T e k n i k O p e r a s i

TIROID
Roys Pangayoman
1
SEJARAH
• Goiter = Gutter (tenggorokan)
• Aulus Cornelius Celcus (30AD) : Struecto! = e"uang
strua
• #aul o$ Aegina (%0&'%(0): operasi strua )arus )ati')ati
engenai A*carotis +an ,*reccurentes
• Al"ucasis (-ag)+a+. 1000) : $irst success$ul t)!roi+ecto!
• Ruggiero /rugar+i 0Roger o$ Salero1 (11&0) : operasi Strua
(+ala C)irurgia 2agistri Rogeri)
• 3orent4 5eister (1%63'1&76). 8eran : tiroi+ektoi pertaa +i
+unia (1&79) +ala 0C)irurgie1*
• T)eo+or :oc)er (16;1'1(1&). -ern. S<iss: 7000 tiroi+ektoi
+gn preser=asi kel*paratiroi+ +an n*laringeus rekurens*
2enurunkan ortalitas +ari 70> en?a+i kurang +ari 1>*
9
• 5alste+. "erguru pa+a :oc)er : (1(0%: 2en!e"u)kan tetani
pasca tiroi+ektoi +engan supleen paratiroi+ sapi@ 1(06:
tetani )u"ungan +engan kalsiu@ 1(90: -uku 0T)e operati=e
stor! o$ goiter1)
• Ra+ical ,eck Dissection
• Operasi tiroi+ per en+oskopi
o Gassless tec)niAue
o Supracla=icular approac)
o 2aar! approac)
3
TERMINOLOGI
• Tiroi+ektoi : pengangkatan kelen?ar
tiroi+
• 3o"ektoi : pengangkatan satu lo"us
kelen?ar tiroi+
• Isulo"ektoi : pengangkatan satu lo"us
kelen?ar tiroi+ "eserta ist)usn!a
• Su"total tiroi+ektoi: engangkat
se"agian "esar tiroi+ ke+ua lo"us (kiri'
kanan) +engan en!isakan ?aringan tiroi+
asing'asing 9B; gra*
;
• ,ear total tiroi+ektoi: isolo"ektoi
+ekstra +an lo"ektoi su"total sinistra +an
se"alikn!a. sisa ?aringan tiroi+ asing'
asing 1B9 gra*
• Total tiroi+ektoi: pengangkatan 0seluru)1
kelen?ar tiroi+
7
ANATOMI
• :elen?ar. <arna coklat terang. ken!al. ter+iri +ari 9 lo"us (kiri +an
kanan) +i)u"ungkan elalui ist)us* (+an ka+ang9 lo"us
pirai+alis)
• 3okasi: anterior le)er. =erte"ra
C7'T1. "erat 17'90 g. pan?ang 7
c. le"ar 9 c. te"al 9'; c*
Te"al ist)us 9'% *
• Dikelilingi 9 kapsul: true capsule
+an $alse capsule (perit)!roi+
s)eat). surgical capsule)
%
&
IMPORTANT STRUCTURES
• Central: plat!sa. $alse capsule.
*sternot)!roi+. *sterno)!oi+
• Superior: kartilago tiroi+
• #osterolateral: caroti+ s)eat) +an
*sternoclei+oastoi+
• #osterior: enepel +engan e"rana
cricot)!roi+ +an cartilago cricoi+
elalui 3igaentu o$ -err!*
• Anterior: strap uscles (sternot)!roi+.
oo)!oi+. sterno)!oi+. t)!ro)!oi+)
• :elen?ar parat)!roi+ (; "ua)) !g
terletak +i posterolateral superior +an
in$erior* Di superior terletak +i antara true +an $alse capsule setinggi
cartilago cricoi+* Di in$erior terletak anterior +ari n*lar!geus reccurens
• /ascia super$icialis +an +eep $ascia*
6
VASKULARISASI
• Arteri
o A* t)!roi+ea
sup B ca"ang
a*carotis eDt
o A* t)!roi+ea
in$ B ca"ang
truncus t)!ro
cer=ical +ari
a*su"cla=ia
o A* t)!roi+ea
ia B ca"ang
arcus aortaE
a*innoinata
(
• C
e
n
a
10
o C* t)!roi+ea sup B enu?u =* ?ugularis interna
o C* t)!roi+ea e+ia B enu?u =* ?ugularis interna
o C* t)!roi+ea in$ B enu?u =* "rac)iocep)alica
• 3i$atik
o Terutaa enu?u no+us ?ugularis interna
o #ole superior +an e+ial ist)us enu?u ke no+us grup
superior
o #ole in$erior enu?u no+us grup in$erior +an no+us pretrac)eal
• #ers!ara$an
o Sipatis: "erasal +ari ganglia sipatis cer=icalis sup +an
e+ial. "er$ungsi s"g =asootor
o #arasipatis: "erasal +ari n* =agus. enu?u ke kel*tiroi+ elalui
ca"ang9 n*laringeus rekurens !g epersara$i otot9 intrinsik
laring F ca"*eDterna n*laringeus superior (*cricotiroi+)
11
19
INDIKASI TIROIDEKTOMI (Chassin, Lore, Zoin!ers,
Car"#s CURRENT$
1* Goiter "esarE ultino+ular goiter
9* :ecurigaan keganasan
3* #enekanan ke organ sekitar
;* Tirotoksikosis resi+i$ setela) peng)entian o"at E nonresponsi$
7* Se=ere opt)alopat)! (eDopt)alus)
%* 5!pert)!roi+is in pregnanc! (Gcontroversy) or c)il+ren
&* Hoan <)o <is) to "ecae pregnant <it)in 1 !ear o$ treatent
6* :osetik
S%h&ar'(: Surgical treatent o$ t)e t)!roi+ is per$ore+:
1* to esta"lis) t)e +iagnosis in a patient <it) a ass <it)in t)e t)!roi+
glan+
9* to reo=e "enign an+ alignant tuors
3* as t)erap! $or t)!rotoDicosis
;* to alle=iate pressure s!ptos attri"uta"le to t)e t)!roi+
13
KONTRA INDIKASI
1* Inopera"le tuor (su+a) ekstensi ke struktur organ lain:
trac)ea. eso$agus. +ll)
9* 5ipertiroi+ (relati$)
KOMPLIKASI
• Iarl!:
o #er+ara)an
o Serak. a$onia. paralisis pita suara
o :risis tiroi+ (t)!roi+ Stor)
o #neuot)oraD B possi"le "ut rare (Lore)
• 3ate:
o 5ipokalseia ()ipoparatiroi+)
o 5ipotiroi+
o ,ekrosis $lap
1;
Ko)*i"asi Lain
• ,on eta"olik:
o ,er=e in?ur! (n*lar!ngeus recurrens  serak E ca"ang
eDternal +ari n*lar!ngeus superior  ti+ak "isa "ersuara
)ig) pitc))
o #er+ara)an
o O"struksi ?alan na$as
o ,ekrosis $lap
• 2eta"olik: ()ipoparatiroi+ise)
o Ter?a+i sekitar 0.%'9.6>
o :linis: "aal'"aal. "aal u?ung ?ari. gelisa). spase
carpope+al (tetani)
17
o T)E: 10 cc Calciu Gluconas IC +ilan?utkan pe"erian
kalsiu oral 1.7'9 g per )ari atau Calcitriol (Rocatrol) 0.97
B 10 icrogra. 9 kali se)ari
KRISIS TIROID (TH+ROID STORM$
= )!pert)!roi+ crises precipitate+ "! surgical stress or traua (Current)
= 2ortalitas J10> ?ika ti+ak +itangani +gn "aik*
Ge?ala:
1* /e"ris
9* Deliriu
3* :e?ang
;* Diare
7* 2unta)
%* Takikar+ia
&* Congesti=e )eart $ailure
6* -erkeringat
T)E:
1* 5entikan operasi
9* Oksigen
3* -olus D ;0> 90'97cc
;* -eta "loker (propranolol) ;0 B
%0g p*o* tiap ; ?a atau 9 g
i= selaa ; ?a
7* #TK 1900 B 1700 gE )ari
(900'970 gE ; ?a peroral)
1%
%* 2et)ia4ole 190 gE )ari (90
gE ; ?a peroral) atau
car"ia4ole 1;';0 g peroral
&* 3ugolisasi (:I 7 gttE % ?a)
6* DeDaet)ason 9 g E % ?a i=
(* Antipiretik
10* :oreksi elektrolit
11* Cega) )ipoteri
,e%hara +- Ghora.e/, MD, PA
Otolar!ngolog! ' 5ea+ F ,eck Surger!
6630 3ong #oint. Suite 60%
5ouston. TeDas &&077
Th.roi0e%'o). In1or)e0 Consen'
Thyroidectomy is an operation in which one or both
lobes of the thyroid gland are removed. The most
common indications for thyroidectomy include a
large mass in the thyroid gland, difficulties with
breathing related to a thyroid mass, difficulties with
swallowing, suspected or proven cancer of the
thyroid gland and hyperthyroidism (overproduction
of the thyroid hormone). Your physician will discuss
the need for thyroidectomy based on your history,
the results of a physical examination and tests. The
most common tests to determine whether a
thyroidectomy is necessary include a fine needle
aspiration biopsy, thyroid scan, ultrasound, x-rays
and/or T scan, and assessment of thyroid hormone
levels. The procedure is usually done under general
anesthesia. The extent of surgery (removal of one or
both lobes) may sometimes be determined in the
course of surgery after microscopic examination of
tissue removed during the surgery.
!fter surgery it is very common to have difficulty in
swallowing. "ccasionally, swallowing may even be
1&
a little painful. This pain usually resolves within #$
to %# hours.
Bleeding or infection are also possible short term
complications. !lthough rare in thyroid surgery,
some patients may develop a thick scar or keloid.
Two complications specific to thyroid surgery are
hypocalcemia and vocal cord wea&ness or paralysis.
Hypocalcemia, or low blood levels of calcium, may
occur after complete removal of both thyroid lobes.
This condition is caused by in'ury or interference
with the blood supply of four tiny glands called
parathyroid glands, which are located within or very
close to the thyroid gland. (ypocalcemia is usually
temporary, but sometimes may re)uire calcium
supplements if sufficiently pronounced. *ermanent
hypocalcemia is fortunately rare. This is why, serum
calcium, magnesium and phosphorus levels are
carefully monitored in the first #$ hours after the
surgery.
Vocal cord weakness or paralysis may be caused
by swelling, stretching, or in'ury to the recurrent
laryngeal nerve which passes very close to the
thyroid gland. Temporary hoarseness may result.
!gain, this is an uncommon, usually temporary
complication. *ermanent vocal cord paralysis is
rare.
Frozen section and final diagnosis: +uring
surgery, the specimen removed is examined by the
pathologist who performs fro,en sections. -n the
ma'ority of cases, the pathologist is able to
distinguish between benign and malignant lesions.
-n a very small percentage of patients,however, the
fro,en section may not identify a small cancer which
is pic&ed up on permanent sections, a few days
later. .hen this happens, the patient may have to
return to surgery for removal of the remaining
thyroid tissue and sometimes lymph node
dissection.
+epending on the final histologic (microscopic
examination) diagnosis of the gland removed, and
on the blood tests, continuous follow-up by the
endocrinologist and / or surgeon may be indicated
for replacement of the thyroid hormone.
/ollowing total thyroidectomy, patients have to ta&e
replacement thyroid hormone for the rest of their life.
I23e ha4e /een !i4en an o**or'5ni'. 'o as"
65es'ions a/o5' ). %on0i'ion, a'erna'i4e 1or)s
16
o1 'rea')en', ris"s o1 non'rea')en', 'he
*ro%e05res 'o /e 5se0, an0 'he ris"s an0
ha(ar0s in4o4e0, an0 I23e ha4e s511i%ien'
in1or)a'ion 'o !i4e 'his in1or)e0 %onsen'-
I23e %er'i1. 'his 1or) has /een 15. e7*aine0
'o )e25s, an0 I23e 5n0ers'an0 i's %on'en's-
I23e 5n0ers'an0 e4er. e11or' &i /e )a0e 'o
*ro4i0e a *osi'i4e o5'%o)e, /5' 'here are no
!5aran'ees-
8888888888888888888888888888888888888888
8888888888888888888888888888888888888888
888888888
Pa'ien' 2 Le!a G5ar0ian
8888888888888888888888888888888888888888
888Da'e9
88888888888888888888888888Ti)e8888888888
3i'ness
TEKNIK OPERASI
1* #osisi pasien +ala SUPINE atau SEMI FOWLER
9* -a)u +igan?al +gn "antal se)ingga LEHER HIPEREKSTENSI
1(
3* :epala +iletakkan +i atas +onut "alloon.
!akinkan posisi +agu se?a?ar +gn long aDis
tu"u) pa+a garis e+ian
;* Aseptik +an antiseptik +i le)er +an sekitarn!a
7* Di"uat MARKER UNTUK INSISI +engan
enggunakan silk 9'0 pa+a lipatan kulit le)er
J 9 ?ari +i atas sternal notc) (atau 1 c +i
90
"a<a) cartilago cricoi+). ean?ang sapai ke otot
sternoclei+oastoi+
%* 8ika "en?olan )an!a pa+a satu sisiE lo"us. insisi tetap saa agar
+apat engekspos sisi lain
&* Insisi kulit. su"kutis +an plat!sa sekaligus en?a+i satu $lap B
mobilized as one layer (untuk encega) per+ara)an. e+ea +an
perlengketan postoperasi)
6* DISEKSI tupul +engan ?ari atau kassa pa+a "atas plat!sa
+engan loose areolar tissue +i "a<a)n!a. tepat super$icial +ari
=ena ?ugularis anterior B no blood technique* Diseksi +ilakukan ke
ara) CAUDAL (sapai sternal notc)) +an CRANIAL (sapai
terli)at cartilago t)!roi+ea) +an +i"uat $lap !ang +i$iksasi ke kain
+rapping*
91
(* INSISI FASCIA colli super$icialis secara =ertikal pa+a GARIS
TENGAH strap uscle )ingga "atas "a<a) sapai le=el sternal
notc). "atas atasn!a sapai cartilago t)!roi+* (#a+a tuor !ang
"esar +apat +ilakukan peotongan otot strap uscle secara
)ori4ontal +i 1E3 proDialn!a setela) s"ln!a =*?ugularis anterior
+iligasi)
99
93
9;
97
10* Diseksi tupul pertenga)an strap uscles sapai $ascia colli
pro$un+a* /ascia ini +iincisi*
11* Dilakukan peisa)an kelen?ar tiroi+ pa+a clea=age plane (antara
kelen?ar tiroi+ +gn *sternoclei+oastoi+eus) L
19* Strap uscle (*sterno)!oi+ +an * sternot)!roi+) +iretraksi ke
kiri +an ke kanan*
9%

13* Dilakukan +iseksi tupul +an ta?a ulai +ari tiroi+ +i "agian
tengan +engan engi+enti$ikasi =*t)!roi+ e+ia* Cena ini
+iligasi +an +ipotong*
9&
96
1;* Diseksi +ilakukan ke pool "a<a) +engan engi+enti$ikasi arteri
+an =*t)!roi+ea in$erior +an +iligasi* 8uga )arus +ii+enti$ikasi
+an +ipreser=asi n* lar!ngeus reccurens !ang terletak +i +aera)
trac)eoeso$ageal groo=e. uun!a "er?alan +i antara "i$urcatio
arteri t)!roi+alis in$erior* 5arus +iingat =ariasi anatois n*
lar!ngeus recurrens

9(

17* Dilakukan +iseksi se+ekat ungkin +engan assa tuor +an
selalu lakukan 9 "ua) ligasi ke ara) pe"ulu) +ara) serta 1
ligasi ke ara) tuor*
30
1%* Diseksi +ilakukan )ingga ke pool atas* #e"ulu) +ara) +ari
+aera) atas (superior) )arus +apat +ii+enti$ikasi +engan "aik (aE=
t)!roi+alis superior +an aE= t)!roi+alis in$erior) keu+ian
+iligasi +an +ipotong*
31
1&* Dilakukan +iseksi tupul untuk eisa)kan kel* #aratiroi+
+engan kel* Tiroi+* :elen?ar paratiroi+ +apat +ii+enti$ikasi
"erupa ?aringan !ang terletak +i posterior tiroi+. "er"entuk
seperti leak +an "er<arna kekuningan*
16* :elen?ar paratiroi+ +ilepaskan
+ari kel*tiroi+. sa"il
+ipreser=asi arteri !ang
eper+ara)in!a
1(* :+n +i+iseksi +an
+ilan?utkan ke ara) ist)us
(pa+a clea=age plane).
ligaentu -err! +an ist)us
+ikle +an +ipotong*
39
90* #er+ara)an +iligasi. sa"il +ili)at apaka) a+a ro"ekan pa+a
trac)ea. keu+ian cuci +engan ,aCl $isiologis*
91* #osisi pasien +ike"alikan ke kea+aan seula (gan?al +i"uka)
se)ingga le)er ke"ali "erelaksasi* :eu+ian +ipasang +rain ke
+asar luka operasi (penrose. =accu)* Strap uscle +irekatkan
se+ekat ingkin* :eu+ian
$ascia colli +itutup +engan
?a)itan interupte+ c)roic 9'0*
#lat!sa +i+ekatkan +an +i?a)it
interrupte+ +engan c)roic 3'0*
:ulit +itutup secara su"kutikular
+engan "enang sintetis ;'0* 3uka
operasi +itutup +engan kassa
steril*
33
PASCA OPERASI
1* #osisi )ea+ up 30
o
9* #eriksa pita suara pasca eDtu"asi
3* -alutan +iperiksa a+aka) )eatoaE "lee+ing
;* #eriksa $onasi suara
7* Drain +ilepas ?ika pro+uksi inial
%* -uka ?a)itan setela) 10 )ari B 9 inggu
3;

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer: Get 4 months of Scribd and The New York Times for just $1.87 per week!

Master Your Semester with a Special Offer from Scribd & The New York Times