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Speciality Procedures:
Endocrine Procedures
Thyroidectomy
Thyroidectomy consists of partial or total removal of the thyroid gland. For diagnostic purposes only, in the situation of a thyroid lump of uncertain origin, the surgery is removal of half of the thyroid ("lobectomy"). This is most often done as an outpatient and requires no use of thyroid hormone afterward. A total or near total thyroidectomy removes virtually all of the thyroid gland, and requires the use of thyroid hormone afterward. Each surgery is relatively brief and non-painful. Incisions are in the skin creases of the front of the neck and are usually quite cosmetic.
Three major issues arise during a thyroid surgery: One is bleeding into the neck after the surgery. These surgeries are intolerant of accumulation of blood. At the point at which a tablespoon of blood is accumulated in the incision, it feels quite tight and painful. This occurs virtually within hours of the surgery, if it is going to occur at all, and is treated by evacuation with a second surgery.
The second issue is a change in voice quality occurring after surgery. This can be due to swelling of the voice box, which is transient. This gives a mild hoarseness and a sense that one cannot swallow completely normally, or project their voice completely normally. This clears over time. The second potential voice change is a loss of voice volume, but preservation of voice quality. This is due to injury to a small nerve that runs across the top of the thyroid. Current technique is designed to avoid injury to this nerve, which cannot generally be identified in the operative field. The final type of voice change is injury to the nerve coming up from the chest, which controls the closure of the vocal chords.
This injury leads to a breathy-sounding voice. This nerve must be seen during the surgery, and is therefore at risk for injury. The nerve can branch in very subtle ways, which makes injury to this nerve a consistent feature after thyroid surgery, although it only occurs in 1 to 2% of the patients. Most current technology involves use of video equipment during the surgery to monitor the function of the vocal chords, and thereby try to prevent injury to this nerve. Recovery from thyroid surgery is relatively rapid. Patients can generally take care of themselves within a day and are able to go back to work within a week or two.
Parathyroid Exploration
Parathyroid exploration, at one time, was considered one of the most formidable of the surgical operations. This is due to the subtle appearance of these small glands within the neck. Today, the surgery is quite refined and highly successful. Patients are generally imaged before surgery to determine where the abnormal parathyroid tissue lies. The surgery then consists of a brief anesthetic, while a small incision is made and only that abnormal parathyroid is removed. In this exact circumstance, the surgeon is unable to tell whether there might be other abnormal parathyroid tissue in the neck. This can occur, despite scans that would indicate otherwise. For that reason, many surgeons employ a method during the surgery that measures the levels of the parathyroid hormone in the blood. Provided the parathyroid hormone drops during the surgery, the surgery can be considered curative with the removal of a single parathyroid. In the event the parathyroid hormone levels do not fall, the surgery is continued to examine the other three parathyroids in the neck. The recovery after parathyroid surgery is also quite brief and comparable to thyroid surgery. The incisions are generally in the skin creases of the neck and slightly off to one side.
Adrenalectomy
Removal of the adrenal glands can be accomplished through a number of approaches. One is through the front of the abdominal cavity, one is through the side of the chest and abdominal cavity, one is through the ribs and the back, and one is with laparoscopes. The latter is currently in vogue and sometimes over applied. Removal of an adrenal gland with laparoscopy is inappropriate for malignancy, as one cannot remove the tissue without risk of breaching it with the laparoscopic technique. In the event that malignancy is suspected, one of the other approaches is advised. Therefore, laparoscopic adrenalectomy is best applied to aldosterone-producing tumors and small cortisol-producing tumors, which are rarely malignant. A laparoscopic adrenalectomy takes two to three hours of operating time and requires generally two days of hospitalization afterward. Recovery is rapid, with return to work within seven to ten days. The other adrenalectomy approaches are more painful and accompanied by a slower recovery.
Adrenal Cryosurgery
We are currently involved with an investigational technique utilizing the magnetic scanner and a very narrow probe, which can freeze tissue when inserted into the correct location. In this protocol, patients are anesthetized and placed within the magnetic scanner. Under the control of the scanner, a probe is inserted through the back, side, or abdomen into the adrenal tumor. It is then frozen and thereby ablated. At this time, this will require an overnight hospitalization, though it is anticipated that this would ultimately be outpatient as more experience is gained. There is no incision with this. This is considered appropriate for aldosterone-producing and cortisol-producing tumors of small size.
Radio-Guided Surgery
This unit has compiled most of the early experience with radio-guided surgery. This consists of injection of patients with a radioactive tracer that accumulates in the tumor to be removed. The tumor is then located in the body with a hand-held radiation counter called a gamma probe. This has been highly useful for islet cell and carcinoid tumors. It is heavily promoted for parathyroid surgery, where it has proven not to be as useful. It can also be used in re-operative surgeries of the thyroid for locating recurrent cancer.
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