OT notes · General Surgery

Total thyroidectomy

Usual anaesthesia
General with endotracheal intubation
Position
Supine, neck extended with sandbag or roll between the scapulae, head on a head ring, head end raised (reverse Trendelenburg)
Setting
elective

Operative note template for total thyroidectomy, with a filled example for a euthyroid multinodular goitre with pressure symptoms.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • voice change or hoarseness from recurrent laryngeal nerve injury, one or both sides
  • breathing difficulty needing tracheostomy if both nerves are injured
  • loss of high pitch and voice fatigue (external laryngeal nerve injury)
  • low calcium with tingling or cramps, temporary or permanent, needing calcium tablets
  • lifelong thyroxine tablets
  • bleeding and neck haematoma causing airway obstruction, may need urgent reopening
  • scar: thick or keloid
  • wound infection and seroma

Pre-operative details for this operation

  1. Indicationdiagnosis (MNG / Graves / carcinoma), FNAC report, pressure symptoms, retrosternal extension on imaging
  2. Thyroid statusEuthyroidToxic, controlled on antithyroid drugs and beta-blockerT3, T4, TSH values and date; for toxic goitre, drugs and doses
  3. Pre-op vocal cord checkIndirect laryngoscopy: both cords mobileFibreoptic laryngoscopy: both cords mobileCord palsy present: sidedate and by whom
  4. Serum calcium (and PTH / vitamin D if done)values and dates
  5. Airway assessmenttracheal deviation or narrowing on X-ray / CT; anaesthetist informed
  6. Blood grouped and cross-matchedgroup, units reserved
  7. Consent includes tracheostomy and lifelong thyroxineYes

Anaesthesia and position

  1. AnaesthesiaGeneral with endotracheal tubeGeneral with nerve-monitoring (EMG) tubeAwake fibreoptic intubation (difficult airway)
  2. PositionSupine, sandbag under shoulders, neck extended, head ring, reverse Trendelenburg
  3. Nerve monitoringNot usedIntermittent nerve stimulationEMG endotracheal tube

Operative findings

  1. Right lobesize, nodules, consistency, retrosternal extension
  2. Left lobesize, nodules, consistency, retrosternal extension
  3. Isthmus and pyramidal lobe
  4. Right recurrent laryngeal nerveidentified, course, relation to inferior thyroid artery, branches, intact at end
  5. Left recurrent laryngeal nerveidentified, course, relation to inferior thyroid artery, branches, intact at end
  6. Parathyroids (count out of four)each gland: preserved in situ / autotransplanted (site) / not seen / found on specimen
  7. TracheaFirmSoftened (tracheomalacia suspected)
  8. Lymph nodes and local invasioncentral nodes, strap muscle or tracheal invasion

Procedure (steps)

  1. Skin incisiontransverse collar incision in a skin crease about 1 cm below cricoid; length
  2. Subplatysmal flaps raisedup to thyroid cartilage, down to sternal notch
  3. Midline raphe opened, strap muscles retractedStraps retractedStraps divided high (reason)
  4. First side: middle thyroid vein(s) ligatedside started, ties used
  5. First side: superior pole vessels ligated close to glandindividual ligation / clips / energy device; external laryngeal nerve
  6. First side: RLN identified and traced, parathyroids preservedinferior thyroid artery branches divided on capsule
  7. First side: ligament of Berry divided, lobe off tracheaisthmus and pyramidal lobe freed
  8. Second side: same stepsrecord the nerve and parathyroids separately for this side
  9. Specimen inspected for parathyroidsany gland found on the specimen: minced and autotransplanted (site)
  10. Parathyroid autotransplantation (if done)fragment sent for frozen, 1-mm pieces into sternomastoid / strap pocket, marked with non-absorbable stitch or clip
  11. Central compartment clearance (if done)side(s), level VI, nodes sent separately
  12. Haemostasischecked again after removing the sandbag

Closure, drains and dressing

  1. DrainNoneSuction drain under straps, through separate stabsize
  2. Strap musclesabsorbable, interrupted or continuous
  3. Platysmainterrupted absorbable
  4. SkinSubcuticular absorbableSkin clipsInterrupted
  5. DressingLight dressingSkin strips / gluePressure dressing
  6. Vocal cords seen at extubationBoth movingNot checkedPalsy: side

Specimens and implants

  1. Total thyroid for HPEorientation stitch (e.g. right upper pole), weight
  2. Central nodes (if cleared)side, separate container
  3. Parathyroid fragment for frozen sectionSentNot applicable

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Positionhead end up 30 degrees
  2. Watch for neck haematoma and stridorneck swelling, stridor, fall in SpO2, tachycardia; inform surgeon at once
  3. Stitch cutter / clip remover at bedsideto open the wound at the bedside if a tension haematoma forms
  4. Serum calciumnext morning (and PTH if the unit does it); watch for tingling, perioral numbness, Chvostek and Trousseau signs
  5. Symptomatic hypocalcaemiaIV calcium gluconate 10 ml of 10% over 10 minutes, then oral calcium; inform surgeon
  6. Voicenote voice and cough; ENT review if hoarse
  7. Drain (if placed)record output; usually removed in 24 to 48 h
  8. Oral intakeliquids when awake and swallowing well
  9. Analgesiadrug, dose, frequency
  10. Thyroxinestart as per plan; delayed in differentiated cancer if radioiodine planned

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.N., 52 years, with a large euthyroid multinodular goitre, both lobes involved, with pressure symptoms on lying flat, FNAC benign (colloid goitre), posted for total thyroidectomy.

Case details

Date: 20/06/2026. Elective. OT 3.

In OT 09:00. Induction 09:10. Skin incision 09:35. Closure completed 12:05.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., present and scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: multinodular goitre, right lobe 7 cm, left lobe 5 cm on ultrasound, choking on lying flat. No retrosternal extension on chest X-ray. Trachea central.

T3, T4, TSH normal (TSH 1.8 mIU/l on 08/06/2026). Serum calcium 9.2 mg/dl.

Indirect laryngoscopy on 10/06/2026 by ENT: both vocal cords mobile.

Blood group A positive, 1 unit cross-matched.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from the patient, wife as witness. Voice change, tracheostomy, low calcium, lifelong thyroxine and haematoma explained.

WHO checklist sign in and time out done. No antibiotic prophylaxis (clean neck surgery, as per unit policy).

Anaesthesia and position

General anaesthesia with endotracheal tube. No nerve monitor.

Supine, sandbag between the scapulae, neck extended, head on a ring, 15 degrees head up. Parts painted with povidone-iodine and draped.

Findings

Both lobes enlarged with multiple colloid nodules, right 7 x 4 cm, left 5 x 3 cm. Pyramidal lobe present. No retrosternal extension. No enlarged nodes. No strap invasion. Trachea firm.

Right RLN: found near the tubercle of Zuckerkandl, passing between branches of the inferior thyroid artery, traced to the ligament of Berry. Intact at the end.

Left RLN: found in the tracheo-oesophageal groove, deep to the inferior thyroid artery, single trunk, traced to the larynx. Intact at the end.

Parathyroids: right superior and inferior, left superior preserved in situ with their blood supply. Left inferior found on the specimen, autotransplanted (see below). 4 of 4 accounted for.

Procedure

Transverse collar incision of 8 cm in a skin crease, 1 cm below the cricoid.

Subplatysmal flaps raised up to the thyroid cartilage and down to the sternal notch.

Midline raphe opened. Straps retracted laterally, not divided.

Right side first: middle thyroid veins (two) ligated with 4-0 absorbable ties and divided. Superior pole vessels skeletonised and ligated individually close to the gland. Inferior thyroid veins ligated close to the gland. Right RLN identified and traced as above. Inferior thyroid artery branches divided on the capsule. Right parathyroids swept off the gland on their pedicles. Ligament of Berry divided sharply. Right lobe freed off the trachea.

Isthmus and pyramidal lobe dissected off the trachea.

Left side: same steps. Left RLN identified and traced as above. Left superior parathyroid preserved. Ligament of Berry divided. Whole gland removed in one piece.

Specimen checked: left inferior parathyroid found on the capsule, dusky. Tiny fragment sent for frozen section, reported as parathyroid tissue. Rest minced into 1-mm pieces and placed in a pocket in the left sternocleidomastoid, pocket marked with polypropylene (Prolene) 4-0 stitch and a metal clip.

Sandbag removed and haemostasis checked again with bipolar cautery. Field dry.

Closure

Suction drain 12 Fr under the strap muscles through a separate stab, fixed with silk.

Straps approximated with interrupted polyglactin 910 (Vicryl) 3-0. Platysma interrupted Vicryl 3-0. Skin subcuticular poliglecaprone 25 (Monocryl) 3-0.

Light gauze dressing.

Vocal cords seen by the anaesthetist at extubation: both moving.

Specimens and implants

1. Total thyroid, long stitch on the right upper pole, weight 110 g, for HPE.

2. Parathyroid fragment for frozen section (reported parathyroid).

Implant: 1 metal clip marking the parathyroid autotransplant site in the left sternocleidomastoid.

End of procedure

Estimated blood loss 150 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Extubated, clear voice, no stridor. Shifted to recovery. Pulse 88/min, BP 132/84 mmHg, SpO2 98% on room air.

Post-op orders

Head end up 30 degrees.

Pulse, BP, SpO2 and neck check every 30 min for the first 6 hours, then 4-hourly. Call the surgeon at once for neck swelling, stridor or breathlessness.

Stitch cutter kept at the bedside.

Serum calcium tomorrow morning. Watch for tingling of the lips or fingers and cramps. If symptomatic: inj calcium gluconate 10% 10 ml IV over 10 minutes and inform the surgeon.

Drain output charted every 8 hours.

Oral liquids once fully awake and swallowing well, then soft diet.

Tab paracetamol as per drug chart.

Thyroxine to start as per consultant plan.

Planned discharge on POD 1 or 2 after calcium result. Review with HPE in the surgery OPD.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 20/06/2026, 12:20.

Must document for this operation

  • Each recurrent laryngeal nerve, right and left separately: seen, course, intact at the end. Bilateral palsy is the most serious complication, and the record shows which side was at risk if the voice or airway changes.
  • Parathyroid count out of four, and any autotransplant with its marked site. It explains post-op hypocalcaemia and tells a future surgeon where the transplanted tissue is.
  • Pre-op laryngoscopy and vocal cords at extubation. A palsy present before surgery must be on record, or it will be blamed on the operation.
  • State of the trachea (firm or soft). Tracheomalacia after a large goitre can cause airway collapse after extubation and may need a planned tracheostomy.
  • Drain and closure layers. Ward staff opening the wound for a tension haematoma need to know which layers to open.
  • Specimen orientation stitch and weight. If cancer is found, the pathologist and the radioiodine team need to know which side and pole it came from.

Common mistakes in these notes

  • Writing 'both RLN preserved' without describing either nerve.
  • Not counting parathyroids, or not mentioning a gland found on the specimen.
  • No order for a post-op serum calcium.
  • No stitch cutter at the bedside in the post-op orders.
  • Not recording the pre-op indirect laryngoscopy (IL) result.

Indian practice and paperwork

  • NABH standard COP.14(e) (5th edition) requires the operative note to be written before the patient is transferred out of recovery. (NABH Hospital Accreditation Standards 5th ed. (April 2020), COP.14 OE e)
  • In NQAS-assessed public hospitals, the OT checkpoint 'Operative Notes are Recorded' looks for the people present, pre- and post-op diagnosis, procedure, length of procedure, estimated blood loss, fluids given, specimen removed and complications. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)

Sources

  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press; 2026, Ch 23, Surgery of the neck: hemithyroidectomy, total thyroidectomy, post-op complications, pp. 521-527.
  • Scott-Conner CEH, Dawson DL. Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 6, Thyroid lobectomy (Bhama AR, Lal G), including total thyroidectomy, pp. 34-44.
  • Shifrin A, ed. Atlas of Thyroid Surgery. Springer; 2022, Ch 5, Total thyroidectomy (Shah US, Nicholson KJ, Carty SE), pp. 53-63.
  • Sriram Bhat M. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 15, Surgery for thyroid and parathyroid, pp. 446-461.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013. Head and neck procedures: prophylaxis not recommended for clean procedures such as thyroidectomy. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • SRB's Surgical Operations, Ch 15, pp. 459 and 461 (hypocalcaemia: IV calcium gluconate 10 ml of 10% (1 g) over 10 minutes for symptomatic patients; asymptomatic early hypocalcaemia not treated).

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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