>> THE THYROID SURGERY IN CHILDREN DOESN'T OCCUR VERY
COMMONLY, SO YOU NEED TO GO TO A PLACE THAT HAS
A THYROID SURGEON THAT DOES THIS FREQUENTLY.
WE DID FIND THAT AS A SURGEON WHO IS PERFORMING THYROID
SURGERIES IN CHILDREN AND ADOLESCENT AT LEAST 30 TIMES
A YEAR.
>> WE DECIDED IT BEST TO GO WITH SOMEONE WHO
IS VERY SPECIFIC IN PERFORMING THAT TYPE OF SURGERY,
AND REALLY, IF WE WERE GOING TO DO THAT,
WE HAD TO COME HERE AT CHOP.
>> I WAS REALLY SCARED AT FIRST,
BUT THEN WHEN I MET DR. ADZICK,
AND HE SAT ME DOWN AND TALKED ABOUT EVERYTHING,
I FELT MORE COMFORTABLE KNOWING THAT MY LIFE
WAS GOING TO BE IN HIS HANDS.
AND IT WAS ALL BASICALLY THE DOCTORS THEMSELVES,
MEETING THEM HELPED A LOT.
>> THERE ARE MANY DIFFERENT APPROACHES TO PATIENTS
WITH THYROID DISEASE WHO NEED SURGERY.
FOR INSTANCE, THERE ARE THOSE PATIENTS WITH GRAVES'
DISEASE, WITH LARGE GOITERS WHO, FOR WHATEVER REASON,
NEED AN OPERATION, USUALLY BECAUSE THEY CAN'T BE
CONTROLLED WELL MEDICALLY, AND THOSE CHILDREN
REQUIRE A TOTAL THYROIDECTOMY.
>> SO WE REMOVE 98 PERCENT OF THE THYROID GLAND,
99 PERCENT OF THE THYROID GLAND WITH THE HOPES THAT WE
MAKE THE PATIENT HYPOTHYROID.
WE WANT TO REMOVE AS MUCH OF THE THYROID GLAND AS SAFELY
POSSIBLE SO THAT THEY NEED TO BE PUT ON THYROID
HORMONE REPLACEMENT.
>> HI, GOOD MORNING I'M FROM ANESTHESIA, HOW ARE YOU?
>> THE ANESTHESIOLOGY TEAM IS VERY CRUCIAL
BEFORE SURGERY, AS WELL AS DURING SURGERY.
CALMING THE PATIENT'S FEARS, EXPLAINING EVERYTHING SO
THAT THEY REALLY UNDERSTAND WHAT'S GOING ON,
AS WELL AS PROVIDING THE APPROPRIATE ANESTHESIA
DURING THE SURGICAL PROCEDURE.
>> ONCE THE PATIENT IS ANESTHETIZED,
THE PATIENT IS POSITIONED AT AN ANGLE, AS FAR AS YOUR
TORSO GOES, AND YOUR HEAD IS BACK,
AND YOUR NECK IS EXTENDED.
AND THE WOUND THAT'S MADE FOR THE OPERATION
IS A SIDEWAYS WOUND BECAUSE THAT ALLOWS GOOD EXPOSURE
OF THE THYROID GLAND, AND IT ALSO FOLLOWS THE SKIN LINES
IN THE NECK TO GIVE THE MOST COSMETICALLY APPEALING
HEALING PROCESS.
AND THEN THERE ARE STRAP MUSCLES IN FRONT
OF THE THYROID GLAND, AND WE PUSH THOSE MUSCLES ASIDE
TO EXPOSE THE BUTTERFLY.
IN THE COURSE OF DOING THE OPERATION AND REMOVING
EITHER ONE SIDE OF THE BUTTERFLY OR THE ENTIRE
BUTTERFLY, IT'S IMPORTANT THAT I FIND AND PROTECT
CERTAIN STRUCTURES.
FIRST OF ALL, TWO NERVES, THEY'RE CALLED THE RECURRENT
LARYNGEAL NERVES.
THERE'S ONE ON EACH SIDE, AND THEY RUN RIGHT IN THE GROOVE
BETWEEN THE WINDPIPE, WHICH IS CALLED THE TRACHEA,
AND THE ESOPHAGUS, WHICH IS FOOD TUBE BEHIND.
AND THOSE NERVES COME UP FROM THE CHEST AND THEY RUN
UP TO WHERE THE VOCAL CORDS ARE AND THE VOICE BOX,
WHICH IS JUST ABOVE THE THYROID GLAND.
AND THOSE NERVES ARE ABOUT THE SIZE,
DEPENDING ON THE AGE OF THE PATIENT,
OF AN ANGEL HAIR PASTA STRAND,
AND THEY'RE VERY DELICATE.
AND, FREQUENTLY, IT WILL ABUT THE THYROID GLAND,
SO WE NEED TO PEEL THE THYROID GLAND OFF OF THOSE
NERVES, ONE OR BOTH SIDES.
>> THOSE NERVES ARE NERVES THAT ACTUALLY CONTROL
THE VOICE BOX.
AND SO, IF YOU HAVE DAMAGE ON BOTH SIDES,
THEN A PATIENT WILL HAVE SIGNIFICANT BREATHING
PROBLEMS TO THE POINT THAT THEY WOULD NEED
A TRACHEOSTOMY.
OR IF THE DAMAGE IS NOT TO BOTH SIDES OR A PROBLEM
WITH THE NERVE, SOMETIMES IT CAN BE PERMANENT ENOUGH
WHERE IT CAUSES HOARSENESS.
>> THAT OCCURS VERY INFREQUENTLY,
BUT WHEN IT DOES OCCUR, IT'S A VERY DEBILITATING PROCESS,
AND IT'S SOMETHING, AGAIN, THAT SHOULD INCREASE
SOMEONE'S CONCERN OF WHO THEY'RE SENDING THE PATIENT
TO AS FAR AS SURGERY BECAUSE THAT REALLY NEEDS TO BE
AVOIDED IN THE BEST INTEREST OF LONG-TERM CARE
FOR THAT PATIENT.
>> THE SECOND IMPORTANT STRUCTURES
ARE PARATHYROID GLANDS.
AND THEY ARE USUALLY FOUR IN NUMBER.
TWO ARE ON THE TOP.
TWO ARE AT THE BOTTOM.
THERE CAN BE ANATOMIC VARIABILITY AS FAR AS WHERE
THEY ARE.
THEY FREQUENTLY SHARE BLOOD SUPPLY WITH THE THYROID GLAND.
AND THEY SOMETIMES NEED TO BE PEELED OFF THE THYROID GLAND.
FOR SURGEONS WHO OPERATE ON CHILDREN WITH THYROID
DISEASE, IT'S IMPORTANT TO HAVE A SORT OF HAND-IN-GLOVE
RELATIONSHIP WITH THE PEDIATRIC PATHOLOGIST.
>> SOMETIMES WE WILL RECEIVE PARATHYROID GLANDS OR TISSUE
THAT IS SUSPICIOUS FOR BEING PARATHYROID,
AND WE CAN DO AN INTRAOPERATIVE CONSULTATION,
A FROZEN SECTION, TO DETERMINE WHETHER OR NOT
THAT'S ACTUALLY WHAT THEY ARE,
OR WHETHER THEY'RE THYROID OR LYMPH NODES
OR CONNECTIVE TISSUE.
>> ONCE WE'RE FINISHED WITH THE THYROID PORTION OF THE
OPERATION, THOSE MUSCLES IN THE FRONT ARE PUT BACK TOGETHER.
AND THEN IT'S VERY IMPORTANT TO CLOSE THE WOUND IN LAYERS
USING ABSORBABLE SUTURES THAT WILL DISSOLVE ONCE THE
CHILD HEALS, SO REALLY THE ONLY THING THAT'S ON THE WOUND
ARE LITTLE STERI-STRIPS RUNNING SIDEWAYS ALONG THE WOUND.
AND THYROID WOUNDS, FOR THE MOST PART,
HEAL BEAUTIFULLY.
INITIALLY, THEY MAY BE A LITTLE RED AND A LITTLE
RAISED AND A LITTLE FIRM, BUT THAT'S NORMAL BECAUSE
THAT'S THE HEALING RIDGE THAT OCCURS WITH ANY WOUND.
LONG TERM, IN SIX TO NINE MONTHS,
IT WOULD BE A VERY UNUSUAL CIRCUMSTANCE IN WHICH THERE
WASN'T A VERY SOFT, FLAT, FINE SCAR THAT MIGHT BE
BARELY NOTICEABLE.