: Admin : 2022-02-09

What is thyroidectomy?

A thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland.

What is the thyroid gland?

The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormones help the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.

What are the five types of thyroidectomy?

Thyroidectomy can be classified into 5 distinct parts depending on the part of the gland or whole of the gland to be removed, the spread of the disease and the type of disease. The different types of thyroidectomy are:-

• Hemithroidectomy

A Hemithyroidectomy is the removal of half of the thyroid gland. This procedure also referred to as a thyroid lobectomy or partial thyroidectomy, is performed to remove symptomatic or cancerous nodules.

• Subtotal thyroidectomy

Subtotal thyroidectomy is a surgical procedure, in which the surgeon leaves a small thyroid remnant (3-5g) in situ to preserve thyroid function, thereby preventing lifelong thyroid hormone supplementation therapy.

• Partial thyroidectomy

Partial thyroidectomy involves the surgical removal of one lobe of the thyroid gland, usually the cancerous portion.

• Near-total thyroidectomy

Near‐total thyroidectomy is an operation that involves the surgical removal of both thyroid lobes except for a small amount of thyroid tissue (on one or both sides less than 1.0 mL).

• Total thyroidectomy

Total thyroidectomy involves the removal of the entire thyroid gland.

Despite all the above classifications of the surgery, this article will mainly be focused to review, analyse and summarising Total Thyroidectomy. However, the principles discussed may be applied to all Thyroidectomy procedures.

 Why is Subtotal Thyroidectomy performed?

The thyroid gland releases thyroid hormone, which controls many critical functions of the body. Total Thyroidectomy is usually performed to treat Grave’s disease, thyroid nodules, thyroid cancer, autoimmune (lymphocytic and Hashimoto) thyroiditis, chronic lymphocytic thyroiditis etc. In simple words, this procedure is used to surgically cut out cancerous lumps and nodules on the thyroid gland. Other indications for surgery include cosmetic (highly enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing).

Total thyroidectomy is also used to treat the thyroid gland when there is an excess secretion of thyroid hormone or hypothyroidism. Grave’s disease is one of the most common causes of this. Goitres which cannot be adequately managed with antithyroid medications (e.g., patients with toxic adenoma or toxic multinodular goitre) can also be removed with this procedure. Thyroidectomy can also be considered as primary therapy in refractory cases of amiodarone-induced hyperthyroidism.

What are the contraindications for this procedure?

There are few true contraindications to thyroidectomy. Given that thyroid cancer is generally a slowly progressive disease, the risk/benefit profile changes with age and this should be discussed with patients who are considering undergoing Total thyroidectomy. 

Anaplastic carcinoma represents a treatment dilemma due to its poor outcomes and propensity for rapid progression. Surgical resection may be offered if gross total resection can be achieved with minimal morbidity and there is no evidence of metastases. Surgical intervention may otherwise be contraindicated.

Surgical factors considered relative contraindications to outpatient surgical management include massive goitre, extensive substernal goitre, locally advanced carcinoma, challenging hemostasis, and a difficult thyroidectomy in the setting of Hashimoto's or Graves' disease.

How to prepare for a Total thyroidectomy surgery?

Once it is determined that you need surgery, the doctor does a physical neck and head check and run tests on you like a CT scan and PET scan and blood tests. He will make sure to check your vocal cords by indirect laryngoscopy to rule out any unsuspected pre-existing unilateral nerve palsy, this is particularly important if the patient has undergone any previous thyroid surgery. These tests will confirm the location and type of cancer. They will also indicate if the patient is healthy enough to pull through with the surgery. Patients should be rendered euthyroid with antithyroid drugs before surgery.

If you have hyperthyroidism, your doctor may prescribe medication — such as iodine and potassium solution — to control your thyroid function and lower the bleeding risk after surgery.

Generally, patients should not eat or drink anything except essential medications after midnight before the surgery. This is because when the anaesthetic is used, your body's reflexes are temporarily stopped. If your stomach has food and drink in it, there's a risk of vomiting or bringing up food into your throat which can cause complications during the surgery. Patients should inform their doctors in case they feel sick, nauseous or uncomfortable.

How many people are required for the surgery in the operating room?

Essential personnel for this procedure include the primary surgeon, 1 or 2 surgical assistants, a circulating/operating room nurse, a surgical technologist, an anesthesiologist and most importantly, the patient. Airway management should be discussed with the anesthesiologist prior to starting the procedure. The personnel can also depend on the kind of procedure, availability etc.

What is the procedure of a total thyroidectomy?

An uncomplicated total thyroidectomy should take less than 2 hours to perform. If you are having a less extensive operation, it will be quicker. During the surgery, your surgeon may use the NIM® Nerve Integrity Monitoring System from Medtronic to help reduce the risk of nerve injury to the nerves controlling your voice. The NIM allows the surgeon to locate the nerves that run close to your thyroid and also to test their functioning during surgery, thereby reducing the risk of damage.

What are the complications that can occur during and after a total thyroidectomy?

Thyroidectomy is a common surgical procedure that has several potential complications or sequelae including temporary or permanent change in voice, temporary or permanently low calcium, need for lifelong thyroid hormone replacement, bleeding, infection, and the remote possibility of airway obstruction due to bilateral vocal cord paralysis. Complications are uncommon when the procedure is performed by an experienced surgeon. But, like every surgery, total thyroidectomy can have several complications. The most important complications of thyroidectomy are listed as follows:

• Recurrent laryngeal nerve injury 

Injury to the recurrent laryngeal nerve has the potential to cause unilateral vocal cord paralysis. Patients with this typically complain of new-onset hoarseness, changes in vocal pitch, or noisy breathing.

• External Branch of superior laryngeal nerve injury

 Damage to the laryngeal nerve can result in loss of voice or obstruction to breathing. Laryngeal nerve damage can be caused by injury, tumours, surgery, or infection. Damage to the nerves of the larynx can cause hoarseness, difficulty in swallowing or breathing, or the loss of voice.

• Hypoparathyroidism

Hypoparathyroidism is an uncommon condition in which your body produces abnormally low levels of parathyroid hormone (PTH). PTH is key to regulating and maintaining a balance of two minerals in your body — calcium and phosphorus.

• Laryngeal oedema-airway obstruction

Laryngeal oedema is a common cause of airway obstruction after extubation in intensive care patients and is thought to arise from direct mechanical trauma to the larynx by the endotracheal tube. The oedema results in a decreased size of the laryngeal lumen, which may present as stridor or respiratory distress (or both) following extubation.

• Bleeding Haematoma

Hematoma is generally defined as a collection of blood outside of blood vessels. Most commonly, hematomas are caused by an injury to the wall of a blood vessel, promoting blood to seep out of the blood vessel into the surrounding tissues.

• Hypothyroidism

 It is a condition in which the thyroid gland doesn't produce enough thyroid hormone. Hypothyroidism's deficiency of thyroid hormones can disrupt such things as heart rate, body temperature and all aspects of metabolism.

• Hyperthyroidism

Hyperthyroidism (overactive thyroid) occurs when your thyroid gland produces too much of the hormone thyroxine. Hyperthyroidism can accelerate your body's metabolism, causing unintentional weight loss and a rapid or irregular heartbeat.

• Surgical Site infection

Surgical site infections (SSI) affected 2% of patients. The risk of infection depended mainly on the quality of pre-operative and post-operative care and on whether there was a break in sterile technique.

• Keloid scar

A Keloid scar is a raised scar after an injury has healed. A keloid is caused by an excess of a protein (collagen) in the skin during healing. Keloids are often lumpy or ridged. The scar rises after an injury or condition has healed, such as a surgical incision or acne. Keloids aren't harmful and don't need treatment. If a person finds them unattractive, a doctor can sometimes minimise the scars.

• Suture granuloma

Suture granuloma is a mass forming benign lesion that develops at the site of surgery as a foreign body reaction to non-absorbable suture material.

What risks should one lookout for?

• Haemorrhage: severe cases may cause airway compression and be life-threatening
• Hypocalcemia may become symptomatic and life-threatening if unrecognized/untreated. Up to 1/3 of patients undergoing total thyroidectomy will have at least transient hypocalcemia postoperatively. It is important to maintain a consistent protocol for calcium management after the total or completion of thyroidectomy to minimize related complications.
• Injury to the recurrent laryngeal nerve: results in hoarseness and potentially aspiration. This is most commonly temporary but may be permanent <1>
• Injury to the superior laryngeal nerve: results in a voice pitch change. Reported rates of injury range from 0% to 58%.
• Post-surgical infection: approximately 6% of cases.
• Oesophagal injury
• Tracheal injury
• Horner syndrome
• Dysphagia
• Chyle leak

What is the recovery and aftercare of the surgical procedure?

The recovery time for a total thyroidectomy is anywhere from 2-3 days, more in case of additional surgeries due to complications. The patient is usually fed via a tube in the recovery period. Ample of rest is advised as long as it is not painful. There may be a change in diet and your care team will give you thorough instructions on how to care for your incision sites and what to do in case of emergencies.

Patients are asked to take 1000 mg of calcium 4 times a day for the first week after surgery and then 500 mg of calcium twice a day for the next 2 weeks until their post-operative visit to help avoid the symptoms of low calcium levels. After the removal of thyroid, patients usually take a prescribed oral synthetic thyroid hormone, levothyroxine (Synthroid) to prevent hypothyroidism. Patients may have a gauze pressure dressing around your neck. The doctor will give instructions on when to remove it. The stitches in the incision will need to be removed in 5-7 days, or patients may have dissolvable stitches that do not require removal. If the incision has been closed with dissolvable stitches, the patient will likely have either skin glue or paper tapes (Steri-Strips) covering the incision. Some people may need to have a drain placed under the incision in the neck. This drain is usually removed the morning after surgery. After total  thyroidectomy, a few people may experience neck pain and a hoarse or weak voice. This doesn't necessarily mean there's permanent damage to the nerve that controls the vocal cords. These symptoms are often short-term and may be due to irritation from the breathing tube that's inserted into the windpipe during surgery, or be a result of nerve irritation caused by the surgery.

You'll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure or your doctor may recommend that you stay overnight in the hospital. When you go home, you can usually return to your regular activities. Wait at least 10 days to two weeks before doing anything vigorous, such as heavy lifting or strenuous sports. It takes up to a year for the scar from surgery to fade. Your doctor may recommend using sunscreen to help minimize the scar from being noticeable.

What is the clinical significance of the surgical procedure?

Thyroidectomy is an important surgical procedure with high-quality evidence for the management of benign and malignant thyroid disease. Due to the close proximity of several critical anatomic structures, safe thyroidectomy requires detailed anatomic knowledge and careful patient selection is paramount.