Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

Thyroid surgery involves a variety of operations including:

  • Total thyroidectomy.
  • Hemithyroidectomy (excision of one thyroid love and the isthmus).
  • Isthmusectomy (resection of the isthmus only).
  • Subtotal thyroidectomy (seldom practiced due to high recurrence/reoperation rate).

Indications for Surgery

  • Goitre / nodule with local compressive symptoms.
  • Graves’ thyrotoxicosis refractory/unsuitable to medical treatment.
  • Thyroid cancer.
  • Diagnostic procedure for a cytologically indeterminate lesion.
  • Improving cosmesis in a large goiter.

Preoperative Work-up

  • Assessment of thyroid function – thyroidectomy is contraindicated in uncontrolled thyrotoxicosis.
  • Cytological assessment of a solitary nodule (fine needle aspiration cytology).
  • Imaging – assessment of functionality with I123 scintigraphy, ultrasound and cross-sectional imaging with CT (for assessment of retrosternal/mediastinal extension and airway compromise).
  • Preoperative vocal cord check (mandatory).
Operative techniques

The patient is prepared supine with neck extension.  A transverse (Kocher’s) skin crease incision is made 1 – 2cm above the notch you feel at the bottom of your neck.

Additional procedures that may become necessary
  • Drain insertion
  • Parathyroid autotransplantation
  • Diagnostic: Obtain a histopathological diagnosis of underlying thyroid pathology.
  • Therapeutic: Treatment of symptomatic thyroid pathology, remove tumour of thyroid gland whether primary or secondary, restore hormonal equilibrium with surgery and postoperative thyroid hormone replacement as required.
Alternative procedures/conservative measures
  • Selective cervical lymphadenectomy (levels III-IV) is recommended for locoregional control in clinically apparent lymph node metastases.  In medullary thyroid cancer bilateral cervical lymphadenectomy is recommended.  
  • The role of prophylactic central compartment (level VI) lymphadenectomy in management of papillary thyroid cancer is contentious and currently recommended in patients with clinically uninvolved central compartment nodes and more advanced tumours (stages T3 and T4).
  • Radio-iodine thyroid ablation.
  • Chemical (drug induced) thyroid suppression.
Serious/frequently occurring risks
  • Early postoperative haemorrhage requiring re-intervention (maximal risk in the first 6 – 12h, overall rate 0.9%).
  • Voice change (overall rate 4.9%).
  • Injury to the RLN (overall 2.5%).
  • Hypocalcaemia (may be temporary or permanent; overall rate 11%, long-term 7%).
  • Mortality (0.24%).
  • Risk of RLN palsy and postoperative hypocalcaemia is greater following lateral cervical lymphadenectomy.
  • Complication rates are higher in re-operative cases.  Individual surgeon complication rates vary and may depend on caseload.
Type of anaesthesia/sedation
  • General anaesthesia.
Follow-up or need for further procedure
  • Check for calcium and PTH homeostasis following a total thyroidectomy.
  • Thyroid function test (thyroxine replacement is titrated against clinical and biochemical response).
  • Post-operative vocal cord check (recommended).

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