• Clinical science

Thyroid surgery

Abstract

Thyroid surgery is a procedure commonly performed to treat benign and malignant thyroid disorders. Total thyroidectomy entails the removal of the entire thyroid gland and is indicated in the management of thyroid cancer or benign thyroid conditions that affect the entire gland (e.g., Graves' disease, multinodular goiter). A small cuff of tissue adjacent to the tracheoesophageal groove is spared in near total and subtotal thyroidectomy in order to protect the parathyroid glands and the adjacent nerves. Lobectomy (removal of a single lobe) or hemithyroidectomy (removal of a single lobe with the isthmus) is performed for unilateral benign thyroid disorders (e.g., toxic adenoma, recurrent thyroid cysts) and for small, low-risk differentiated thyroid cancers. Postoperative complications include hematoma formation, hypoparathyroidism, nerve palsy (recurrent/superior laryngeal nerve), and hypothyroidism. The greater the extent of resection, the greater the risk of complications. However, the most extensive resections (total thyroidectomy) are associated with the lowest rates of recurrent disease.

Thyroid gland anatomy

Preparation

References:[1][2][3][4][5][6]

Procedure/application

Steps of thyroid surgery

  1. Position (Kocher's position): supine with a pad placed under the shoulders to enable neck extension and adequately expose the thyroid gland
  2. Kocher's incision: a skin crease incision ∼ 2–3 cm above the clavicular heads; as deep as the subplatysmal plane
  3. Raising the skin flaps (subplatysmal plane) to the thyroid cartilage superiorly and the suprasternal notch inferiorly
  4. Separation of the strap muscles: The deep fascia is incised longitudinally in the midline and the strap muscles are retracted laterally to expose the thyroid gland.
  5. Ligation of the middle thyroid vein
  6. Ligation of the superior thyroid artery and vein; identification and preservation of the superior laryngeal nerve
  7. Identification and preservation of the recurrent laryngeal nerve
  8. Ligation of the inferior thyroid vein and thyroid branches of the inferior thyroid artery
  9. Identification and preservation of the parathyroid glands
  10. Autotransplantation of parathyroid glands into the sternocleidomastoid muscle is indicated if the glands appear ischemic or if they have been mistakenly excised during thyroidectomy (to avoid permanent hypoparathyroidism). Depending on the extent of resection (see below), the procedure can be repeated on the other side (for total/near total/subtotal thyroidectomy).
  11. Closure: Hemostasis is achieved, the wound bed is irrigated, the strap muscles are sutured in the midline, and the skin flaps are sutured together.
Procedure Description Indication Advantages Disadvantages

Total thyroidectomy

Near total thyroidectomy

  • Lower risk of injury to the adjacent nerves and the parathyroid gland
  • Possibility of achieving euthyroid status without thyroid hormone replacement
  • Dunhill procedure: minimizes the risk of recurrence while preserving the parathyroid glands (on the side of the subtotal thyroidectomy)
Subtotal thyroidectomy

Lobectomy

  • Removal of the affected thyroid lobe
  • Risk of recurrence
  • Some patients may require completion total thyroidectomy.
Hemithyroidectomy
  • The affected lobe with the isthmus is removed (lobectomy + isthmusectomy).
  • Minimally invasive/robotic thyroidectomy: Endoscopic/robotic instruments are tunneled into the neck to perform thyroidectomy; small incisions are made in the axilla/chest wall. The advantage is that no scars are left on the neck.

References:[7][1][8][9][10][11]

Complications

Unilateral RLN palsy Bilateral RLN palsy
Pathophysiology
  • The ipsilateral vocal cord (VC) assumes a paramedian/lateral position → failure of VC approximation during phonation/coughing/swallowing
  • Both VCs assume a median/paramedian position → airway obstruction
Clinical features
Treatment
  • Voice therapy: in all patients
  • Medialization of the VC (laryngoplasty): indicated in patients with an ineffective cough or high risk of aspiration pneumonia
  • Immediate re-intubation or tracheostomy (if intubation is not possible)
  • Re-exploration and repair of a transected RLN may be necessary.
  • Permanent tracheostomy or laser posterior cordectomy: in patients with permanent bilateral RLN palsy

References:[7][12][1]

We list the most important complications. The selection is not exhaustive.

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  • 2. OpenAnesthesia. Endocrine Disease (Anesthesia Text). https://www.openanesthesia.org/endocrine_disease_anesthesia_text/. Updated March 21, 2017. Accessed March 21, 2017.
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  • 5. Randolph GW. The importance of pre- and postoperative laryngeal examination for thyroid surgery. Thyroid. 2010; 20(5): pp. 453–458. doi: 10.1089/thy.2010.1632.
  • 6. Chapter 21: Surgery of the Thyroid. In Endotext: Comprehensive Free Online Endocrinology Book . Kaplan E, Mercier F, Applewhite M, Angelos P, Grogan RH. url: https://www.ncbi.nlm.nih.gov/books/NBK285564/ Accessed March 21, 2017.
  • 7. Kaplan E, Mercier F, Applewhite M, Angelos P, Grogan RH. Surgery of the thyroid. http://www.thyroidmanager.org/chapter/chapter-21surgery-of-the-thyroid/. Updated September 25, 2015. Accessed February 18, 2017.
  • 8. Rayes N, Seehofer D, Neuhaus P. The surgical treatment of bilateral benign nodular goiter: balancing invasiveness with complications. Dtsch Arztebl Int. 2014; 111(10): pp. 171–178. doi: 10.3238/arztebl.2014.0171.
  • 9. Vaiman M, Nagibin A, Hagag P, Buyankin A, Olevson J, Shlamkovich N. Subtotal and near total versus total thyroidectomy for the management of multinodular goiter. World J Surg. 2008; 32(7): pp. 1546–1551. doi: 10.1007/s00268-008-9541-9.
  • 10. Hanks JB, Inabnet III WB. Controversies in Thyroid Surgery. Cham, CH: Springer International Publishing; 2015.
  • 11. Mazzaferri EL. Management of low-risk differentiated thyroid cancer. Endocr Pract. 2007; 13(5): pp. 498–512. doi: 10.4158/EP.13.5.498.
  • 12. Carroll TL. Unilateral Vocal Fold Paralysis. In: Unilateral Vocal Fold Paralysis. New York, NY: WebMD. http://emedicine.medscape.com/article/863779-overview. Updated March 29, 2015. Accessed February 18, 2017.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
last updated 11/19/2018
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