Thyroid Surgery Complications Medical Slides

Present the identification approach: visual identification of the RLN is the gold standard (mandatory — never divide any structure crossing the tracheoesophageal groove without visual identification). Key landmarks: RLN enters the larynx at the cricothyroid joint posterior to the inferior cornu of thyroid cartilage. On the right, nerve crosses posterior to inferior thyroid artery (variable); on the left, loops under the aortic arch. Non-recurrent RLN occurs in ~0.5% on right (associated with aberrant subclavian artery). Intraoperative nerve monitoring (IONM): intermittent or continuous — does NOT prevent injury but allows early identification of signal loss (loss of signal algorithm: verify equipment → assess nerve visually → wait → if no signal return, consider staging bilateral procedures). Meta-analyses show IONM reduces permanent RLN injury from 1.5% to 0.9%.

Present the emergency management: postoperative hematoma occurs in 1-2% within first 6-24 hours, causing rapidly progressive airway compromise from external compression and laryngeal edema. Signs: neck swelling, dyspnea, stridor, wound tension/drain output. CRITICAL: this is an airway emergency — do NOT attempt awake intubation (laryngeal edema makes this extremely difficult). Protocol: (1) Open wound at bedside immediately (remove clips/sutures, evacuate clot — this alone relieves compression), (2) Call anesthesia for intubation, (3) Return to OR for formal exploration and hemostasis. Key teaching point: all thyroid patients should have bedside suture removal kit, and ALL staff (nursing, residents) must know to open the wound at bedside if airway compromise develops. Overnight observation is standard after total thyroidectomy.

Present the monitoring and replacement protocol: Check intact PTH at 4-6 hours post-operatively (PTH >15 pg/mL predicts eucalcemia with 90% accuracy). Low PTH (<15) — start calcium carbonate 1-3 g TID + calcitriol 0.25-0.5 mcg BID. Symptoms of hypocalcemia: perioral/digital paresthesias, Chvostek sign, Trousseau sign, QTc prolongation, carpopedal spasm. Severe symptomatic hypocalcemia (Ca <7.5 or symptomatic) — IV calcium gluconate 1-2 g over 20 min, continuous infusion 0.5-1.5 mg/kg/hr. Transient hypoparathyroidism (recovers within 6 months): 20-30% after total thyroidectomy. Permanent (>6 months): 1-2%. Parathyroid autotransplantation into sternocleidomastoid muscle if devascularized gland identified intraoperatively. Long-term: risk of renal stones, nephrocalcinosis — monitor renal function and 24-hour urine calcium annually.