Surgery Of The Endocrine Organs Flashcards
Is the adrenal gland a surgeon friendly organ?
- no!
- Close to many bit vessels, eg. R kidney close the phrenicoabd vein (tumor spread right into cava!)
- colorful bs - Renal a/v, aorta, phrenic v/a - but the phrenicoabd most prevalent one.
What are the surgical procedures of the adrenal gland
Adrenalectomy
Adrenalectomy indication
- classic unilateral tumor (cushings, pheochroomocytoma(catecholamine - bp change,etc) , hormonally inactive adenoma or adenocarcinoma (hormone not problem bu they can get big)
- dep on the operability - caudal v. Cava spread?
- accurate diagnosis - endocrinology and morphology. Surgeon must have whole picture and have the control to provide correct pre/post up care
Describe the pathogenesis of caudal v. Cava involvement
(Vessel involvenent: Usually vena cava, renal vein)
Depending on vessel invasiveness:
1. pheochromicytoma more typically grows into the phrenicoabd vein lumen, incr in size toward lumen of v cava - thrombocytes adhear to surface (tumural-thrombus - they accelerate eachother. May even reach the diaph artery!)
2. Or on surface of vessel
What is the preop management of adrenalectomy
In cushings and pheochromocytoma we need preop management!
- Cushings: pushing down the cortisol level as much as we can (immunosuppr)
- pheochromocytoma: stabilize bp/hypertension!
What are the prerequisites for adrenalectomy
At least 5 prerequisite should be present for this procedure!
- Not to small
- not too fat,
- L sided
- non invasive
- not too big tumor.
- (Cushing: small, fat, 50% R sided, 50% invasive esp chronic, bigger than 3-5cm! = this is the problem of laparoscopy. The invasiveness is the most imp here. Involvement of vessels.
What is the surgical tehniques of adrenalectomy
- laparoscopy: (lying on R side, enter from lareral, adenoma)
- Paracostal: no v. Cava involvement, non-invasive
- midline laparotomy: in case of v. Cava involvement, invasive tumor
- R intercostal btw 12-13th rib (gives close approach to R adrenal, but dealin with ribcage.. others better)
Describe how we go about an adrenal tumor with vena cava invasiveness
Cran and caud to affected area . Tourniquet. Other branches - clamps
- need to be quick, inc along vena, turn out thrombus w/tumor, then sas.. clamp to partly stop the blood flow then suture
- Eg. Thrombus reaching diaph from v cava. Close the vcava at diaph, and anothe clamp by kidneys, then pull out thrombus, was solid so easier. More fragile thrombus - in pieces, takes more time.
What is the post op treatment of an adrenalectomy
- cushings reg. Treatment
- pheochromocytoma: bp monitoring
- HP - adenoma vs. Adenocarcinoma, imageing - CT, MRI - should get HP back before talking to owner - malgent - we need to re-check for recurrance within the first year.
Describe the bs of the thyroid gland and other anatomical points
- Opportunistic bs from sorrunding tissues
- Retrophar Ln involvement - desc spread to mediastinum!
- pharyngeal paralysis
- nerves
- trachea
- esophagus
- imp vassels
Many possible involving organs!
What is the possible surgical interventions of the thyroid gland
thyroidectomy
What is the indication of thyroidectomy
We must look at ca vs fe cases differently!
DOG - carcinoma, often normal hormone function, unilat, egg-like structure, originally mobile - middle of neck(!), incr immobility with time also decr prognosis. No other signs than lump, in 10% we see hyper/hypothyroidism.
CAT - benign adenoma/hyperplasia, rarely malignent carcinoma. Hyperthyroidism, bilat, hyperplastic or adenoma. NO SURGERY ONLY CONSERVATIVE except: conservative treatment failure, or enlargement of thyroid as it indicates malignancy.
Describe the positioning of thyroidectomy procedure
- Dorsal recumbancy, fl down-caud, pillow under neck
What types of thyroidectomy surgeries are there
2 types + 2 subtypes = 4 types of surgery
- extracapsular
- modified extracapsular - intracapsular
Extracapsular thyroidectomy
- Dissect around capsule. Push down capsule from structure
- PT gland protect!!! Lig cran and caud to it
- We will make dead space - must put penrose drain! + slignt compression bandage around neck for some days, collar not suitable. Force the 2 lamillae to adhere.
