This presentation discusses the historical evolution of thyroid surgery

1. Thyroid Historic perspective Dr T Balasubramanian

3. Initially they did not know that goitre is enlargement of thyroid gland

4. It was documented that consuming sea weeds caused remarkable cure in these patients

5. It goes without saying that sea weeds contain large amounts of iodine

7. Thyroid gland was discovered 200 years before Greeks used this term

9. He drew sketches of the gland in great detail

10. He used the term laryngeal glands to describe the thyroid

11. He also discussed in great detail the vasculature of the thyroid gland

13. He also clearly described that this swelling moved up and down when the patient attempts to swallow

15. Thyroid is a Greek word to indicate shield shape

16. It was coined with the thyroid cartilage in mind as it is shaped like a shield.

18. Paracelsus in 1527 was the first to link goitre and cretinism

19. Platter in 1562 came out with convincing proof that cretinism was seen in children born of goitrous mothers

21. Chinese merchants were the ones who taught the Europeans that consuming sea weed could cure goitre

22. Courtois in 1812 discovered that sea weeds contained large quantities of iodine

23. Coindet in 1820 popularized iodine treatment for goitre in Sweden

25. This work never got the recognition it deserved

27. He used thyroid extracts to save dogs in whom he performed total thyroid removal

29. It was only after Akron study which was carried out in school children that goitre preventive role of iodine came to be recognised

31. His work was not published till much later

32. Coindet described the symptoms of thyrotoxicosis without realizing its significance

33. Graves in his talk described few of his patients with goitre and palpitation. He initially considered it to be a cardiac malady

34. Basedow discussed in detail the symptoms of thyrotoxicosis

36. It was approximately during this time surgeons were successful in partially removing this hyperfunctioning thyroid glands

38. It was first described in London. The term myxoedema was used because of oedematous skin due to accumulation of myxoid tissue

39. Initially it was considered to be a neurologic / skin disease

41. He was not beleived at first

42. A committee was constituted which concluded 5 years later that his observation was true

44. This provoked scientists to try out other organ extracts too

45. In 1891 Murray injected sheep thyroid extract which cured a patient with myxoedema

47. Baumann identified iodine in the thyroid gland extract

48. It was the english man Harrington who indentified the exact molecular structure of thyroxine

49. Harrington suspected there could be another hormone in addition to thyroxine

51. He successfully synthesized thyroxine

52. Since it was a free acid absorption was poor

53. Hence until 1960's dessicated thyroid was used in the management of goitre

55. He was the first person to associate goitre with exophthalmos

57. First thyroid surgery was performed by Albucais in spain. This surgery was performed to treat a patient with goitre. He used a cruciate incision for this purpose.

59. This was practised when the goitre was adherent

60. Shoe lace ligature is encircled around the mass and firmly kept tied for 3 hours

61. The goitre which had become avascular was sectioned away.

64. Heinrichs the IV started this procedure

65. He was credited with nearly 1000 cures by simply touching the neck of the patient. (Such was the devotion they had towards their king thosedays).

67. He described his futile attempts to stop bleeding from the neck following surgery by using digital pressure by his assistants for two days who worked as a relay team

69. Adolf Vogel – circular incision

70. Benjamin Gooch – Vertical incision

71. Desault – Median longitudinal incision

73. He was the first to emphasise ligation of superior / middle / inferior thyroid pedicles before removing thyroid

74. His feat was considered unbeleivable

76. This allowed for better wound healing during procedures

77. He was the first to observe tracheal flattening / distortion

79. He first ligated both superior arteries of thyroid gland and this was ineffective

80. He ligated both superior and inferior arteries of one side. This provided temporary relief for about 6 months

81. He proved that arteries supplying the opposite lobe was not capable of maintaining integrity of opposite lobe

83. He used long median incision to expose neck

84. Separated strap muscles / fascia – mobilized superior pole using fingers

85. Used aneurysm needle to thread around superior pole and ligated it. Repeated same maneuver in the other portions of gland and excised it in full

87. Used midline vertical incision to expose the gland

88. Ligated superior and inferior thyroid arteries

89. Transfixed and double ligated the isthumus

90. Removed the mass completely

91. Incisions

93. He was the first to report symptoms of thyroid deprivation

95. He advised against total thyroidectomy

96. He believed total thyroidectomy somehow disturbed blood supply to the brain

98. He also beleived ligation of inferior thyroid artery somehow damaged the nerve

100. He divided sternohyoid, omohyoid and sternothyroid muscles transversely

101. Artery forceps was freely used by Billroth. This facilitated better haemostasis

103. He left a sleeve of thyroid gland along the tracheo oesophageal groove in order to protect the recurrent laryngeal nerve from injury

104. He insisted that this technique is useful even in treating malignant lesions of thyroid gland

106. He attempted to explain the tracheal oedema that followed thyroid surgery by suggesting vascular congestion to be the cause.

108. Partial thyroidectomy

109. Enucleation

111. He was instrumental in disseminating vital knowledge pertaining to thyroid surgery to other surgeons

112. His clinic played a vital role in this purpose and still continues to do so

113. Thank you