2007_03_01_archive

Necked Truth

Neck surgery is fun. The anatomy is cool, it requires delicacy of

technique, and it's a good example of the value of working in exact

layers, to which I've previously referred. (There's also the fact that

when the good part is over, it only takes a couple of minutes to

close.) In particular, I'm talking about the thyroid. Despite being

right under the surface, which makes it easily accessible, it's

secreted under several layers, like the trinket in a surprise package

(to quote my favorite book.) Skin, fat, platysma muscle,

sternocleidomastoid muscle, omohyoid muscle, sternohyoid muscle,

sternothyroid muscle. I was taught, once under the platysma, to

develop abundant flaps up to the top of the thyroid cartilage, and

down to the sternum and to divide those vertical muscles at the

slightest provocation. In practice, I decided neither was usually

necessary, cutting down on post-op swelling and discomfort. The trick

is to find the exact middle of the vertical muscles -- which is

sometimes quite obvious and sometimes not -- and find your way to the

perfect surface of the thyroid. Not a cell layer too shallow. Then you

can sweep your finger all across the gland, which is bi-lobed, shaped

like two wings of a butterfly, and free it from the under-surface of

all those muscles. While that sweep isn't as dramatic as feeling the

liver, it's still pretty slick. Your finger is sucked into a quite

tight space, enough that it feels as if it shouldn't be able to move

at all. Yet when just right, you can insinuate it quite far into the

upper and lower reaches of the neck, feeling the adventitial layers

give way, bloodlessly. Having done so, and if the gland isn't too

enlarged, you can pop each wing/lobe forward and partially out of the

neck, after which you can work your way to the backside, where all the

action is. By "action" I mean the nerves to the voice-box (laryngeal

nerves), injury to which leaves the patient hoarse or -- if you booger

both of them -- with breathing difficulty; and the parathyroid glands,

accidental removal of or damage to which can leave the victim with

dangerously low calcium levels. This is where eagle eye and careful

technique are essential, and once again when being in exactly the

right layer makes all the difference. Pushing gently with a peanut

sponge grasped at the the end of a small clamp slides the surfaces

clear like the gentlest of receding waves, like rain on a clean

window.

One of the best tricks I learned for thyroid surgery is to place

sutures in the poles of the gland as I work my way to their apexes.

Place a suture for traction, use some careful blunt dissection, place

another higher up and pull some more. Sometimes it takes three or four

sutures in each zone, but it really facilitates the process and is

part of what allows leaving the vertical muscles uncut. With respect

to avoiding injuring the laryngeal nerves, there are two ways to go:

be sure you see them, or be sure you don't. I sort of like the latter.

Meaning, don't cut, tie, or cauterize a damn thing until you are

absolutely sure it's NOT a nerve. That protects as well as laboriously

dissecting the little wisp of a thing. Never dinged one, happily.

There are big thyroid glands, and there are huge ones. Those big boys

require a little more work to get there, cutting those muscles I like

to avoid, but interestingly sometimes getting them to roll out and

relinquish their grip is no harder than in the normal size ones.

Sutures, however, are entirely irrelevant.

I think one of my professors might have been the first to use

electrocautery to cut through thyroid tissue. Prior to that, the

method was unbelievably laborious: take little tiny bites of gland

with a little tiny clamp, cut above the clamp with a knife, leave the

clamp in place and move higher, until the gland was entirely freed and

the patient looked liked she was wearing an African necklace, made of

at least thirty or forty clamps. Then every nib was tied with silk

suture as each clamp was removed.

Way back when, it was also standard procedure to have an emergency

tracheostomy set nearby for a post-op thyroidectomy patient, for two

reasons: injuring both laryngeal nerves could leave the person in need

of ventilatory assistance; and bleeding into the wound could compress

the trachea suddenly. "Trach set at bedside" was part of my orders all

during training and for a few years after. Somewhere along the line,

it occurred to me that it really didn't make sense: bilateral vocal

chord paralysis would be apparent in the recovery room. Bleeding

(never had it happen) would only need a snip-snip on the skin closure.

'Course I'd also abandoned the taught-technique of tight closure of

those midline muscles. I figured if there were bleeding, I wanted it

free to flow away from the trachea. One more example of realizing not

everything I was taught was true.

There are some situations at the very outset of which you know you're

in for a good time; others where you know you're headed for trouble. I

think of standing at the top of a cool water-slide on a hot day,

surveying the scene and concluding you're about to have a great ride;