We’ll discuss our approach to thyroidectomy in general terms then address specific variations that apply to thyroidectomy for cancer, goiter, thyroid nodules, and endoscopic techniques. Click on these pages for other issues related to thyroidectomy: pre-op care, post-op care, post-op issues, risk of surgery, follow-up.
The patient is taken to the operating room and given general anesthesia. Intravenous medication is given. Once the patient is completely asleep a tube is placed in the trachea to breathe for the patient during the procedure. This tube has a device on it that allows us to monitor the vocal cords during the procedure.
An incision is made on the lower neck, horizontally, typically in a skin crease. The size of the incision varies according to the size of the thyroid, the patient’s body habitus, and the reason for surgery. Generally, it is 4 cm or less.
The operation last 1-3 hours again depending on a variety of factors that we’ll discuss later. If the patient’s family waits in the waiting room, we will keep in touch by phone regarding the progress of the operation. The wound is closed with skin glue. There are no stitches or bandages. Drains are not used.
When the operation is over Dr. Faust will discuss the operative findings with the patient’s family. If the patient has a total thyroidectomy, calcium supplements are started in the recovery room (usually 1 ultra-strength tums every 6 hours or with each meal and at bedtime). Importantly, paitients are also given presciption Vitamin D ( Calcitriol) twice daily to help them absorb their calcium supplement. Thyroid replacement therapy is started the next day.
After the operation, the patient is taken to the recovery room typically spending about an 1 and 1/2 hours there. The patient is then taken to an extened recovery area. IV fluids are continued until the patient is fully awake and taking fluids by mouth. The patient is encouraged to be out of bed. Most patients are observed 4-6 hours. Discharge is considered after this time if the patient feels well, they are taking food well, there is no significant neck swelling and the patient is comfortable with the idea of going home. If the patient lives reasonably close to the hospital and has a responsible adult to be with them the night after surgery they are allowed to go home 5-6 hours after surgery. well over 95% of our patient go home the day of their surgery. Any patient who desires to stay in the hospital over night is welcome. All patients are discharged within 23 hours of surgery.
Thyroidectomy for cancer
A total thyroidectomy is performed. If the diagnosis is papillary, medullary or hurthle cell cancer a level 6 lymph node dissection is also done. This usually takes about 2 1/2 hours. The lymph nodes that need to be removed are interspersed with the parathyroid glands on the affected side. To remove these nodes frequently one or, rarely, both of the parathyroids on the side of the cancer may have to be removed. We dissect the parathyroid gland away from the lymph nodes, cut it into small pieces and re-implant it in the muscles of the neck where it will re-grow and start working in about 6-8 weeks. If the thyroid gland is fairly normal in size we typically make about a 3-4 cm (< 2 inch) incision. With follicular cancer again a total thyroidectomy is performed, but a lymph node dissection is not done unless grossly metastatic nodes are present. The same discharge criteria apply.
Thyroidectomy for goiter
A total thyroidectomy is recommended. Partial or subtotal thyroidectomy offers no advantage to the patient. Thyroid replacement therapy is still required. In experienced hands the risks are similar. Leaving thyroid tissue behind could lead to re-growth of the goiter. While this is infrequent, it may result in re-operation, which may be attended with significant risks. The incision size depends on the size of the goiter, but it is uncommon that it is longer than 5-6 cm even with very large goiters. The operation usually takes about 2 hours. The recovery is the same as thyroidectomy for cancer. Patients are observed 5-6 hours. The same discharge criteria apply. Over 90% of patients go home the same day.
Thyroidectomy for thyroid nodules
Removal of half of the thyroid is appropriate. This called a thyroid lobectomy or hemi-thyroidectomy. If the thyroid gland is normal in size, we usually make a 2.5-3 cm incision. The operation last about an hour. Discharge the same day is routine, though the patient may stay the night if they desire. There is no concern about low calcium. Usually thyroid replacement medication is not required. However, up to 1 patient in 4-5 may ultimately require some degree of thyroid hormone support.
Endoscopic Thyroidectomy and robot assisted thyroidectomy
A variety of new operative techniques have been developed in the last 10 years in an effort to minimize the invasiveness of thyroidectomy. The effort was initially to make the incision in the neck as small (and ,ultimately, as inconspicuous as possible). Laparoscopic techniques were adapted which allowed for 2-2.5cm incisions. Ultimately, we found that modifying traditional techniques allowed for similar size incisions and outcomes and laparoscopic technique are no longer commonly used.
“Robot” assisted techniques have been developed that place the incision in the axilla ( armpit) or in the hairline in front of the ear. While these techniques have become common place with good result abroad ( Korea and other far east counties), the results in the USA have not been as favorable and very few places in America offer the operation or have extensive experience with the procedures. To be considered for a Robotic approach your BMI should be less than 25 and your thyroid nodule should be no larger than 2-3 cm. At this time it cannot be recommended for the treatment of thyroid cancer. Our group has looked into the issue in great detail. At this time, we do not offer this approach in our practice.