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1、3 himalayas women with endemic goitersThyroiddisease Abnormal function/anatomy extremely common in population hypothyroidism 1%women hyperthyroidism 1%thyroid nodules 3%-4%at some time in human live span88岁 2006,10,19手术1600 BC Chinese were using burnt sponge and seaweed treat goitres(enlarged thyroi
2、d glands)650 AD Sun Ssu-Mo孙思邈(唐朝,581-682年)used a combination of seaweed dried powdered mollusc shells and chopped up thyroid gland treat goitre Historycontributions to surgical fields including hernias gastro-intestinal tract orthopedic fields brain Kocher mobilization move duodenum for look inferio
3、r caval vein&pancreas head Thyroid improved thyroid resection 5000 thyroidctomies mortality only 1%1898 (13%1872)Dr.KocherT(1841-1917)winner of Nobel Prize 1909Contents.Principlesofsurgery1Preoperativemanagement2Anaesthesiaandpainrelief3Postoperativemanagement4Surgicaltechniques5Nutritionandthesurgi
4、calpatient.Breastsurgery32BreastSurgeryEndocrineSurgery33Thyroid34Parathyroid35Tumoursoftheadrenalgland36EndocrinetumoursofthepancreasHeadandNeckSurgery37Ocularinjuryandinfection38Otorhinolaryngology39HeadandneckTumoursHernias40HerniasSkinandSoftTissues41Tumoursandcystsoftheskin42Softtissuetumours43
5、Infectionsoftheextremities44PrinciplesofplasticsurgeryEtiologyofNeckMassesCongenitalBranchialcleftcystThyroglossalductcystCystichygroma(lymphangioma)InflammatoryViral,Bacterial,Mycobacteria(Scrofula)AcquiredRanula,LaryngoceleNeoplasticBenignLipoma,Hemangioma,Carotidbodytumor,SalivaryglandMalignantMe
6、tastaticAerodigestivesquamouscell-95%SkinCaDistantsitesSinonasalParotidMelanomaPrimaryLymphomaSarcomaThyroid/ParathyroidSalivaryOP620In 2003,1st Affiliated Hospital of Sun Yat-sen Uni admitted 938 cases patients with Thyroid disorderNon-OP318NG良性肿瘤良性肿瘤 恶性肿瘤恶性肿瘤 炎症炎症Gravses住院病人住院病人手术手术498437372492813
7、1 2228089In 2003,1st Affiliated Hospital of Sun Yat-sen Uni admitted 938 cases patients with Thyroid disorderSimple Goiterdefinition of a goiter morethantwicenormalthyroidsize diffuse goiter nodular goiter SimpleGoiterClassificationofNontoxicGoiter DiffuseGoiterEndemicIodine deficiency Iodine excess
8、,Dietary goitrogensSporadicdefect in thyroid hormone biosynthesis chemical agents(e.g.lithium,thiocyanate)Iodine deficiency compensatory following subtotal thyroidectomy NodularGoiteruninodular or mutinodularfunctional,nonfunctional,or bothSimpleGoiterIncidence remains a worldwide problem in 1958 WH
9、O estimated 7%of the worlds population 200 million personsthyroid glands normal clinically autopsy study of 821 patients 50%have nodules 75%multinodular 25%single nodulesultrasound study nodules 50%of population 50 yrSimpleGoiterMechanism growth factors growth cell populations nodular areas within t
10、hyroid new follicular cells occurs numerous areas throughout thyroid SimpleGoiterPathology thyroid gland slightly to massively enlarged multinodular goiter characteristic nodular surfacediffusely enlarged thyroid gland most common cause enlarged thyroid most common disease of thyroidSimple GoiterCli
11、nical features neck mass found by routine physical examination patient self incidentally nodule hemorrhage pain compression of neck structures Simple GoiterClinical featuresriskofmalignancymustbeconsideredinpatientswithnodulargoiterSimpleGoitertreatmentSurgical procedureGoal:remove all abnormal nodu
12、lar thyroid tissueindication compressive symptoms substernal goiter giant goiter affecting work and life quality accompany with hyperthyroidism dubious malignancy goiter Remove one nodule is not enoughSimpleGoiterTreatmentAfter surgical procedure prescribe thyroid hormone e.g.thyroxine to inhibit TS
13、H release stop stimulate thyroid prevent recurrence Thyroiddiseaseaspect Historyofmanagethyroiddisease Thyroidgrossanatomy Physiologyofthyroid Simplegoiter Hyperthyroidism Thyroidadenoma Thyroidcarcinoma PrimaryhyperparathyroidismTopicsHyperthyroidismcausedby high levels of thyroid hormone loss norm
14、al feedback controlling of thyroid h.Typesofhyperthyroidisminsurgerybook diffuse toxic goiter secondary toxic multinodular goiter toxic adenoma Hyperthyroidism irritability weight loss heat intolerance emotional instability physical findings of goiter exophthalmos other eye signs Clinical manifestat
15、ionHyperthyroidismLaboratory examinations standard to confirm diagnosismeasuring circulating thyroid hormone concentration total thyroxin(TT4)total T3(TT3)free T4(FT4)free T3(FT3)TSH assay low TSH levels hyperthyroidism not routinely performed measurement of thyroid uptake of 131I elevated basal met
16、abolic rate may help Hyperthyroidism131IscanningLaboratoryexaminationsnormalGravesPlummersHyperthyroidismLaboratoryexaminations US plus color-doppler measurementNormalsizeofthegland.RichdiffusevascularizationofthelobesHyperthyroidisma number of strategies to manage hyperthyroidism reduce thyroid hor
17、mone secretion block b-adrenergic receptors by antithyroid drugs reducing volume of functional thyroid tissue by surgical removal destructs most thyroid tissue by 131I TreatmentHyperthyroidismAntithyroidRadioiodineSurgerySuccessincontrolYesYesYesRecurrence72%10%10%AdverseeffectsWBCPermanenthypo-post
18、hypo-15%in40-70%at10yrdamagetoRLNPeripheralneuritisHepatitisarthraigiaMyalgiaLymphadenophathysychosisContraAllergyPregnancyIndicationToxicityHyperthyroidismSubtotal thyroidectomyIndications secondary hyperthyroidism or hyperfunctional adenomamoderated or serious hyperthyroidismhyperthyroidism with h
19、uge goiter associated with compressive symptoms or with substernal goiter recurrent hyperthyroidism after antithyroid or radioiodine therapyHyperthyroidismContraindications the patient 20 yr mild hyperthyroidism the patient intolerance surgery because of age conexisting illnessSubtotal thyroidectomy
20、HyperthyroidismPreparation Perform operation under euthyroidism control thyrotoxicosis medically use Tabazol,etc.Marksabsence of symptomspulse lower than 100 beats/minnormal precordial activity confirmed by normal thyroid function testHyperthyroidismPreoperative preparation sedative drugs blockade o
21、f b-adrenergic receptors e.g.Indernal Vitamine usually treated with Lugols solution for 10 days before operation to decrease vascularity of gland HyperthyroidismSurgicalprinciplesresect 89-90%of thyroid tissue ligation superior thyroid vessels middle thyroid vein,inferior thyroid vein excise anterol
22、ateral part,isthmus pyramidal lobesave each lobe 3-4 g.saveintactrecurrent laryngeal nerve superior laryngeal never parathyroid gland Hyperthyroidismneckisextendedsymmetrical,gentlycurvedincisionaboveclavicle1-2cmHyperthyroidismdevelopupperandlowersubplatysmalflapsdeepcervicalfasciaisdividedinmidlin
23、edividingthestrapmusclestransverselyexposinganteriorsurfaceofthethyroidlobeHyperthyroidismthyroidlobeisdissectedfromsurroundingfasciamiddlethyroidveinisligatedclosetothyroidHyperthyroidismthyroidlobeiscarefuldissectedidentifyrecurrentlaryngealnerveparathyroidglandsligatedsuperiorthyroidarteryligatee
24、achsmallbranchnearthyroidHyperthyroidismremovethelobeHyperthyroidismclosewounddepositedsuctioncatheterHyperthyroidism Postoprativedyspneaandasphyxia trachea collapse resulted from tracheal cartilage degeneration by compression of goiter bilateral recurrent laryngeal nerve injured hematoma from hemor
25、rhage of operative field glottis edema emergency situation requires emergency tracheotomy Complication of thyroidctomyHyperthyroidismComplication of thyroidctomy recurrentlaryngealnervedamage occurs unilaterally immediate hoarseness loss its timbre and focus occurs bilaterally acute paralysis of bot
26、h vocal cords obstruct the airwayHyperthyroidismComplication of thyroidctomy superiorlaryngealnervedamagevulnerable to injury during thyroidectomy injure external branch of superior laryngeal nerve cricothyroid muscle paralysis voice loss its timber injure internal branch of superior laryngeal nerve
27、 loss sensation of laryngeal mucosaHyperthyroidism injury of the prarthyroid gland very important complication resection PTG injury of PTG blood supply leads to prarthyroid infarction result in parathyroid insufficiency clinical presentation numbness of the face or hand carpopedal spasms tonic-cloni
28、c convulsions serum calcium level decreasedHyperthyroidismComplication of thyroidctomythyroidcrisis Hyperthermia tachycardia profuse sweating Hypertensiontreatment Lugols solution Hydrocortisone sedative drugsThyroidctomyEndoscopicThyroidectomy(minimal surgery)ThyroidctomyEndoscopicThyroidectomy(min
29、imal surgery)Thyroidctomy Thyroiddiseaseaspect Historyofmanagethyroiddisease Thyroidgrossanatomy Physiologyofthyroid Simplegoiter Hyperthyroidism Thyroidadenoma Thyroidcarcinoma PrimaryhyperparathyroidismTopicsTHYROIDADENOMASbenign neoplasms arising from follicular tissue follicular adenoma,most com
30、monpapillary cystic adenoma,rare most of papillary tumors are malignant THYROIDADENOMAS well circumscribed solitary homogenous lesions usually surrounded by a capsule separating it from adjacent normal thyroid tissueTHYROID ADENOMASfollicular adenoma surrounded by thin white capsule.subtotal thyroid
31、ectomy be safefollicular adenoma,firm,well-circumscribed.scintigraphic scan was coldTHYROIDADENOMAS found in the woman 40 yr typically asymptomatic discover incidentally by patient or physician round or elliptic shape smooth surface harder than adjacent thyroid tissue tenderness occur as intracystic
32、 hemorrhageClinicalfeatureTHYROIDADENOMAShardtodistinguishfromnodulargoiterclinically thyroid adenomas found outside epidemic area of simple goiter nodular goiter tending multiple nodules adenoma remains solitary ClinicalfeatureTHYROIDADENOMASUSscanningfoundsinglenoduleClinicalfeatureTHYROIDADENOMAS
33、131IscanningnormalColdnoduleHotnoduleClinicalfeatureTHYROIDADENOMASSurgical management because 20%tending hyperthyroidism 10%develop malignancy partial resection follow biopsy to identify carcinoma TreatmentTHYROIDADENOMASTreatmenta heterogeneous group of tumorsshow considerable variability in biolo
34、gic behavior histologic appearance response to therapy approximately 1%of all malignancies Thyroiddiseaseaspect Historyofmanagethyroiddisease Thyroidgrossanatomy Physiologyofthyroid Simplegoiter Hyperthyroidism Thyroidadenoma Thyroidcarcinoma PrimaryhyperparathyroidismTopicsTHYROID CARCINOMAPatholog
35、ic Classification main types papillary adenocarcinoma follicular adenocarcinoma medullary carcinoma undiffentiated carcinomaTHYROID CARCINOMApapillary adenocarcinoma comprised 60%of all thyroid carcinoma usually occurs in young,female patient low grade of malignancy tumor grows slowly,invade cervica
36、l lymph node THYROID CARCINOMAFollicularcarcinoma occupies 20%of thyroid cancer always seen in middle age patient moderate grade of malignancy grows quickly tends to metastasize to lung or bone by the way of blood streamTHYROID CARCINOMAUndifferentiatedcarcinoma occupies 15%of the thyroid carcinoma
37、found in the old patient higher malignant grade and grows quickly invade cervical lymph node in early stage directly invade RLN,trachea or esophagus metastasize to lung or boneTHYROIDCARCINOMAMedullarycarcinoma arises from prarfollicular cell(C cell)moderate malignant grade invade cervical lymph nod
38、e early tends to metastasize to lung via blood serum calcitonine level increases THYROIDCARCINOMAClinical manifestation without symptom in the early stage hoarsenessvoice cord paralysis injure RLN dysphagia press esophagus Dyspnea press trachea Horners syngrome press sympathetic nerve invade local l
39、ymph node distance metastasis to lung and boneTHYROIDCARCINOMAB-USCTSolitary firm nodule hypoechoic,dishomogeneous;irregular borders microcalcificationsLargelaterocervicalmassDiagnosis image study THYROIDCARCINOMAscintiscanningfineneedlebiopsyLarge cold nodule on middle and lower part of left lobeDi
40、agnosisTHYROIDCARCINOMATreatmentPTC/FTC resects total affected lobe,isthmus great part opposite lobe dissect LN when local lymph node involvedTHYROIDCARCINOMATreatmentUTC biopsy,resects isthmus,trachstomy external radiation therapyMTC receive extensive surgical treatment resects bilaterally lobe dis
41、sect cervical lymph node follow up by serum calcitonine levelTHYROIDCARCINOMATreatmentAftersurgerygive thyroid hormone inhibit TSH secretion block stimulation to thyroid Thyroiddiseaseaspect Historyofmanagethyroiddisease Thyroidgrossanatomy Physiologyofthyroid Simplegoiter Hyperthyroidism Thyroidade
42、noma Thyroidcarcinoma PrimaryhyperparathyroidismTopicsHyperparathyroidismThere are 4 parathyroid glands usually located next to the thyroid gland in the neckHyperparathyroidismPTG make parathyroid hormone(PTH)controls the levels of calcium in the bodyHyperparathyroidismIn patients with hyperparathyr
43、oidism one or more PTG become enlarged make too much parathyroid hormone causes the levels of calcium to rise in blood in the US about 100,000 people/year develop hyperparathyroidism PTG adenomaEnlargement of 2 PTGEnlargement of 4 PTG HyperparathyroidismduetohighcalciumcanincludeSymptomsfatiguelosso
44、fappetitemuscleachesjointpainconstipationHyperparathyroidismSymptomsMoreseveresymptomsstomachulcersdepressionlossofbonedensitybone pain/fractureskidney stonesHyperparathyroidismDiagnosis of hyperparathyroidism made based on a high blood calcium a high blood PTH levelin the majority(80%)of patients A
45、 single enlarged parathyroid gland or a parathyroid adenoma is the cause of the hyperparathyroidismHyperparathyroidismFor many years,PTG surgery was exploratory No simple and reliable imaging procedures for identifying abnormal PTGBefore surgery determine abnormal parathyroid gland B-US CT parathyroid scanLocationdiagnosisHyperparathyroidismHyperparathyroidismParathyroid gland scanning20min 120minHyperparathyroidismminimally invasive radioguided parathyroidectomy(MIRP)Parathyroid scanner positive image HyperparathyroidismTreatment-remove the abnormal PTGThanks!