Tutorial: Thyroid Surgery

Tutorial: Thyroid Surgery

 

Endocrine Service

Endocrine Surgery Tutorials

Adrenal Mass

Hypercalcemia (High Calcium Levels) and Parathyroid Disease

Neck (Thyroid) Mass

Thyroid Cancer

Surgical Approach to the Adrenal

Surgical Approach for Hyperparathyroidism

Surgical Approach for Thyroid Mass

 

The patient who comes to thyroidectomy or neck exploration for a thyroid mass should have a preoperative evaluation and discussion with an endocrine surgeon who specializes in these procedures. The patient can expect to come to the hospital on the day of surgery. The operations typically last approximately two to three hours. Most are performed with general anesthetic, but selected patients may be appropriate for local anesthetic and sedation. Depending on multiple factors about the patient and the procedure, some patients may be appropriate to be discharged from the hospital on the same day as surgery, but many will need to spend the night.

The risks of surgery should be fully discussed and understood by the patient prior to surgery. The primary risk of thyroid surgery, particularly total thyroidectomy, is recurrent laryngeal nerve damage on one or both sides. The recurrent laryngeal nerves control the muscles that move the vocal cords and damage to one or both recurrent laryngeal nerves can result in severe hoarseness. An experienced endocrine surgeon knows the location of the recurrent laryngeal nerve and should be able to keep the likelihood of such injury very low. In patients having a total thyroidectomy, voice weakness can occur because of traction on the thyroid and tension on the external branch of the superior laryngeal nerve. This can result in a bothersome voice weakness, which occurs at the end of the day or with long conversations. It may take several weeks to resolve.

A second complication, particularly for patients having a total thyroidectomy, is hypoparathyroidism. An experienced endocrine surgeon knows where the parathyroid glands are and will check for viability of these glands upon completion of the procedure. The parathyroid glands share blood supply with the thyroid and, in most circumstances, can be preserved. The glands may also be removed, sliced into small pieces, and placed in a muscle bed in the neck (parathyroid autotransplantation). If this is done appropriately, a 95% success rate should occur. If the parathyroids do not work postoperatively, a state of surgically induced hypoparathyroidism (lack of function of the parathyroid glands) occurs. If this should occur and there is no source of parathyroid hormone, the patient will experience a significantly low calcium level requiring calcium supplementation until the parathyroid glands recover, or possible for the rest of his or her life if the damage to the parathyroid glands is permanent.

A third complication is bleeding into the area of the surgery after the patient has left the operating room. Even a small amount of bleeding in this location can be dangerous as the resulting “hematoma” can lead to difficulty breathing. This is rare, but may require urgent reoperation when it does occur. This is one of the main reasons that it is important to watch patients in the hospital for at least the early part of the recovery phase when these hematomas are most likely to happen.

A final consideration is that the endocrine surgeon may not be able to determine exactly whether or not a thyroid nodule is cancerous. This is a particular problem with "follicular" lesions. Preoperative fine needle aspiration is unable to tell the difference between a benign and cancerous follicular lesion and intraoperative frozen section will not be of any greater benefit. Therefore, the patient with follicular cells diagnosed preoperatively by fine needle aspiration must understand that the endocrine surgeon must use his own best judgement as to the nature of the diagnosis and the extent of the surgery. If a lesion is removed with less than a total thyroid resection and a the final pathology evaluation later confirms that this represents a follicular cancer, a second surgery requiring completion thyroidectomy may be required. Such surgeries can be difficult and require that the surgeon have experience in reoperative neck surgery.

If you desire further information regarding thyroid surgery, we recommend reviewing the “Thyroid Gland” portion of the American Association of Endocrine Surgeons (AAES) Patient Education Site. Patients may find that many websites offer confusing or conflicting information regarding thyroid disorders.  The AAES site offers reliable information.