Intrathoracic goiter often has symptoms of compression, and some of them have secondary hyperthyroidism. It has a high tendency of malignant transformation, and once diagnosed, intrathoracic goiter and thyroid tumor resection should be performed as soon as possible. The surgical method varies depending on the location, depth, shape, size and relationship with surrounding organs of the mass. For those who have secondary hyperthyroidism, anti-hyperthyroidism treatment should be performed before surgery.
1. Anesthesia selection
Depending on the surgical incision.
①Cervical plexus anesthesia or local anesthesia
It is suitable for surgery with low neck collar incision and small masses. The patient is awake during the operation and can cooperate with swallowing and puffing movements, so that the swelling can be easily elevated for surgical operation, and can talk with the patient to prevent damage to the recurrent laryngeal nerve.
②General anesthesia
It is suitable for patients with large masses, deep location, completely located in the chest, with inspiratory difficulties, preoperative radiographs confirming tracheal compression, displacement and superior vena cava compression, with hyperthyroidism. Intraoperative oxygen supply can be ensured to keep the whistle tract open and ensure the stability of the whistle and circulatory system.
2. Incision selection
According to the relationship between the tumor and cervical thyroid, whether the tumor is partially or fully located in the thoracic cavity, where the tumor is located in the mediastinum and the invasion or pressure of the tumor on the surrounding organs, the following incisions can be selected.
(1) Low collar incision of the neck
(1) Low neck collar incision is suitable for most of the drop-in intrathoracic goiter located in the anterior superior mediastinum behind the sternum, which can be removed through this incision.
(2) Low neck collar incision with median sternal crackle
It is suitable for (1) huge drop-in intrathoracic goiter that cannot be retrieved from the entrance of the sternum; (2) drop-in intrathoracic goiter with inferior location and partial blood supply from the chest; (3) suspected malignant change; (4) history of neck surgery and difficulty in surgery with scar adhesion; (5) with superior vena cava syndrome or significant tracheal compression and deformation with stridor.
(3) Chest incision
For vagal intrathoracic goiter without cervical mass or with unclear diagnosis; for those who have a clear preoperative thyroid mass in the posterior mediastinum, the posterior lateral incision can be used.
(4) Combined cervicothoracic incision
The indications are basically the same as those for the open-chest approach, but the damage to the inferior thyroid artery and the recurrent laryngeal nerve can be reduced.
3. Common complications and prevention
(1) Intraoperative injury to the recurrent laryngeal nerve
Any intraoperative incision should be separated from the perineum of the thyroid gland. In case of cervical plexus anesthesia, intraoperative dialogue with the patient is necessary to avoid injury to the recurrent laryngeal nerve.
(2) Postoperative bleeding leading to tracheal compression asphyxia
During surgery, the thyroid stump should be closed with overlapping mattress sutures, the upper and lower thyroid arteries should be firmly ligated, and surgical separation should be performed as far as possible within the peritoneum to prevent damage to the surrounding tissues, which may cause unexpected tissue injury and bleeding. At the end of surgery, negative pressure suction is routinely placed in the incision to drain blood from the wound in a timely manner and to facilitate observation of active bleeding.
(3) Tracheal collapse or stenosis
If a large intrathoracic goiter compresses the trachea for a long period of time, the trachea can be deformed and distorted by extension. If the tracheal wall is found to be softened intraoperatively, it should be sutured and fixed with the anterior cervical muscles to prevent postoperative tracheal collapse or stenosis. If the symptoms of acute whistle obstruction appear, tracheotomy should be performed immediately to ensure that the whistle is unobstructed.
4. Postoperative adjuvant therapy
If the resection of intrathoracic thyroid malignant tumor is incomplete, the residual foci should be marked, and postoperative supplemental radiation therapy should be performed, and the amount of radiation therapy should be 55~65Gy. Like cervical goiter, intra-thoracic goiter must be treated with thyroxine tablets for a long time after complete bilateral resection; if it is a malignant tumor of thyroid, thyroxine tablets should also be taken after surgery with good effect.