Thyroidectomy is the surgical removal of the thyroid gland, performed for colloid goiter, tumors, or hyperthyroidism that does not respond to iodine therapy and anti-thyroid drugs.
Description of Thyroidectomy
Surgical removal of the thyroid is necessary in some situations where a goiter becomes life-threatening or in the presence of some cancers.
Post-thyroidectomy treatment with thyroid hormone is routinely done to prevent a condition known as myxedema. The lack of circulating thyroid hormone in the body gives rise to a series of signs and symptoms which represent a severe form of hypothyroidism (underactivity of the thyroid gland). There is swelling of the face and limbs because of fluid deposited under the skin. This may particularly affect the area around the eyes, hands, and feet. The skin becomes dry and rough and there may be some hair loss. The person exhibits slowness of action and thought, and this mental dullness is accompanied by slow speech, with a voice that may become hoarse. Lethargy and weakness may be associated with slowed reflexes, a slow pulse, lowered metabolism and subnormal body temperature. Myxedema also may arise through primary disease of the thyroid.
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Reasons for Thyroid Surgery
Thyroid surgery is performed in a number of circumstances:
- as a treatment for thyroid cancer
- when an enlarged thyroid (goiter) or multiple nodules cause cosmetic, breathing or swallowing problems
- in a pregnant woman, when her hyperthyroidism is not controllable by antithyroid drugs, and requires immediate treatment
- when other forms of treatment for hyperthyroidism -- i.e,. antithyroid drugs or radioactive iodine have not been effective. (This is applicable in the U.S. Outside the U.S., surgery is sometimes performed as a hyperthyroidism treatment before or instead of radioactive iodine.)
- in children, if the practitioner or parent wishes to avoid radioactive iodine
- when the patient refuses antithyroid medications or radioactive iodine
- when a patient wants to try to get pregnant quickly after treatment.
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Types of Thyroid Surgery
There are three main types of thyroid surgery:
- Total Thyroidectomy -- Complete Removal of the Thyroid
This is the most common type of thyroid surgery, and is often used for thyroid cancer, and in particular, aggressive cancers, such as medullary or anaplastic thyroid cancer. It is also used for goiter and Graves'/hyperthyroidism treatment.
- Subtotal/Partial Thyroidectomy -- Removal of Half of the Thyroid Gland
For this operation, cancer must be small and non-aggressive -- follicular or papillary -- and contained to one side of the gland. When a subtotal or partial thyroidectomy is performed, typically, surgeons perform a bilateral subtotal thyroidectomy which leaves from 1 to 5 grams on each side/lobe of the thyroid. A Harley Dunhill procedure is also popular, in which there's a total lobectomy on one side, and a subtotal on the other, leaving 4 to 5 grams of thyroid tissue remaining.
- Thyroid Lobectomy -- Removal of Only About a Quarter of the Gland
This is less commonly used for thyroid cancer, as the cancerous cells must be small and non-aggressive.
The issue of a subtotal/partial, vs. total thyroidectomy is controversial. Some practitioners prefer to perform a partial thyroidectomy whenever possible, believing that they will leave behind enough thyroid tissue to prevent hypothyroidism. (A total thyroidectomy has nearly a 100 percent chance of causing hypothyroidism). The risk of hypothyroidism with subtotal thyroidectomy is, however, quite high, and some experts say that more than 70 percent of patients receiving a subtotal thyroidectomy will become hypothyroid. Since one of the main reasons for subtotal thyroidectomy is to prevent hypothyroidism, and that goal is achieved in only a minority of cases, experts increasingly believe that there is no added benefit to subtotal thyroidectomy, and are more routinely recommending a total thyroidectomy.
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What You Are Likely to Experience
In most cases, surgery of the thyroid is not highly complicated, and usually takes no more than two hours.
Removal of half of the thyroid takes 45 minutes to an hour, so if the entire gland is being removed, the surgery will last about an hour and a half.
Check with your surgeon about medications you are taking, and what you should/shouldn't take in the days prior to surgery.
You will most likely be asked to check into the hospital the morning of your surgery. Typically, your surgeon will ask that you refrain from eating or drinking after midnight the night before surgery.
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Outpatient or Hospital Admission
Depending on the condition of the patient, an overnight or two-night hospital stay may be planned. Outpatient thyroid surgery is becoming increasingly popular, however, and research shows that outpatient thyroid surgery is safe, effective -- and less expensive -- for most patients, and may be preferable to traditional inpatient hospital stays.
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General or Local Anesthesia
Thyroid surgery is more commonly performed with general anesthesia. Some surgeons are now using local anesthesia, plus a sedative, however, to perform thyroid surgery.
The benefits of local anesthesia are that it is associated with a shorter hospital stay, shorter actual surgery time, and less vomiting and nausea after surgery.
If you choose local anesthesia, your doctor will typically give you numbing medication for the thyroid area, plus a mild sedative to help you stay calm. You will, however, be awake during the surgery, and able to interact with your surgeon.
Not many surgeons are trained to do thyroid surgery under local anesthesia. So if you want to proceed with this option, be sure your surgeon has done a number of thyroid surgeries with local anesthesia. (Some experts suggest you look for a surgeon who has performed this procedure at least 50 times.)
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The Surgical Procedure
In the surgery, the surgeon will cut a 3- to 5-inch incision across the base of your neck in front. The skin and muscle are pulled back to expose the thyroid gland. The incision is usually made so that it falls in the fold of the skin in your neck, making it less noticeable.
Blood supply to the gland is "tied off," and the parathyroid glands are identified (so that they can be protected). The surgeon then separates the trachea from the thyroid, and removes all or part of the gland.
A newer technique, known as endoscopic thyroid surgery, involves using a small magnifying camera inserted in the neck. Carbon dioxide gas is pumped into the neck area to help make it easier to see and work on the gland. A second small incision is made, and a thin tube with a scalpel-like edge is inserted through that incision. This tube is the surgical tool that is used to remove the thyroid. Endoscopic surgery, because it involves two small scars of less than one inch, usually leaves less visible scarring, and allows a quicker return to normal activity. Sometimes, the entry point is under the arm -- known as axillary surgery.
Endoscopic surgery is not common, however, and you'll need to investigate to find a surgeon with experience doing these surgeries.
Most surgeons use dissolvable stitches, but you may want to ask your surgeon ahead of time which kind he plans to use, because the non-absorbable stitches actually tend to cause less scarring. If you have any history of allergic skin reactions to past stitches, you may also want to ask your doctor about using hypoallergenic suture material.
After the surgery, you will usually remain under observation at the hospital for at least 6 hours. If you are having outpatient surgery, you may be discharged after that point.
Before you are discharged, your incision is usually covered with a clear protective waterproof glue called colloidium. (This allows you to bathe or shower after the surgery.)
Rarely, if there is concern about bleeding or if the thyroid is very large and the surgery has left a large open space, a drain will be left in your wound to prevent fluid from accumulating. You'll need to return to the surgeon a few days later to have the drain removed.
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Development of minimally invasive thyroid surgery
Since the early 1980s, minimally invasive surgery has revolutionized the surgical management of conditions in the chest and abdomen, drastically reducing recovery from invasive procedures and expanding the range of therapeutic interventions.
Some disorders of the head and neck have traditionally required large incisions to gain access to small areas or structures. Examples of this include thyroid surgery for benign nodules, parathyroid surgery, lymph node biopsy and implantation of a vagal nerve stimulator (an anti-seizure implant similar to a pacemaker).
In these cases, disfiguring incisions are made in visible areas of the neck simply for surgical access. In response to this problem, less invasive techniques have been developed and are now in practice around the globe.
Minimally invasive surgery of the neck was first developed for management of thyroid and parathyroid disorders. Since that time, a variety of minimal-access techniques have been developed which accomplish the desired surgical goal. These techniques are currently practiced worldwide, and multiple clinical trials confirming the safety and benefit of these procedures have been performed.
Dr. Wright has been performing video-assisted procedures since 2002. He performs most thyroid and parathyroid surgeries using this technology, minimizing the length of surgical scars. Some thyroid patients are candidates for a scarless, totally endoscopic procedure, which involves the creation of no visible incision. In addition, Dr. Wright has developed a minimally invasive technique for placement of the vagal nerve stimulator which eliminates any scar on the neck.
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Video-assisted thyroidectomy
The video-assisted surgical technique markedly shortens incision length (typically around one inch vs. three inches with traditional surgery). It also reduces post-operative pain and speeds recovery time.
This technique has been performed thousands of times around the world with consistently safe results comparable to the conventional technique. It does not increase operative time and incurs no increased risk.
Originally developed in Italy, the video-assisted technique has only recently been taught in the United States. A handful of surgeons in this country have been doing this technique for a number of years, including Dr. Wright, who is one of the most experienced surgeons in the United States with this technique.
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Totally endoscopic thyroidectomy
A second, more sophisticated variation of minimally invasive thyroidectomy may be an option for some patients. Using special instrumentation and techniques, part or all of the thyroid gland can be removed through small puncture sites in the underarm area, avoiding any incision on the neck whatsoever. Much less pain and much more rapid recovery can be expected with this approach.
The surgeon operates using laparoscopic instruments and supervises the case through endoscope cameras under high magnification. In many cases, the surgeon can see better in this technique than in a conventional open procedure. Only selected patients are suitable for this operative approach, however.
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Side-by-side surgical comparison
| |
Conventional |
Video-assisted |
Totally Endoscopic |
| Incision length |
2 — 4 inches |
½ — 1 inch |
Underarm area only |
| Pain |
Can be significant |
Mild |
Minimal |
| Recovery time |
2 — 3 weeks |
1 — 2 weeks |
1 week |
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After Your Surgery
Thyroid surgery is generally considered extremely safe. There are some common short-term side effects after thyroid surgery such as pain when swallowing, and neck stiffness. Most patients also become hypothyroid after surgery and require thyroid hormone replacement therapy.
While complications are not common, a few can result from thyroid surgery. These include hypoparathyroidism and hypocalcemia, and laryngeal nerve damage. Signs can include numbness and tingling around your lips, hands, and the bottom of your feet, muscle cramps and spasms, bad headaches, anxiety, depression, hoarseness, and difficulty speaking loudly.
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