The primary goal is to progress toward entrustment in EPA: Management of Patients with Diseases of the Thyroid and Parathyroid.

• Ultrasound & FNA: Demonstrate the ability to identify thyroid nodules and perform a simulated ultrasound-guided FNA.

• Anatomy: Identify key structures: Recurrent Laryngeal Nerve (RLN), Superior Laryngeal Nerve (SLN), Parathyroid glands, and the Berry ligament.

• Surgical Technique: Perform a systematic lobectomy and/or total thyroidectomy with meticulous nerve preservation.

• Secondary Objective (Time Permitting): Perform an emergent/planned surgical tracheostomy.

Scenario B: Primary Hyperparathyroidism

Patient: A 62-year-old male with incidental hypercalcemia (11.2 mg/dL) and elevated PTH (110 pg/mL) found by his PCP. 

Anatomy and Physiology:

• https://operativereview.com/thyroid-anatomy-physiology

• https://operativereview.com/parathyroid-anatomy-physiology

Specific Conditions:

• https://operativereview.com/thyroiditis-hypothyroidism

• https://operativereview.com/hyperthyroidism

• https://operativereview.com/goiter

• https://operativereview.com/thyroid-nodule-management

• https://operativereview.com/thyroid-cancer

• https://operativereview.com/primary-hyperparathyroidism

• https://operativereview.com/secondary-tertiary-hyperparathyroidism

• https://operativereview.com/parathyroid-carcinoma/

Operative Considerations:

• https://operativereview.com/thyroidectomy

• https://operativereview.com/parathyroidectomy

Ultrasound/FNA

• Correctly identifies trachea, carotid, and internal jugular on US

• Stabilizes the transducer while maintaining needle visualization

• Successfully "aspirates" the simulated lesion

• Correctly discusses the Bethesda criteria for thyroid pathology

Thyroidectomy

• Creates a symmetric transverse collar incision

• Elevates subplatysmal flaps to the thyroid notch and sternum

• Correctly identifies and divides the midline raphe  

• Identifies, ligates, and divides the middle thyroid vein

• Rotates the thyroid lobe medially to expose the TE groove

• Isolates the superior pole vessels

• Ligates superior vessels individually and close to the capsule

• Identifies the Recurrent Laryngeal Nerve (RLN)

• Identifies and preserves the parathyroid glands

• Meticulous division of the Ligament of Berry

• Divides the isthmus from the trachea with energy or ties

• Correctly re-approximates the strap muscles and platysma  

Parathyroidectomy

• Identifies the relationship of the RLN to the parathyroid glands

• Demonstrates careful dissection of the adenoma

• Verbalizes the Miami criteria for successful adenoma resection

Tracheostomy (Optional Bonus)

• Identifies the cricoid and 2nd/3rd tracheal rings

• Creates an appropriate tracheal window (Bjork flap or slit)

• Successfully places and secures the trach tube