1. Lie on your back, lift your shoulders, raise your head back, and fully expose your neck [Figure1-1]; Both sides of the head are fixed with small sandbags to prevent the head from moving left and right to pollute the incision during the operation.

2. The incision is made at 2 fingers above the suprasternal notch, and an arc incision is made along the dermatoglyphics, with both ends reaching the outer edge of sternocleidomastoid muscle; If the gland is large, the incision can be bent upwards and lengthened accordingly [Figure 1-2]. Cut the skin, subcutaneous tissue and platysma muscle, pull up the upper and lower flaps with tissue forceps, separate the loose tissue behind platysma muscle with a knife, and go up to the lower edge of thyroid cartilage [Figure 1-3] to make the sternal stalk notch. There are few blood vessels in this space, and it is easy to bleed if it is too deep and shallow. Protect the incision with a sterile towel, open the incision with a small retractor, and suture the bilateral anterior jugular veins with No.4 silk thread [Figure 1-4].

3. Cut the anterior thyroid muscle group to expose the thyroid gland, cut the fascia of the medial margin of sternocleidomastoid muscle on both sides, separate the sternocleidomastoid muscle from the anterior cervical muscle group, then cut the deep fascia longitudinally in the middle line of the neck, and then use vascular forceps to separate the muscle groups to reach the thyroid sac [Figure 1-5]. The index finger and the handle extend below the anterior cervical muscle group, gently separate the thyroid gland between the thyroid gland and the pseudocapsule, jack up the muscle, cut across the vascular clamp, and expand the exposure of the thyroid gland. Pay attention to the fact that the muscle transection site should not be on the same level as the skin incision to avoid scar adhesion after healing [Figure 1-6].

4. In order to treat the upper pole of thyroid, surgery is usually performed from the right lobe first. In order to facilitate the treatment of the upper pole, the suspensory ligament of thyroid should be separated, cut off and ligated inside the upper pole. This ligament has blood vessels, so be careful in separation and firm in ligation. Then peel off the upper pole along the outer edge of the lateral thyroid lobe with your fingers, so that the upper pole of the right lobe is fully exposed. Pull the right lobe of thyroid downward and inward (or insert a needle through the right upper pole of thyroid, and then pull the upper pole of thyroid downward and inward), and then pull the upper broken end of anterior thyroid muscle group upward with a small retractor to expose the upper pole. The operator holds the tip of the upper pole with his left thumb, forefinger and middle finger, and bypasses the deep part of the superior thyroid artery and vein with his right hand from inside to outside, and holds it with his left forefinger, passing through a No.7 silk thread, and ligating the upper pole vessel at a distance of about 0.5 ~ 1.0 cm from the upper pole [Figure 1-7]. Then two vascular clamps were used to clamp between the ligation line and the upper pole, and the blood vessel was cut between the vascular clamps, and the vascular stump was sutured again [Figure 1-8]. Pay attention to the strong ligation and suture of blood vessels here, otherwise once the blood vessels retract, there will be more bleeding and it will be difficult to deal with. The superior polar vessels should be treated as close as possible to the gland to avoid damaging the lateral branches of the superior laryngeal nerve [Figure 1-9]. Continue to passively separate the upper back of the thyroid gland. In case of blood vessel branch, it can be ligated and cut off. Gently pull the thyroid gland inward, and you can find the middle thyroid vein in the middle of the outer edge of the gland. After separation, connect them and cut them [Figure 1- 10].

5. Treat the hypothyroid pole, pull the thyroid inward and upward, and separate it from the hypothyroid pole along the outer edge of the thyroid. Pull down the lower broken end of the anterior thyroid muscle group with a small hook to expose the lower pole. At the lower pole, the inferior thyroid vein is shallow, with 3-4 branches on each side, slightly lower than the inside. When found, it will be ligated and cut off [Figure 1- 165438+] In a few cases, there is the lowest thyroid artery here. If so, it should be ligated and cut off. Generally, it is not necessary to expose or ligate the inferior thyroid artery, so as not to damage the recurrent nerve, make the thyroid ischemic and lead to dysfunction. If ligation is needed, it should be done in the cyst, not the trunk, but only the branch of the inferior thyroid artery far from the recurrent laryngeal nerve, and enter the true cystic gland [Figure 1- 12]. Generally, it is not necessary to expose recurrent laryngeal nerve routinely.

6. After the isthmus is completely separated from the hypothyroid pole, the gland is pulled outward to expose the isthmus, and the posterior part of the isthmus is separated upward from the front of the trachea at the lower edge of the isthmus with vascular forceps, and the tip of the forceps passes through the upper part of the isthmus [Figure 1- 13]. Open the vascular clamp, enlarge the gap between isthmus and trachea, lead out two thick silk threads, and then tie the left and right isthmus separately and cut them between the two ligatures. If the isthmus is wide, two rows of vascular forceps can be used to clamp, cut off, ligate or suture it in turn, and the cut isthmus will continue to separate laterally until it reaches the front side of trachea [Figure 1- 14]. At this time, the right thyroid gland has been basically separated.

7. Wedge thyroidectomy turns the thyroid body forward from the outer edge of the gland, exposing its back and determining the boundary of the resected gland. The parathyroid gland must be kept below the tangent to avoid damaging the recurrent laryngeal nerve. Use one or two rows of mosquito-type straight vascular forceps to clamp a little gland tissue along the predetermined cutting line outside [Figure 1- 15]. Then wedge thyroidectomy was performed above the vascular clamp. The number of glands removed depends on the degree of poisoning of the patient. In the case of hyperthyroidism, about 90% glands should be removed. Generally, there is a thin remnant gland tissue on each side, about the size of the distal thumb, covering the parathyroid gland and recurrent laryngeal nerve, which is enough to maintain its physiological function without recurrence. For patients with nodular goiter, we should take more (about twice as much as patients with hyperthyroidism). The retroglandular bursa should be preserved as much as possible to prevent parathyroid gland and recurrent laryngeal nerve from being damaged [Figure 1- 16]. In order to reduce cross-sectional bleeding, the surgeon or assistant can press the inferior thyroid artery with his left hand under the forceps or cut between two rows of vascular forceps to stop bleeding to reduce bleeding. The bleeding point of gland stump should be ligated or sutured, and then the edge should be sutured [Figure 1- 17]. When suturing, be careful not to insert the needle too deep to avoid suturing the recurrent laryngeal nerve. After excision, the thyroid fossa was closed with hot saline gauze. After the right lobe is removed, the left lobe is removed in the same way.

8. Drainage and suture the incision. After completely suturing the bilateral thyroid residual surfaces to stop bleeding, apply hot saline gauze to the wound surface. At this time, the pad under the patient's shoulder is pulled out to relax the patient's neck and take out the hot saline gauze; Check for bleeding spots and see if the whole wound is bleeding. Put a tubular rubber plate or a thin drainage tube with a diameter of 3 ~ 5 mm in the left and right glandular fossa, and lead it out from the inner edge of sternocleidomastoid muscle and the two corners of the incision and fix it [Figure 1- 18, 19]. The incision was stitched layer by layer.