Thyroidectomy Operative Note

Date of Surgery: [Date]

Surgeon: [Full name and credentials]

Assistant(s): [Names and roles]

Anesthesia Provider(s): [Names and roles]

Preoperative Diagnosis: [Diagnosis with explicit laterality when relevant]

Postoperative Diagnosis: [Diagnosis with explicit laterality; include any changes based on intraoperative findings]

Procedure(s) Performed: [Standardized procedure name(s) with explicit laterality and extent] (Use standardized terminology; include all compartments/levels for any neck dissections.)

Anesthesia: [Type and airway details; note EMG endotracheal tube if nerve monitoring used]

Indications

[Concise rationale for surgery including indication(s), planned extent of resection with rationale, and statement that informed consent was obtained. Include results of preoperative voice assessment or vocal fold mobility exam only if performed.]

Operative Description

(Chronological narrative with short paragraphs. Do not claim a specific number of parathyroids preserved unless visualized and counted; otherwise use "preserved when encountered." Do not state a nerve was intact without specifying the basis for that assessment.)

Positioning, Preparation, and Exposure: [Patient position, antibiotic prophylaxis if given, incision type and location, subplatysmal flap elevation, strap muscle handling]

Thyroidectomy – Right Side

(Include only if right side was addressed.)

Superior Pole: [Management of superior pole vessels with protection of external branch of superior laryngeal nerve]

Recurrent Laryngeal Nerve: [Method and location of identification; visual confirmation and/or stimulation response]

Parathyroid Glands: [Number identified with preservation method and vascularity, or "preserved when encountered" if not confidently counted]

Isthmus: [Handling of isthmus relative to right lobe resection]

Thyroidectomy – Left Side

(Include only if left side was addressed.)

Superior Pole: [Management of superior pole vessels with protection of external branch of superior laryngeal nerve]

Recurrent Laryngeal Nerve: [Method and location of identification; visual confirmation and/or stimulation response]

Parathyroid Glands: [Number identified with preservation method and vascularity, or "preserved when encountered" if not confidently counted]

Isthmus: [Handling of isthmus relative to left lobe resection]

Nerve Monitoring

(Include only if nerve monitoring was used. If not used, omit this section; RLN identification is documented within side-specific narrative above.)

Modality: [Intermittent / continuous] nerve monitoring with EMG endotracheal tube

System Check: [Baseline system check completed with acceptable impedances]

• Right Side Signals: V1 [vagus signal], R1 [initial RLN signal], R2 [post-dissection RLN signal], V2 [final vagus signal]
• Left Side Signals: V1 [vagus signal], R1 [initial RLN signal], R2 [post-dissection RLN signal], V2 [final vagus signal] (Include only if left side addressed.)

Loss of Signal: [None / Side, timing, troubleshooting steps performed, and impact on surgical plan including staging decision if applicable]

Parathyroid Autotransplant

(Include only if performed.)

[Gland identity and side, reason for autotransplant, tissue preparation method, implant site with side specified, marking method if used]

Hemostasis

[Vessel control methods, irrigation and inspection of thyroid bed, Valsalva maneuver or increased airway pressure to check for venous bleeding, hemostatic adjuncts if used]

Drain Decision

[Drain placed: type, size, location, exit site, suction method, securing method / No drain placed: brief rationale]

Closure

[Strap muscle reapproximation, platysma closure, skin closure method, local anesthetic infiltration if used, dressing type]

Specimens

(Omit section if no specimens removed. Specimen list must reconcile with procedures performed.)

• [Specimen with laterality and orientation markers when relevant for oncologic interpretation]
• [For lymph node specimens: compartment/level and side]

EBL

[Estimated blood loss] (May omit if minimal.)

Complications

[None / Description of complication(s) with intraoperative management. If RLN injury suspected or confirmed, document side, mechanism if known, and basis for assessment.]

Counts and Disposition

Counts: [Correct / specify discrepancy and resolution]

Condition: [Patient condition at case end; extubation status with rationale if remained intubated]

Disposition: [PACU / ICU]