Few areas of my medical practice have undergone the evolution that has the surgery of thyroid disorders. No other area has benefited from such extensive experience over the last 20 yrs, and no other area demonstrates the competency that procedure after procedure has brought to me today.
My initial experience in the OR with thyroid was during my surgical intership. An endocrine surgeon at Iowa in the general surgery division first captivated me with the detail and precision that this neck procedure requires. Professor Dr Gurl was meticulous in surgery, and even more meticulous in drawing and documenting his operative findings. As a benefit of his attending status, he could have allowed the resident on the case to dictate the operative report, but oh no!, Dr Gurl sat down after each and every case and very carefully described the operative findings and his intervention. My young, learning eyes were watching and soaking up every detail and lesson.
When I had finished residency and fellowship, I had the great fortune in the USAF to be stationed at Travis AFB, California, a tertiary care center for the military. Again I scrubbed with very experienced and talented thyroid surgeons. Dr. Lisa Boyle taught me among other things her very successful technique in the presentation and preservation of the parathyroids and the staff endocrinologists shared their nuances of the subsequent post op calcium management. An environment like this of shared learning without the issues of turf wars is seldom found, but I like to think it was due to our interest in patient care and our military dedication to a higher good that created these possibilities.
So when I started the UNC ENT division at WakeMed and then transitioned to my own private practice, thyroid surgery was firmly in my cache of abilities. But there is nothing like experience, one after another, to make a capability a specialty. Such has been the opportunity of being the head and neck consultant for Butner Federal Medical Center and developing laisons with endocrinologists here in Raleigh. I have had the honor and opportunity to help hundreds of patients with their goiters and thyroid nodules. Every case involves the meticulous dissection of the recurrent laryngeal nerve which controls the movements of the vocal cords. If hurt, the patient would be quite hoarse with a dysfunctional voice (one of my patients was the public address specialist at Seymour Johnson AFB, a damaged voice would have ruined her USAF career, he did more than fine). This nerve runs right next to the gland, and is mere milimeters away. The other vital structure to maintain is the parathyroids, which control calcium levels in the bloodstream. Low post op calcium levels will lead to heart and nerve irregularities that can be fatal. It is not unusual to require calcium supplements post op in even the best operation. Fortunately, in my patients, no one has suffered voice issues or need for prolonged calium supplements post op.
After the initial incision in the neck, the skin flaps are dissected up and down, and the muscles of the neck are seperated in the midline. Directly beneath lies the thyroid, with its extensive blood suppy. The operation requires increment by increment removal and cautery of feeding veins, arteries, and connective tissue, all the while ;ulling the gland over in sponges toward the midline while retracting on skin and muscles laterally by an assistant to gain exposure to the promised land of recurrent laryngeal nerve and parathyroid glands. Each movement takes only 3 to 4 mm of tissue away, so it is not unusual to spend 2 or more hours per thyroid lobe to successfully complete.
When the gland or lobe (1/2 of the thyroid removed to evaluate a suspicious nodule) is removed, then full hemostasis (stoppage of bleeding) is assured, and the wound is closed with a only a fine line of incision and therefore scar left. It is my goal to make it hard to see 6 months later that an operation was ever done.
Few operations require such concentration and surgical skill for hour after hour. I love it.