52-year-old female with a medical history of hypertension previous smoker was evaluated for a right side of thyroid nodule with compressive symptoms. PC noticed swelling to the right side of her neck for 6 months with palpable nodule on the thyroid. Intermittent dysphagia to solid foods. After multiple consultations, it was determined she would have a right thyroid lobectomy and isthmusectomy. This procedure was performed in February of 2024.
The operative note will be attached below. There's not appear to be any notation of complications and she was observed overnight. There's a nursing notation concerning a burn to the PC's neck. It was listed as "most probably due to bovie” and basic dressing was applied.
According to PC the surgeon was aware, however did not provide any follow-up wound care. She was instructed to follow up with the surgeon in two weeks as part of a typical recheck appointment. At that appointment, the PC states the surgeon was “surprised” how big it was but did not provide further treatment options.
PC saw primary care starting approximately 1 week later to discuss neck burn.
Attached in the photos section, you will see a series of photos from the PC that are time stamped with the progress of the wound. She we'll have permanent scarring to the site.
We are seeking a general surgeon who has experience and is currently performing thyroid lobectomies to determine if this injury is within a reasonable range of recognized complication, in addition would this warrant further evaluation by a specialist?
If any further information is needed, please request. We appreciate your time and opinions in advance.
***OPERATIVE NOTE***
SERVICE: Surgery
PREOPERATIVE DIAGNOSIS: Enlarging nodule on the right lobe of the thyroid
gland associated with dysphagia and compressive symptoms.
POSTOPERATIVE DIAGNOSES:
4, Enlarging nodule on the right lobe of the thyroid gland associated with
dysphagia and compressive symptoms.
2. 3. om benign follicular adenoma based upon frozen section.
PROCEDURE: Right thyroid lobectomy and isthmusectomy.
RESIDENT SURGEON: Paul Shadowen, MD
ANESTHESIA: General endotracheal anesthesia. Local anesthesia.
ESTIMATED BLOOD LOSS: 50ce.
FLUIDS: Crystalloid.
TECHNIQUE: With the patient in the supine position, the neck was sterilely
prepped and draped in the usual fashion after our neuromonitoring system was
placed. The patient was intubated.
Next, we began by performing @time-out. We made a 3cm curvilinear incision
below the cricoid cartilage in the region of the thyroid gland. We dissected
down to the platysma. Below the platysma, we dissected flaps in the craniad
and caudad directions, in a subplatysmal plane. We then divided the sternohyoid and sternothyroid muscles. We identified the thyroid. We could
palpate the nodule within the thyroid gland. We began by mobilizing the
superior pole and ligating the vessels with a combination of silk sutures and
LigaSure. We then identified our recurrent laryngeal nerve as it entered into
the cricopharyngeus muscle. We identified the nerve, dissected it out, and we
then took our middle thyroid lobe vein with the LigaSure and suture. We
mobilized the tubercle of the thyroid gland and mobilized our parathyroids
away from the thyroid gland and preserved them. Next, we once again identified
our recurrent laryngeal nerve as we mobilized our inferior pole. We confirmed
this with our neuromonitoring probe, and then we ligated our inferior pole
vessels with silk suture and LigaSure. We used the LigaSure to take down the
ligament of Berry and to mobilize the isthmus, Once we had the isthmus
mobilized, we then used the LigaSure to transect the specimen away from the
remaining left side of the thyroid gland.
Specimen was sent to Pathology for frozen section evaluation. If this came
back suspicious, we were planning to doa compartment V1 dissection, but the
results returned as a 3 cm follicular adenoma. No concerns or suspicion for
thyroid cancer.
At this point, we irrigated the neck. We had Anesthesia do Valsalva. We
controlled some bleeding. We left a piece of Evarrest along the
tracheoesophageal groove near the nerve. This
was an area with a small amount of oozing. Once that was completed, we closed
the median raphe, reapproximated with running Vicryl suture. We closed the
platysma and deep dermis with interrupted Vicry! suture, and then closed the
skin with Monocryl, dressed with Dermabond.
The patient was taken to the recovery room.
Files:
No questions yet!
Do you believe there might have been medical error?
probably a full thicknes burn of skin either to pressure injury or thermal injury.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
probably a technical error during the case.
What makes you a good expert for this case?
I am a practicing head and neck surgeon and thyroid surgeon.
How often do you encounter cases similar to this one in your practice?
It is extremely rare for me or my partners to happen. I have seen minor burns during thyroidectomy, but a full-thickness burn is very unlikely. I have not seen this in my practice before.
Do you believe there might have been medical error?
I suspect the injury was from the ligasure or the bovie. If either instrument is not placed in a "holder" or on a wet towel both can easily burn a patient and the drapes. I can understand how it happens, but the surgeon, recovery room nurse and scrub tech should have noticed the burn especially when the drapes were room.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The surgeon is responsible as is the scrub tech and assistant to ensure instruments, needles. etc are properly secured so a patient or OR personal does not get injured. A burn in a "sentinel" event in any operating room and has to be investigated. In addition, the patient needs to be notified.
What makes you a good expert for this case?
I have completed 100s of thyroid procedures in my career and I have never seen this type of injury.
How often do you encounter cases similar to this one in your practice?
Thyroid cases are very common.
Do you believe there might have been medical error?
There is obviously a burn superior to the incision site. most likely from a bovie. This can be seen during this type of surgery but not a full thickness burn that this appears to be. It was not described in the op note or mentioned to the patient by the surgeon. It seems unlikely that this would not have been noted by the surgeon when closing the incision, and therefore, should have been mentioned to the patient after the surgery. Additionally, I have seen very small bovie injuries during neck surgeries, but to have a full thickness burn seen in the photos is very uncommon, and shows poor technique by the surgeon
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
To give that deep of a burn during neck surgery, the surgeon would have been using poor and careless technique. It is incumbent on the surgeon to see the whole field that an energy releasing instrument may touch to avoid such a complication. If it does occur, offering an explanation to the patient would be standard of care
What makes you a good expert for this case?
I am a trauma and acute care surgeon at a busy verified level one trauma center ad have worked i this setting for 18 years. I do may tracheostomies with similar incisions to thyroid surgery incisions ad also do several neck explorations due to trauma each year
How often do you encounter cases similar to this one in your practice?
I have seen bovie injuries occasionally,, but never a full thickness injury that this appears to be
Do you believe there might have been medical error?
Patient sustained a cautery burn perhaps when flap s were created or while obtaining hemostasis. Could have been excised at time of surgery! At minimum should have been disclosed in the recover room or immediately there after!
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It’s an obvious cautery burn of the skin. Could have been dealt with at time of surgery completion under anesthesia!
What makes you a good expert for this case?
Trauma surgeon that deals with neck injuries that required neck incisions and injury repairs within the neck
How often do you encounter cases similar to this one in your practice?
Rarely, but if I did, unless very unstable patient, would correct it at time of surgery
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