsi on the patient \200 \231s back. The skin ellipse is usually placed under the brassiere strap as orientation to fill the mastectomy defect after rotation of the flap. Position Supine with the arm abducted for the mastectomy/excision of mastec- tomy scar and axillary surgery. Then place the patient in the lateral posi- tion to harvest the latissimu s dorsi, and finally reposition the patient supine to reconstruct the breast. Procedure (cid:142)(cid:3) Excise the mastectomy scar, raise skin flaps superiorly to the s econd intercostals space and inferiorly to the inframammary fold. CHAPTER 5 Breast and endocrine surgery 162 Skin elipse LD Posterior: extent of dissection Posterior: position of scar Position of implant Skin elipse LD Anterior: after transposing flap to chest wall Anterior: final result Fig. 5.6 Latissimus dorsi flap (cid:142)(cid:3) Dissect in the axilla to identify the thoracodorsal pedicle. Divide the branches of the thoracodorsal trunk to serratus anterior. (cid:142)(cid:3) Identify the anterior border of latissimus dorsi. Cover the mastectomy defect with a dressing. Turn the patient to the lateral position and incise the skin ellipse. Develop the plane bel ow Scarpa \200\231s fascia and identity the borders of latissimus dorsi. Divide the attachm ents of latissimus dorsi to the thora- columbar fascia and iliac crest and elevate the musc ulocutaneous flap. Tunnel the flap through the axilla to the mastectomy defect. Divide the latissimus dorsi tendon and the thoracodorsal nerve if required. (cid:142)(cid:3) Close the donor site over suction drains. Reconstruct the breast after returning the patient to the supine posi- tion. Attach the lat issimus dorsi to pectoralis major superiorly and insert the expander/implant into the submu scular pocket. Then complete the inset of the flap. Closure Close both wounds in layers over suction drains. Complications (cid:142)(cid:3) Functional impairment at the extremes of shoulder extension Partial or total flap loss, infection and haematoma. BREAST RECONSTRUCTION1 163 Transverse rectus abdominis myocutaneous (streetcar) flap The transverse rectus abdominis m yocutaneous (streetcar) flap uses tissue from the lower abdominal wall, which is supplied b y perforators from the superior and deep inferior epigastric vessels, to reconstruct the br east. The pedicled streetcar flap uses the rectus muscle isolated on its superior epigas- t ric vascular pedicle, which is rotated up to fill the mastectomy defect. The free streetcar flap uses rectus muscle and sheath, harvested with the deep inferior epigastric vessels, w hich are detached from their origin and anasto- mosed to vessels in the axilla or the inter nal mammary artery. Indications Immediate or delayed breast reconstruction. Contraindications (cid:142)(cid:3) Previous surgical division of the inferior epigastric vascular pedicle (cid:142)(cid:3) Obe sity, diabetes mellitus, smoking (relative). Consent The patient should be aware of the spe cific complications of partial or complete flap loss and incisional hernia at the donor sit e. Though an excellent cosmetic result can be achieved with a streetcar flap, the proce- du re is lengthy, incurring additional scarring and a longer convalescence. Preoperative preparation (cid:142)(cid:3) Examine the abdomen for the presence of hernias, divarication of the recti, abdominal incisions, and weakness of the anterior abdominal wall. (cid:142)(cid:3) Mark the inframammary fold and upper margin of excision of the mastectomy scar. (cid:142)(cid:3) Mark the streetcar flap on the lower abdomen. This is an ellipse extend- i ng from the anterior superior iliac spines to the umbilicus superiorly and the suprapubic r egion inferiorly. Position Supine on the operating table with both arms abducted. Place a sandbag under the s capular region on the mastectomy side to facilitate exposure of the axillary vessels. Inser t a urethral catheter and place an intermittent venous compression device on the legs. Operative technique (cid:142)(cid:3) Excision of mastectomy scar (cid:142)(cid:3) Mark the inframammary fold and the upper margin of the mastectomy scar preoperatively. (cid:142)(cid:3) Excise the mastectomy scar. Elevate the upper skin flap extending the inci sion laterally to allow exposure of the axillary vessels. (cid:142)(cid:3) Raising the streetcar flap (cid:142)(cid:3) Excise skin and subcutaneous tissue down to fascia along the lines marked preoperatively. (cid:142)(cid:3) A lateral and medial row of myocutaneous perforators emerges through the rectus sheath. Raise the flap from lateral to medial in the plane above the dee p fascia. Preserve the medial row of perforators on the pedicled side to supply the subcuta neous tissue and skin of the flap. CHAPTER 5 Breast and endocrine surgery 164 (cid:142)(cid:3) Harvest the medial portion of rectus sheath and muscle below these perforators and extend this from the umbilicus to the arcuate line. Continue the rect us sheath incision inferiorly and laterally to- wards the origin of the deep inferior epiga stric vessels. Identify the deep inferior epigastric vascular pedicle, divided flush at its origin from the external iliac vessels to raise the flap. (cid:142)(cid:3) Closure of donor site (cid:142)(cid:3) Advance the free lateral edge of the rectus sheath to the midline and sutu re it to the linea alba with continuous non-absorbable sutures, reinforce the repair by dou ble-breasting the lower medial sheath to its lateral counterpart. (cid:142)(cid:3) Flap ins et and creation of breast mound The most commonly used recipient vessels are the thoracodor sal or circumflex scapular vessels. (cid:142)(cid:3) Secure the flap to the chest wall with temporary sutures while a microvasc ular anastomosis is performed. The creation of a breast mound involves replacement of the b reast volume, shape, skin defi- cit and re-establishment of the inframammary fold. (cid:142)(cid:3) Attach the flap to the chest wall under the upper skin flap. (cid:142)(cid :3) Inset the skin ellipse and suture it to the mastectomy defect. (cid:142)(cid:3) Leave d rains in the inframammary fold and axilla, but avoid suction in the region of the microvascular anastomosis. Postoperative care Nurse the patient in a warm room with analgesics and keep her well- hydr ated. Any compromise of flap perfusion may necessitate urgent surgical exploration. (cid:14 2)(cid:3) Remove the drains when drainage is minimal (cid:142)(cid:3) Remove the urethral c atheter once the patient is ambulatory. Complications (cid:142)(cid:3) Seroma (cid:142)(cid :3) Partial and total flap loss (cid:142)(cid:3) Fat necrosis (which may mimic recurrence o f breast cancer) (cid:142)(cid:3) Incisional hernia at the donor site. BREAST RECONSTRUCTION1 165 Mastectomy scar streetcar flap streetcar flap : Final result Incision for streetcar flap Fig. 5.7 streetcar flap CHAPTER 5 Breast and endocrine surgery 166 Incision and drainage of breast abscess (intermediate) Breast abscesses are most likely to occur during pregnancy, the early post-natal period, or during lactation, although they can also occur at anytime. When not occurring in the context of lactation or pregnancy, the in fection is usually sited in the main part of the breast and is usually related to mammary d uct ectasia when close to the nipple areolar com- plex or, occasionally, an infected tuberc le of Montgomery. The latter is not a true breast abscess but rather an infection in one of the large modi- fied sweat glands around the areolar, and should be treated as any skin ab scess or infected epidermoid cyst. In mammary duct ectasia simple incision and drainage of the abscess may result in mammillar y fistula and a more formal excision of the duct system may be required to treat the underl ying problem. Aspiration of the abscess may also be possible and causes the risk of fistula . Incision Place this over the fluctuant abscess, circumferential to the nipple areolar compl ex. Procedure (cid:142)(cid:3) Incise the abscess. Take a swab of the pus for culture and sensi tivity. (cid:142)(cid:3) Breakdown any loculi with your finger and send part of the cyst wa ll to histology, as occasionally inflammatory breast carcinoma can mimic an abscess. Curett e or lavage the cavity to remove adherent debris. (cid:142)(cid:3) Pack the cavity. Occasio nally a tube drain will be required in large abscesses that are not in the dependant part of the breast. (cid:142)(cid:3) Use wide bore needle aspiration, either freehand or under ultrasound guidance in small abscesses. (cid:142)(cid:3) Antibiotic cover and repeat aspiration has been shown to be success- ful. This avoids anesthesia and in-patient say, which is particularly important for the breast-f eeding mother. Closure (cid:142)(cid:3) Leave the wound open with a small pack in situ. This is particular ly important if there is surrounding cellulitis or skin damage. Remove the antiseptic-soake d packs under general anesthetic (if required) 24 \200\22348 hours later. Once the infectiv e process is controlled, closure is rapid and may not need further packing. (cid:142)(cid:3) Consider delayed primary closure. This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 168 Excision biopsy of breast lump (intermediate) Indications (cid:142)(cid:3) When fine needle aspiration or Trucut biopsy has failed to exclude malignancy. (cid:142)(cid:3) When the patient elects to have the lesion removed for symptomatic reasons. Preoperative preparations (cid:142)(cid:3) Confirm the side and the site of the breast lump and ask the patient to indicate it to you. (cid:142)(cid:3) Mark the lump and the forearm on the affected side with an indelible marker. (cid:142)(cid:3) Ensure the patient is lying in the position she will be on the operating table when the marking is made. Position of patient Supine with the arm abducted on a side board. Incision Use Langer \200\231s lines and make the incision, circumferential to the areola if possible. Procedure (cid:142)(cid:3) Incise the skin and fat underlying it, deepen the incision down to the breast tissue. Use diathermy for haemostasis as the operation pro- gresses. With cir cumscribed benign lesions stay close to the lesion itself, avoiding unnecessary excision of otherwise healthy breast tissue. In more diffuse areas when a diagnostic biopsy is being p erformed, aim to reduce less than 20g tissue to optimize cosmetic outcome. (cid:142)(cid:3) Do not remove skin or lymph nodes at the time of a diagnostic excision \200\224this is onl y appropriate during a therapeutic operation. (cid:142)(cid:3) If there is a significant ri sk of malignancy, place the incision in such a position that any subsequent surgery can be carried easily to include the first scar. Some breast lumps are very mobile and it may be n eces- sary to hold and stabilize them with Allis forceps during dissection. (cid:142)(cid:3) Dissect the breast tissue using the scalpel, scissors or diathermy, depending on preference. Closure (cid:142)(cid:3) Aim for complete haemostasis with diathermy by inspecting all quadrants of the biopsy before closure begins. If there is a large cavity or dead space or if there is oozing from the cavity, then bring out a small suction drain through a separate stab wound. (cid:142)(cid:3) Close the breast tissue and subcutaneous tissues with Vicryl on a cutting needle and use subcuticular Monocryl or Prolene for the skin. (cid:142)(cid:3) Infi ltrate the wounds with local anesthetic at the end of the closure and dress them with an ad hesive waterproof dressing, so that the patient can bathe in the early postoperative period . This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 170 Microdochectomy (intermediate) Indications Discharge from a single duct in the nipple. Spon taneous discharge which has repeatedly stained clothing should be treated in this way. Preoperative care Under anesthesia and before making the incision, press the breast in a ra dial fashion around the nipple areolar complex to try and palpate the thickened duct beneat h it or induce the discharge. The anticipated site of the abnormal duct dictates the line o f the incision. Consent Warn the patient that any operation on the duct system may make sub- sequent breast feeding difficult or impossible. Occasionally there may be reduced nipple sensation after surgery. Position of the patient Supine with the arm abducted. Incision Radial in the line of the suspected abnormal duct, just lateral to the edge of the pigmented skin of the areola. Procedure (cid:142)(cid:3) Identify the duct on the nipple using a fine lachrymal probe. Us ing a size 15 blade, cut down from the nipple along the line of the probe to the edge of the areo la. Dissect the duct with a small margin of breast tissue around it. (cid:142)(cid:3) Using fine forceps and iris scissors, remove the probe with the opera- tive specimen. Closure Secure haemostasis. Close the incision with a subcuticular 3/0 absorbable suture su ch as Vicryl, leaving the nipple slightly open distally allows drain- age of any further bl ood or serum without the need for a formal drain. This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 172 Hadfield \200\223Adair operation (intermediate) Indications (cid:142)(cid:3) Complicated ma mmary duct ectasia (particularly when there has been a mammillary fistula). (cid:142)(cid:3) Subareolar biopsy of a breast lump. (cid:142)(cid:3) Nipple inversion rela ting to duct ectasia or previous surgery. Consent Patients should be warned that breast fee ding will not be possible after this operation and that there may be reduced sensation in t he nipple. Very rarely nipple necrosis occurs. Position of patient Supine with the arm by t he patient \200\231s side or an arm rest. Incision (cid:142)(cid:3) Make a circumferential incision around the inferior half of the areola. (cid:142)(cid:3) Take care to prevent unde rcutting of the skin and avoid going more than halfway around the circumference to minimize the risk of nipple necrosis. The edge of the areola can be lifted up with skin hooks. Procedure (cid:142)(cid:3) Continue the dissection from the back of the areola to the under surface of the nipple, disconnecting the nipple from the underlying terminal ducts and bre ast tissue. (cid:142)(cid:3) Be careful not to buttonhole the skin or the nipple in doing this. In duct ectasia, large ducts may be seen and these will exude secre- tions. If there is con cern that the material secreted is infected, send a swab for microbiology analysis. (cid:142)(cid:3) Once the ducts have been disconnected from the nipple, excise a pyramid of tissue from underneath the nipple reaching back into the breast tissue, the base of which will be 3 \200\2234cm. (cid:142)(cid:3) Send the excised tissue for histology. (cid:142)(cid:3) If the nipple was inverted now evert and maintain it in position by using a fine Vicryl purse-string suture. Closure (cid:142)(cid:3) Ensure meticulous haemostasis. (cid:142)(cid:3) Use a 3/0 Vicryl s uture to close the breast tissue or subcutaneous fat in the defect left by the excision. Cl ose the skin with a subcuticular absorbable or non-absorbable suture and place a waterproof dressing over the whole nipple areolar complex. (cid:142)(cid:3) Infiltrate the skin with local anesthetic at the end of the procedure. Complications (cid:142)(cid:3) Persistent infection. Rarely, if persistent infection and di scharge is a problem, it may be necessary to excise the nipple areolar complex. (cid:142)(cid:3) Fistula formation. (cid:142)(cid:3) Recurrent inversion of the nipple. This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 174 Fine needle aspiration cytology of the thyroid gland Indications (cid:142)(cid:3) Cytology diagnosis of a thyroid swelling (cid:142)(cid:3) Drainage of a thyroid cyst. Preoperative preparation (cid:142)(cid:3) Explain to the patient what you are going to do. (cid:142)(cid:3) Inform the patient that bleeding occasionally occurs but that this very ra rely leads to further complications and consent is not required. (cid:142)(cid:3) There is no known risk of disseminating malignancy by fine needle aspiration biopsy. Procedure (cid:142)(cid:3) Use a sterile, disposable 20ml syringe with a 17 gauge (blue) ve nupunc- ture needle, holding the syringe in a syringe holder, which gives better maneuverab ility of the biopsy apparatus. (cid:142)(cid:3) Local anesthetic is not required. Clean the skin and arrange biopsy glass slides adjacent to the patient. Pierce the skin and the thyroid swelling with the needle an d aspirate. Make two or three passes through the thyroid in the direction of the biopsy. Mu ltiple passes made at different angles through the gland tends to increase the risk of hemo rrhage and a \200\230bloody \200\231 tap. (cid:142)(cid:3) Release suction on the needle once the sampling is completed but before the needle is removed from the biopsy target. Ask an assistant to press on the skin with a cotton wool swab while the slide is prepared. (cid:142)(cid:3) Detach the needle containing the aspirated material from the syringe, suck air into the syringe and then blow the contents of the needle on to the previously prepare d slides. These slides should be air-dried and then sent to the Cytology Department for ana lysis. (cid:142)(cid:3) Place a small adhesive dressing on the site of puncture in the neck. In mu ltiple nodules or difficult cases, ultrasound-guided biopsy may be preferable. This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 176 Thyroid lobectomy (major) (see Chapter 3 \200\224Anatomy for surgeons) Indications (cid:142 )(cid:3) To remove a proven thyroid malignancy, usually as part of a total thyroidectomy. (cid:142)(cid:3) To remove a suspicious thyroid swelling to confirm a diagnosis for malignancy. (cid:142)(cid:3) To remove a large benign goiter, causing compressive or cosmetic symptoms as part of a unilateral or total thyroidectomy. (cid:142)(cid:3) To treat thyrotoxicosis, either as a unilateral lobectomy for a single toxic nodule or as a bilateral procedure for Grave \200\231s disease. Preoperative preparation (cid:142)(cid:3) Avoid nodulectomy or partial lobectomy as a diagn ostic procedure. Avoid operating on any nodule without a preoperative needle aspira- tion d iagnosis. (cid:142)(cid:3) Biopsy the thyroid nodule before removal (see Fine needle aspiration cytol ogy of the thyroid). Check the patient \200\231s thyroid function tests, thyroid antibodies and serum calcium before admission. Patients with thyrotoxicosis need preoperative blockag e and replacement therapy (typically Carbimazole and Lugol \200\231s iodine to reduce vascu larity). In thy- roid malignancy or bilateral benign disease, total thyroidectomy will be t he appropriate operation but for all other procedures, thyroid lobec- tomy should be carrie d out. (cid:142)(cid:3) Estimate any retrosternal extension preoperatively with X-rays of the thoracic inlet, CT, or MRI scanning. Consent (cid:142)(cid:3) Inform the patient that there will be a scar and a small risk of p erma- nent voice change, and difficulty in swallowing if damage to the recur- rent laryngea l nerve occurs (around 1%). Use indirect laryngoscopy to record preoperative cord function. (cid:142)(cid:3) Inform the patient of the risk (15 \200\22320%) of temporary hypocalcaemia (hemorrhage rare) postoperatively. (cid:142)(cid:3) Inform patients undergoing diagnostic lobectomy of the possible need for a second operation to remove the contra-lateral lobe. (cid:142)(cid:3) Inform patients undergoing less than total thyroidectomy for thyro- toxicosis of the risk of recurrent hyperthyroidism and lateral chance of hypothyroidism, an d the need for thyroid replacement therapy and/or calcium supplements together with the nee d for occasional drainage (around 10% of patients). Position of the patient (cid:142)(cid:3 ) Supine with the neck extended at 20 \200\22325% and the table foot down to empty the neck veins. Place the head in a padded ring with a pillow or pad beneath the shoulders. (cid:142)(cid:3) Seal the drapes around the neck with a plastic adhesive sheet, such as Ops ite. This prevents blood trickling down the neck and into the hair. (cid:142)(cid:3) Use general anesthetic with a secure cuffed endotracheal tube. THYROID LOBECTOMY (MAJOR)1 177 Incision (cid:142)(cid:3) Mark the incision beforehand with a marking pen or suture garrott e midway between the sternal notch and thyroid cartilage. (cid:142)(cid:3) Make sure the incision does not extend beyond the medial border of the ste rnomastoid on each side. Infiltrate the neck with local anaes- thetic containing adrenaline , which reduces skin bleeding. Procedure (cid:142)(cid:3) Deepen the incision through the skin into the fat and the platys ma muscle. Raise superior and inferior flaps in the subplatysmal plain, using either the diath ermy or scalpel. (cid:142)(cid:3) Use Joll \200\231s retractor to hold the skin flaps apart, exposing the st rap muscles. These should be divided in the midline and retracted laterally. In large goiters, divide the strap muscles transversely at the latter end to avoid branches from the ansahypo lossi rather than retracting them. (cid:142)(cid:3) Palpate both lobes to ensure the \200 \230normal \200\231 contra-lateral lobe is free of disease. (cid:142)(cid:3) Sweep away the structures to the lateral aspect of the thyroid lobe (the c ommon carotid artery and the internal jugular vein) allowing the hilum of the gland to be s een. This is easier once the middle thyroid vein is identified, divided and ligated. Now th e superior and inferior parathyroids can usually be seen. Keep the operative field as dry a s possible to mini- mise blood staining, which makes identification of the parathyroids and the recurrent laryngeal nerve difficult. The parathyroids are normally located within a 1c m radius of the inferior thyroid artery. Superior thyroid vein Pyramidal lobe Cricothyoid vein cartilage+ muscle Superior thyroid artery Common carotid artery Internal jugular vein Middle thyroid vein Thyroid gland Recurrent laryngeal nerve Inferior thyroid vein Fig. 5.8 CHAPTER 5 Breast and endocrine surgery 178 (cid:142)(cid:3) An assistant should apply counter traction, which is essential for identif ying the tissue planes. Use pledgelet dissection to mobilize the lobe. (cid:142)(cid:3) Take inferior thyroid artery branches close to the capsule with small clips and draw down the superior pedicles, ligate them in continuity or secure between clip s and tie them doubly. Secure the inferior thyroid veins between ties or ligaclips, allowin g the lobe to be reflected off the trachea. (cid:142)(cid:3) Identify the superior laryngeal nerve external branch when mobilizing the upper pole and securing the superior thyroid artery. (cid:142)(cid:3) Now remove the lobe by dividing the isthmus and oversewing this with Vicryl. (cid:142)(cid:3) Carry out total thyroidectomy by performing the same procedure on the contra-lateral side. Closure (cid:142)(cid:3) Use a suction drain if there is a large dead space or oozing. (cid :142)(cid:3) Reapproximate the strap muscles with 3/0 Vicryl (continuous). Close the skin with 4/0 subcuticular Monocryl. Skin clips can also be used but they can prove dif ficult to remove in an emergency unless they are Michel type with a specific removal device . Postoperative care (cid:142)(cid:3) Ask the anesthetist to identify the cords postoperative ly, although their appearance may be misleading. (cid:142)(cid:3) Return the patient to the recovery area without a dressing on the wound so that any neck swelling can be rapidly identified and the patient returned to theater for t he evacuation of the haematoma. (cid:142)(cid:3) Remove suction drains after 24 \200\22348 hours. (cid:142)(cid:3) Check se rum calcium daily and commence thyroid replacement ther- apy immediately. Patients can usually be discharged within 48 hours, for total thyroidectom y at 72 hours. Complications (cid:142)(cid:3) Thyrotoxic storm \200\224uncommon if the patient has been sa tisfactorily blocked prior to surgery. (cid:142)(cid:3) Hemorrhage \200\224(rare) take the patient back to theater if there is any difficulty in breathing or swelling in the early postoperative period and evacuate the haem atoma. (cid:142)(cid:3) Unilateral recurrent laryngeal nerve palsy presents as a voice change post operatively. If bilateral, presents as a compromised airway, which may need to be treated b y tracheostomy urgently. (cid:142)(cid:3) External laryngeal nerve damage presents as a change in the timbre of the voice. (cid:142)(cid:3) Wound infection. (cid:142)(cid:3) Hypocalcaemia (carry out calcium check). Administer calcium supple- ments, either oral or intravenous, with or without vitamin D me dica- tion if indicated. Late complications (cid:142)(cid:3) Recurrent thyrotoxicosis (cid:142)(cid:3) Tracheal mala cia. THYROID LOBECTOMY (MAJOR)1 179 Sub-total thyroidectomy Most surgeons now perform a total lobectomy or total thyroidectomy for virtually all thyroid disease. It is desirable to leave a small remnant of thyroid tiss ue and this can be achieved by placing a ring of haemostats around the edge of the thyroid and incising into it with a scalpel to re- move the desired volume of tissue. Then leaving approximately one eighth of the lobe on each side, the remnant can then be oversewn with co ntinuous 3/0 Vicryl. Thyroid cartilage Superior laryngeal nerve Superior parathyroid Thyroid gland Inferior thyroid artery Inferior parathyroid Ligament of Berry Recurrent laryngeal nerve Fig. 5.9 Anterior dislocation of the right thyroid lobe to show recurrent laryngeal nerve a nd parathyroids Inferior thyroid vein ligated Ligament of Berry Recurrent laryngeal nerve Superior parathyroid gland Inferior thyroid artery Inferior parathyroid Fig. 5.10 Anterior dislocation of the left thyroid lobe to show recurrent laryngeal nerve a nd parathyroids CHAPTER 5 Breast and endocrine surgery 180 Parathyroidectomy (major) Indications (cid:142)(cid:3) Hyperparathyroidism (cid:142)(cid:3) Parathyroid carcinoma (cid:142)(cid:3) Secondary hyperparathyroidism (cid:142)(cid:3) As p art of multiple endocrine neoplasia syndromes. Preoperative preparation and consent (cid:142)(cid:3) Inform the patient that in primary hy perparathyroidism the usual pathology is that one gland is overactive. Use localization sca ns (ultrasound and MIBI) to localize the parathyroid if carrying out a focused approach or laparoscopic approach. (cid:142)(cid:3) In gland exploration, local studies are not necessary. (cid:142)(cid:3) Ha ve frozen section facilities available to confirm the presence of parathyroid tissue in the resected samples. Position of the patient Supine with the head in a neck ring, the neck extended and a 20 \200\22325(cid:13) upward tilt. Incision and access As for thyroidectomy. Procedure for open operation (cid:142)(cid:3) Divide the middle thyroid vein and mobilize t he gland by lifting it forwards into the wound. Using a pledgelet, push away the loose areo lar tissue to the lateral aspect of the thyroid, including the common carotid artery and th e internal jugular vein. The parthyroids lying close to the inferior thyroid artery will ex pand into any dead space when they are enlarged. (cid:142)(cid:3) Start to look for them near the inferior thyroid artery. Each gland is a y ellowish-brown color, will have a definitive vascular pedicle, in most instances it will be easy to see. In a focused approach or laparoscopic approach, remove only the previously id entified gland. (cid:142)(cid:3) Use PTH measurements perioperatively to assist in confirming that the targ et has been successfully identified. Expect a 50% fall in PTH level within 10 minutes if th e offending adenoma has been removed. If more than one gland is diseased, carry out careful search in all the conventional sites on both sides. If the gland is not in the normal posi - tion inspect the thyrothymic ligament, the upper thymus, the carotid sheath, behind the u pper pole of the thyroid and palpate the thyroid lobe itself carefully in case the adenoma is intrathyroidal. It is more common to fail to find an adenoma in the conventional positio n than to have an ectopic gland and an anatomical variant of the norm. (cid:142)(cid:3) If in doubt about the nature of the tissues removed, send biopsies for frozen section. PARATHYROIDECTOMY (MAJOR)1 181 (cid:142)(cid:3) Once identified, the adenoma is removed by securing its vascular pedicle w ith diathermy or clips, taking care not to breach the capsule \200\224damage to which can c ause spillage of contents producing multiple seedlings of parathyroid tissue throughout the neck (parathormatosis). (cid:142)(cid:3) Use laparoscopic approach or a focused scan in preoperatively localized adenomas. Target the dissection over the site of the adenoma and proceed directly to it. Laparoscopic or minimally invasive removal or parathyroid tissue is gaining positio n in the armamentarium of parathyroidectomy, but it is essential to have two concordant loc alization studies to direct the surgeon to the appropriate site. Closure (cid:142)(cid:3) Drainage is seldom required. (cid:142)(cid:3) Following an open op eration, close the strap muscles and platysma with 3/0 Vicryl and the sin with 4/0 Monocryl. (cid:142)(cid:3) In focused approach, only t he skin need be closed. Postoperative care (cid:142)(cid:3) In the recovery room, leave the wound undressed to perm it checking for any swelling and bleeding. (cid:142)(cid:3) Carry out calcium checks. (cid:142)(cid:3) Swallowing difficulties or hoar seness may indicate evidence of unilateral recurrent laryngeal nerve injury. (cid:142)(cid:3) Stridor usually indicates bilateral nerve injury and Horner \200\231s synd rome, damage to the cervical sympathetic chain. CHAPTER 5 Breast and endocrine surgery 182 Adrenalectomy (major) Indications (cid:142)(cid:3) Functioning adrenal tumor, Cushing \200 \231s syndrome, Conn \200\231s syndrome or phaeochromacytoma (cid:142)(cid:3) Incidentaloma over 3.5cm in size (cid:142)(cid:3) Suspected adrenal carcin oma. Preoperative care (cid:142)(cid:3) Carry out intensive work-up to exclude or confirm the pr esence of a functioning adrenal tumor. In Cushing \200\231s syndrome this will require esti mation of cortisol in the plasma and urine and ACTH levels. In Conn \200\231s syndrome, mea surements of aldosterone, renin, and potassium. In phaeochormocytoma, this will require est imations of urinary catecholamines and plasma catecholamine levels. (cid:142)(cid:3) Imaging the adrenal glands using CT scan, MRI, or MIBG (meta iodo benzyl g uanidine). Additionally, octreotide scanning may be helpful. (cid:142)(cid:3) In functioning tumors, the principle of block and when required, replaceme nt therapy. The active hormone should be blocked pharmacologically, e.g. phaeochromacytoma block with alpha blockade, hyper-aldosteronism blocked with spironolactone. Consent (cid:142)(cid:3) Obtain consent for a laparoscopic or open procedure. (cid:142)(cid :3) Inform the patient of the possible need for postoperative steroid re- placement therapy. Position of patient (cid:142)(cid:3) Anterior, patient supine, foot down 30(cid:13), latera l tilt. (cid:142)(cid:3) Lateral, patient in full lateral position, table broken to 30(cid: 13) over ribs 10 and 11 (also used for laparoscopic approach). Strap the patient to the tab le for both approaches. Incision (cid:142)(cid:3) Anterior, long midline incision, extend it laterally through tran s-pyloric plane if access difficult. (cid:142)(cid:3) Laparoscopic (open approach) over rib 11 from the lateral border of sacro-spinalis to abdominal wall. Procedure (cid:142)(cid:3) Anterior approach. Left adrenal: pack the small intestine downwards, retract the costal margin upwards, place the left hand over the spleen and divide the posterior parietal peritoneum from the splenic flexure to the oesophageal hiatus. Apply several pairs of forceps to retract the peritoneu m downwards. Identify the kidney with the adrenal gland above it. Identify and divide betwe en ligatures the adrenal vein, which drains into the left renal vein, mobilize and remove t he gland by blunt dissection, cauterize bleeding vessels. ADRENALECTOMY (MAJOR)1 183 Right adrenal: retract the liver upwards and the hepatic flexure down- wards. Note the vena cava and kidney. Divide the posterior parietal peritoneum along the upper pole of the kidn ey to the vena cava. Iden- tify the gland, divide the two or three adrenal veins, which dra in into the vena cava between ligatures, remove the gland by blunt dissection. Secure haemo stasis. (cid:142)(cid:3) Laparoscopic approach. Divide the lieno renal ligament on the left side allowing the spleen to be mobilized medial ly. The adrenal gland will be seen lying close to the lower pole of the spleen between it a nd the kidney. Mobilize the gland using an ultracision harmonic scalpel and secure the adre nal vein with ligaclips. Right side: Mobilize the right lobe of the liver and retract it in a head- wards direction. The adrenal gland lies just lateral to the inferior vena cava abo ve the right kidney. Identify the adrenal vein early and ligate it with ligaclips to mobili ze the gland. Place the gland in a retrieval system and remove it through one of the port s ites. Postoperative care (cid:142)(cid:3) Blood pressure and blood sugar in patients with phaeoch romacytoma in high dependency or intensive care unit. Monitoring of fluid requirements as there may be further vasodilation once the phaeochromocytoma is removed. (cid:142)(cid:3) Use steroid replacement therapy in Cushing \200\231s syndrome as the contralateral gland is usually suppressed. Patients with Cushing \200\231s syndrome usually have associated myopathy and obesity which make postoperative recovery slow. (cid:142)(cid:3) Suspected adrenal carcinomas, remove a pad of fat around the adrenal gland to ensure adequate tumor clearance. Complications (cid:142)(cid:3) Hypotension due to volume disturbance (cid:142)(cid:3) Acute Addison \200\231s disease (cid:142)(cid:3) Wound infection (cid:142)(cid:3) Hemorrhage (ci d:142)(cid:3) Chest infection as a result of subphrenic operation. CHAPTER 5 Breast and endocrine surgery 184 Pancreas (complex major) (Refer to Hepatobiliary Surgery) Pancreatic endocrine tumors may b e solitary or part of a multiple neoplasia syndrome (MEN1). Indications (cid:142)(cid:3) Removal of functioning endocrine tumors (e.g. insulinoma, glucagonoma, somatostatinoma, gastrinoma and tumors which are secreting pancreatic polypept ide). (cid:142)(cid:3) Non-functioning pancreatic tumors which may or may not be malignant. Chapter 6 185 Upper gastrointestinal surgery Y. K. S. Viswanath and S. Dresner Bleeding peptic ulcer disease 186 Perforated peptic ulcer disease 188 Oesophageal rupture and perforation 190 Gastro-oesophageal reflux disease 192 Para-oesophageal hiatus hernia repair 194 Open (Heller \200\231s) cardiomyotomy for achalas ia 196 Open splenectomy 198 Weight reduction surgery for morbid obesity 200 Radical surgery for gastric cancer 202 Preoperative preparation for oesophagectomy 206 Left thoracic subto tal oesophagectomy 208 Transhiatal oesophagectomy 210 Abdominal & right thoracic subtotal o esophagectomy 212 Three stage oesophagectomy 214 Gastric interposition as an oesophageal su bstitute 216 Colonic interposition for oesophageal replacement 218 Oesophageal anastomosis after subtotal oesophagectomy 220 Complications following oesophagectomy 224 CHAPTER 6 Upper gastrointestinal surgery 186 Bleeding peptic ulcer disease Patients with major upper gastrointestinal hemorrhage require urgent resuscitation and careful monitoring followed by early endoscopic as- sessment. Thi s is essential to identify the site and cause of bleeding and to initiate appropriate endos copic therapy. IV omeprazole 80mg bolus followed by 8mg/hour infusion for 72 hours is benef icial but does not stop active bleeding. Indication Failure of endoscopic control (including significant re-bleeding after initial s uccessful endoscopic therapy). Incision Upper midline. Position of patient Supine. Bleeding duodenal ulcer (cid:142)(cid:3) Kocherise the duodenum. Apply 2/0 Vicryl stay sutu res and perform a longitudinal duodenotomy with diathermy. With the advent of PPI medicatio n, definitive ulcer surgery (such as vagotomy) is not indicated and therefore the pyloric r ing is preserved. (cid:142)(cid:3) Clear the stomach and duodenum of clotted blood with suction. Achieve bleeding point haemostasis with digital pressure. (cid:142)(cid:3) Secure any bleeding or exposed vessel (either a branch or the main trunk of the gastroduodenal artery) by under-running with interrupted 2/0 Vicryl /2/0 PDS o r 2/0 Prolene on a small needle avoiding underly- ing structures such as the common bile du ct. Irrespective of the mate- rial employed, sutures inevitably slough off as the ulcer hea ls, long after the vessel has thrombosed. If the ulcer cavity has a tough fibrous base it m ay be feasible to exclude it from the lumen using interrupted 2/0 Vicryl or PDS. (cid:142)(cid:3) Close the duodenotomy transversely with interrupted 2/0 Vicryl or PDS, as longitudinal closure may cause stenosis. If transverse closure is not possible due to a long duodenotomy, carry out longitudinal closure with Roux-en-Y gastroenterostomy (see Radical surgery for gastric caner, this chapter). An alternative is a Finney pyloroplasty (side-to- side gastroduodenostomy in two layers with interrupted 2/0 Vicryl or PDS. Use thi s approach also if the pyloric ring has been transgressed although it is more common to clo se such a gastroduodenotomy transversely with interrupted 2/0 Vicryl or PDS as a Heineke \200\223Mickulicz pyloroplasty. BLEEDING PEPTIC ULCER DISEASE1 187 With giant ulcers the first part of the duodenum may completely disintegrate and once opene d prove difficult to close. Retrieve this situation with an antrectomy with Roux-en-Y recon struction (see Radical surgery for gastric cancer, this chapter). Close the duodenal stump primarily with a linear sta- pler or interrupted 2/0 Vicryl or PDS. Alternatively, suture t he margins to the fibrous ulcer cavity overlying the pancreas (Nissen technique). To preven t duodenal stump leak, drain the duodenum with a Foley catheter inserted through the closur e line or, preferably, by a T-tube in the healthy lateral wall of the second part of the du odenum. CHAPTER 6 Upper gastrointestinal surgery 188