>> 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.
>> THERE ARE MANY DIFFERENT APPROACHES TO PATIENTS
WITH THYROID DISEASE WHO NEED SURGERY.
FOR INSTANCE, THERE ARE THOSE PATIENTS WITH
A THYROID NODULE WHO PROBABLY HAVE
HAD A FINE NEEDLE ASPIRANT.
AND WE MAY NOT KNOW FOR SURE WHETHER OR NOT THAT
IS MALIGNANT OR BENIGN AND THEY MAY NEED AN OPERATION,
WHICH WOULD INCLUDE A THYROID LOBECTOMY
AND ISTHMUSECTOMY, TAKING OUT THE THYROID LOBE
THAT'S AFFECTED AND THE MIDDLE PORTION OF THE THYROID.
IF THE PATHOLOGIST SAYS, "YES, THIS IS CANCER,"
THEN WE'RE GOING TO GO AHEAD WHILE THAT
CHILD IS STILL ANESTHETIZED AND TAKE OUT THE REST
OF THE THYROID GLAND AND DO THE LYMPH NODE DISSECTION.
IF THE PATHOLOGIST SAYS, "THIS LOOKS BENIGN,"
THEN WE'RE JUST GOING TO STOP AND WE'RE GOING
TO CLOSE THE NECK AND WE'RE GOING TO WAIT
FOR THE FINAL SECTIONS.
AND THE FAMILY SHOULD UNDERSTAND THAT THE FINAL
SECTIONS MAY STILL SHOW A LITTLE AREA OF CANCER.
>> IF THE LESIONS ARE ULTIMATELY FOUND TO BE
CARCINOMA, A FOLLICULAR THYROID CARCINOMA
OR FOLLICULAR VARIANT OF PAPILLARY THYROID CARCINOMA,
THEN THE FAMILY AND THE PATIENT HAVE TO UNDERGO
A SECOND PROCEDURE, USUALLY FOR A COMPLETION THYROIDECTOMY.
>> THERE ARE OTHER PATIENTS WHERE,
CLEARLY, THERE'S A DIAGNOSIS,
NOT ONLY OF A THYROID NODULE,
BUT A THYROID CANCER.
AND THOSE PATIENTS NEED A TOTAL THYROIDECTOMY,
REMOVING THE ENTIRE THYROID GLAND AS WELL AS
THE POSSIBLY AFFECTED LYMPH NODES THAT SURROUND
THE THYROID.
AND THEY'RE THE ONES THAT EXTEND FROM THE UPPER LEVEL
OF THE VOICE BOX, ALL THE WAY DOWN TO WHERE
THE BREASTBONE IS, AND FROM THE CAROTID ARTERY ON EITHER SIDE.
>> THE ANESTHESIOLOGY TEAM IS VERY CRUCIAL BEFORE
SURGERY AS WELL AS DURING SURGERY.
CALMING THE PATIENTS' 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,
IN 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 ARE CALLED THE RECURRENT LARYNGEAL NERVES.
THERE'S ONE ON EACH SIDE.
THEY RUN RIGHT IN THE GROOVE BETWEEN THE WINDPIPE,
WHICH IS CALLED THE TRACHEA, AND THE ESOPHAGUS,
WHICH IS THE 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 WILL ABUT
THE THYROID GLANDS AND 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 A 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 INTERESTS 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 COULD BE ANATOMIC VARIABILITY AS FAR AS WHERE
THEY ARE.
THEY FREQUENTLY SHARE A BLOOD SUPPLY WITH
THE THYROID GLAND.
AND THEY SOMETIMES NEED TO BE PEELED OFF THE THYROID GLAND.
>> THEY MAY BE DIFFICULT TO IDENTIFY JUST BY LOOKING
AT THEM IN THE OPERATIVE FIELD.
SO 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.
>> 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.
>> WHEN WE RECEIVE TISSUE FROM THE OPERATING ROOM
IN THYROID SURGERY, WE WILL BE LOOKING AT THYROID TISSUE
FIRST AND FOREMOST, BUT OFTEN THE SURGEON
WILL ALSO SEND OTHER TISSUES.
FOR INSTANCE, THERE MAY BE SOME LYMPH NODES
THAT ARE IN THE AREA WHERE THERE'S A CONCERN AS TO,
"IF THIS IS A MALIGNANCY, HAS THAT SPREAD
TO THE LYMPH NODES?"
AND IT'S ONE OF THE JOBS THAT PATHOLOGISTS
TO LOOK AT THOSE LYMPH NODES AND DETERMINE WHETHER
OR NOT THERE IS TUMOR IN THE LYMPH NODES.
>> THAT'S VERY IMPORTANT.
YOU HAVE TO BE ABLE TO TAKE THAT INFORMATION TO THE BANK
BECAUSE IT CAN AFFECT WHAT YOU DO IN THE OPERATING ROOM.
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 IS HEALED.
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.