Thyroidectomy Basics

Synonyms: Thyroid resection surgery, Thyroid removal surge

Definition: Thyroidectomy is the surgical removal of all or part of the thyroid gland. A “thyroidectomy” should not be confused with a “thyroidotomy” (“thyrotomy”), which is a cutting into the thyroid, to get access for a median laryngotomy, or to perform a biopsy.

Indications:

  1. Proven neoplasm (FNAC)
  2. Suspected neoplasm
    • Age: Extreme
    • Sex: Male
    • Hard, irregular texture and fixity
    • Hoarseness of voice
    • Enlarged cervical nodes
  3. Recurrent cysts
  4. Pressure symptoms due to goiter
  5. Patient’s wish or Cosmesis

thyroidectomy types

Types of thyroidectomy:

Thyroidectomy typesResected partsIndications
Lobectomy or HemithyroidectomyIsthmus (Isthmectomy) + 1 lobe of thyroidBenign diseases of single lobe:
a. Recurrent cysts
b. Solitary toxic  or non-toxic adenoma

Minimal Papillary carcinoma (<1 cm, no local invasiveness, no lymph node metastases)

Subtotal thyroidectomyAll except about 4 grams of lobe on each sideToxic multinodular goiter (MNG)

Hashimoto’s disease

Near-total thyroidectomyAll except a rim of thyroid tissue (<1 gm or 1 cm) on one or both sides – saves parathyroid and recurrent laryngeal nerveSuspicious for malignancies

Malignancies

Total thyroidectomyAllMalignancies (Papillary carcinoma, Follicular carcinoma, Meduallry carcinoma)
Completion thyroidectomyRemnant thyroid tissue following procedures less than total or near-total thyroidectomy.Malignancy detected on biopsy
Hartley-Dunhill operationLobectomy on one side + Subtotal thyroidectomy on other sideNon-toxic Multinodular Goiter (MNG)

Note: Anaplastic carcinoma of thyroid gland is often inoperable. Isthmectomy may be done to relieve the tracheal compression.

Modalities of thyroidectomy:

  1. Conventional thyroidectomy
  2. Endoscopic thyroidectomy
  3. Robotic thyroid surgery

Steps of thyroidectomy:

1. Anesthesia: General anesthesia with Endotracheal intubation

2. Position: Supine with neck hyper-extended by placing a sand-bag under shoulder; table titled to 30° anti-trendelenburg position to reduce venous engorgement

thyroidectomy incision3. Kocher’s thyroid incision: Transverse “collar” incision, 2 finger breadths above the suprasternal notch from one sternocleidomastoid to another

4. Development of subplatysmal plane:

  • Skin flaps retracted together with platysma – upper  flap raised upto thyroid cartilage and lower flap upto sternoclavicular joint.
  • Investing layer of deep cervical fascia is opened longitudinally between strap muscles and between anterior jugular veins.

5. Retraction of strap muscles: Away from thyroid

6. Exposure of thyroid gland: through vertical division of pretracheal fascia

7. Ligation of middle thyroid vein: 1st vein to be ligated

8. Mobilization of thyroid and ligation of vessels in series: Superior followed by inferior

Note: Parathyroids must be identified and Recurrent laryngeal nerve should be identified and saved in Beahr’s or Riddle’s triangle formed by Common carotid artery, Inferior thyroid artery and tracheo-esophageal groove.

9. Division of Berry’s ligament: Separation of isthmus and thyroid lobe from trachea

Thyroidectomy procedure

10. Removal of thyroid: Based on the type of thyroidectomy – the procedure may be repeated on the other side as well

11. Wound closure:

  • Reapproximate strap muscles and platysma
  • Skin closure with subcuticular stitch
  • Dressing

Complications of thyroidectomy:

Intra-operative:

  1. Anesthetic complications
  2. Bleeding
  3. Thyrotoxic storm (in cases of toxic glands)
  4. Recurrent Laryngeal Nerve (RLN) injury
  5. Injury to other surrounding structures

Early:

  1. Respiratory obstruction:
    • Hematoma
    • Laryngeal edema
    • Recurrent laryngeal nerve injury
  2. Thyroid strom
  3. Hypocalcemia
  4. Wound infection

Late:

  1. Hypothyroidism
  2. Hypoparathyroidism
  3. Keloids
  4. Stitch granuloma

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