In exophthalmic cases it may be held to be especially desirable to enucleate the thyroid from within its capsule. This makes the performance easier in some respects and more difficult in others.
Extreme caution should be taken in two particular respects: First, that the trachea be not compressed, nor its caliber interfered with, by the traction efforts used in removing the mass. The second caution necessary in exophthalmic cases is to make the least possible amount of pressure upon the thyroid during the operative procedure, since, as mentioned above, its secretion is depressing to the heart, and it would complicate matters to force more of this material into the circulation at a time when everything conspires to reduce blood pressure and the reliability of the heart’s action. A certain amount of manipulation is unavoidable, but this should be made as gentle and as slight as possible. Moreover, these cases are to be drained to permit of free escape of thyroidal secretion. (Mayo.)
In performing thyroidectomy for Graves’ disease advantage should be taken of the pneumatic suit devised by Crile, and the patient placed in the semi-upright position. These are advisable precautions to take in every such operation. The position allows more natural emptying of the veins at the base of the neck and the suit permits of the blood pressure being maintained by mechanical means. In order to use the suit to best advantage the blood pressure should be noted throughout the course of the operation.
The enucleation or extirpation concluded, hemostasis should be observed, as with returning cardiac vigor secondary hemorrhage is by no means an impossible event. Every vessel which can be recognized should be carefully tied, and tissues which ooze should be caught up with suture and tied en masse. All the deeper portions of the wound should be brought together by buried sutures in such a way as to leave no dead spaces. Cases where a retrosternal pit has been left, by removal of a low-lying growth, should be drained to avoid the accumulation of blood. Where doubt exists as to security from secondary hemorrhage it is the writer’s custom to place secondary sutures, and to pack the cavity with gauze dipped in balsam of Peru, leaving this packing in place for two days, then removing it and closing the wound by utilization of the sutures.
Shock after these operations may be extreme, and is to be combated by transfusion or infusion of salt solution, with small amounts of adrenalin.
Should the surgeon attack a so-called malignant goitre he must be prepared to meet with greater difficulties and perhaps to abandon the operation before its completion. Death on the table is not unusual in such cases.
Operation under cocaine local anesthesia is often most advantageous, and is the rule in such clinics as that of Kocher, in Berne. The patient should be well narcotized with morphine, after which a weak cocaine solution is injected along the proposed line of incision. The pain produced by the balance of the work is not beyond endurance, while the dangers are certainly minimized, especially in cases where there is compression of the trachea or excessive heart action, the latter being particularly true in Graves’ disease. There is less fulness of veins, and there is neither coughing nor vomiting. The operative features are the same as those described. As the anterior thyroid artery is approached all possibility of including the recurrent laryngeal nerve in the ligature is avoided by having the patient talk, injury to the nerve producing instant hoarseness. If the growth extend low and into a pit behind the sternum it may be possible to extirpate it from above downward, and finally to lift it from its bed, securing its base or pedicle with an elastic ligature.
Fig. 500
Patient placed in semivertical position, and enclosed in Crile’s pneumatic suit, as recommended for many cases of goitre, brain tumor, or other serious operations about the head and neck. (Crile.)