Procedures
Thyroidectomy
We discuss our approach to thyroidectomy in general terms for different disorders involving the thyroid gland. Click on the according menu to the right for other topics related to thyroidectomy.
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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.
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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.
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A goiter is an enlarged, abnormal thyroid gland. A total thyroidectomy is typically recommended to remove all of the pathology and prevent needing future surgery. If all of the pathology is confined to one side, then that part can be removed with preservation of the normal side. However, if pathology (nodules, abnormal tissue) is present on both sides, typically a partial or subtotal thyroidectomy offers no real advantage, but does leave the patient open to the possibility of developing a recurrent goiter, and then requiring reoperation in the future.
Thyroid hormone replacement therapy may be 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.
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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.
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A variety of new operative techniques have been developed in the last 10-15 years in an effort to minimize the cosmetic result related to thyroid surgery. The effort was initially to make the incision in the neck as small as possible. Laparoscopic techniques were employed to view through a smaller incision in the front of the neck, which allowed for incision length to get smaller, at the expense of operating room time and equipment expense. Ultimately, we found that modifying traditional techniques allowed for similar size incisions (about 2.5 - 3 cm for parathyroidectomy and 3.5 - 5 cm for thyroidectomy) with excellent cosmetic outcomes. The laparoscopic techniques for thyroid and parathyroid surgery is 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 with good results abroad (Korea and other Asian countries), the adoption in the US has been less vigorous due to many factors, including patient factors, cost to patient, cost to healthcare system, postoperative recovery, robotic console availability, surgeon volumes, etc. Our group has looked into the technique in great detail. At this time, we do not offer this approach in our practice due to what we believe are limitations in the approach and barriers to the excellent outcomes and level of care that we expect for any technique adopted for our patients.
Parathyroidectomy
Our approach to Parathyroidectomy in general terms to address specific surgical procedures related to the different disorders affecting the parathyroid glands.
Cervical Lymphadenectomy
Covers the Cervical lymphadenectomy or lymph node dissection procedures
Adrenalectomy
Laparoscopic adrenalectomy is the standard of care for most adrenal tumors. It hurts less and the time in the hospital and overall recovery is dramatically less than with traditional opened techniques. Laparoscopic adrenalectomy is appropriate for benign adrenal tumors and small malignant tumors. Laparoscopic adrenalectomy can be performed through the transabdominal (transperitoneal) or posterior retroperitoneal approaches.
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Laparoscopic adrenalectomy is the standard of care for most adrenal tumors. It hurts less and the time in the hospital and overall recovery is dramatically less than with traditional opened techniques. Laparoscopic adrenalectomy is appropriate for benign adrenal tumors and small malignant tumors. Laparoscopic adrenalectomy can be performed through the transabdominal (transperitoneal) or posterior retroperitoneal approaches.
For a transabdominal laparoscopic adrenalectomy, the patient is brought to the operating room and a general anesthetic is given. The patient is then placed on their side – left side up for left adrenal tumors and right side up for a right adrenalectomy. Generally, four ports are placed along the rib margin about 3 inches apart for the right, three or four ports on the left. On the left, the spleen and pancreas are elevated away from the adrenal gland, the vein coming from the gland is tied off and the gland is separated from the surrounding tissues and kidney. The tumor is placed in a sterile bag and then removed. In large tumors the exit incision may have to be slightly enlarged to remove the specimen. On the right, the liver is elevated away and again the large vein leaving the gland is ligated and the tumor is removed. The procedure last 1 1/2 to 2 1/2 hours depending on the size of the tumor and the size of the patient. The patient spends about an hour in the recovery room and then is admitted to a regular floor bed for observation over night. If the patient feels well the next day they are discharged. Pheochromocytomas are handled slightly differently. After resection of a pheochromocytoma, the cardiovascular stimulation caused by the tumor resolves. However, the patients may still have some vascular instability, usually low blood pressure. For this reason, patients with pheochromocytomas that have been removed are observed in the intensive care unit over night. Once the patient is stable and feels well they are discharged, usually on post-op day 2 or 3.
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For posterior retroperitoneal laparoscopic adrenalectomy, the patient will be placed in the prone (face down) position prior to surgery. Typically, three laparoscopic ports are placed below the ribs on either the right or the left side, depending on which side the tumor is located. The tumor is identified and separated from its blood vessels while preserving the important structures surrounding it. On the right side, this would include the right kidney, liver, and inferior vena cava. On the left side, this would include the left kidney and spleen. This approach has the benefit of avoiding entry into the abdominal cavity. This can avoid encountering adhesions formed from prior abdominal surgeries.
The incisions are then closed and the patient awakened and admitted for recovery. Pain from this operation is minimal and patients are often times ready to be discharged the following day. However, discharge from the hospital may depend on other tests for normalization of biochemical function if the mass was secreting too much hormone.
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Patients with large tumor (> 10cm) derive less benefit from laparoscopic techniques and the risk of malignancy goes up substantially. The most important issues become adequate negative margins and safe removal of the tumor. In this situation standard open surgery is appropriate. With open surgery most patients are in the hospital 3-4 days and return to full activity is 4-6 weeks.
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Other procedures
This section covers additional procedures we perform.
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This technology involves using a small diameter needle ( a little bigger than the sized used to draw blood) to apply heat energy into a benign thyroid nodule. High frequency waves are generated to the tip of the needle heating it and this cauterizes the nodule from the inside out. The nodule is then broken down by the body over a few months. Most nodules shrink 50% to 75% over three to six months. By one year a nodule may reduce in size by up to 90%. This technology is not compatible with pacemakers or implanted defibrilators.
The procedure is specifically indicated for large benign nodules which may be causing symptoms. It works best with solid nodules. Nodules that are close to critical structures such as the nerve to the vocal cord or large blood vessels may not be amenable to this technique for safety reasons.
RFA is done in the office with local anesthesia. It takes 30 to 45 minutes in most situations. The patient may experience mild pressure or heat discomfort which typically is very brief. A “popping” sound is frequently perceived. After the procedure ice is applied and most patients are observed for 15 to 30 minutes. Most patients experience very little post-procedure discomfort. An ice pack, Tylenol or Advil is used in these situations. We follow up with an ultrasound at one month, three months, six month and one year. Larger nodules (greater than four cm) might require another procedure.
The risks associated with the procedure are very small. The risks include issues with local pain, bleeding, infection, and voice problems and breathing problems. The risk profile is similar to the risks associated with thyroid lobectomy.
The primary advantage of RFA is no surgical scar, less post procedural discomfort, and minimal recovery as compared to surgery. It also allows for preservation of the thyroid function which may be an issue in up tp 20% of patients undergoing surgery for a benign nodule.
The cost of the procedure is much less than the total cost of surgery. However, because the procedure is relatively new in the US, the participation of insurance companies is variable. We will work these issues out with your insurance company before the procedure so that you will know your financial responsibility prior to the RFA procedure.
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FNA is a common procedure done in the office with local anesthesia. It is the best way to diagnose thyroid cancer. Its accuracy approaches 95%. A small amount of local anesthetic is injected into the skin and the underlying tissues. This is the most uncomfortable part of the procedure. A small needle is inserted into the nodule usually under ultrasound guidance. There is a mild aching sensation when the biopsy is taken. The actual procedure takes only a few seconds. Patients tolerate it well. Most patients comment that the worse part is the anxiety about the procedure not the discomfort. Some bruising may occur but significant issues with bleeding are rare. Any mild residual discomfort is easily handled with ice and tylenol. Narcotic pain medication is not required. Be sure to tell us if you are on blood thinners. Aspirin, plavix or aggrenox are okay but coumadin should be stopped a few days before the biopsy.
The pathologist commonly assigns the results of a needle biopsy to one of 6 categories:
Category 1: non-diagnostic
Category 2: benign
Category 3: indeterminate ( less likely to be malignant: maybe a 25-30% risk)
Category 4: indeterminate (somewhat more likely to be malignant; maybe a 40-50% risk)
Category 5: suspicious for malignancy ( 85-90% risk)
Category 6: diagnostic of malignancy ( >99% risk)
Once we do an FNA, we have the patient come back in a few days to discuss the findings. There are four possible outcomes:
The biopsy is positive. It is concerning for, or diagnostic of cancer ( category 6)
The biopsy is negative. It shows benign changes ( category 2).
The biopsy is indeterminate. (categories 3 and 4)
The biopsy is non-diagnostic. The pathologist cannot draw a conclusion ( category 1)
If the FNA is diagnostic of cancer it will almost always be papillary cancer, the most common type of thyroid cancer. If a definitive diagnosis for papillary cancer is seen on FNA, then we can proceed with definitive surgery. Total thyroidectomy with central lymph-node removal is our usual approach.
If the FNA is definitively benign then observation may be considered. Follow-up ultrasound is require (typically in 6 months) to ensure that the nodule is stable as there is a small single digit percentage risk of false negative results with any FNA
An “indeterminate” result (commonly reported as “follicular neoplasm”) is a more complicated problem and is more completely discussed on the next page. We need to discuss follicular neoplasms in more detail. A common “indeterminate” result on FNA is “follicular neoplasm”. “Follicular” refers to the appearance of the specimen under the microscope. “Neoplasm” is a medical term for a growth or tumor. It does not indicate if it is cancer or not. If a follicular neoplasm is benign it is called a follicular adenoma. If a follicular neoplasm is cancer it is called a follicular carcinoma.
The nature of a follicular neoplasm can only be determined by detailed examination of the tumor by a pathologist after the tumor has been completely removed. If invasion of tumor cells is seen into the lining of the tumor or into blood vessels in the tumor, then the pathologist calls it follicular cancer. This is impossible to see on a needle biopsy and very difficult to see on the preliminary pathological exam at the time of surgery (frozen section). When we get a diagnosis of follicular or hurthle cell neoplasm on FNA a complicated decision tree presents itself. A variety of issues may keep the pathologist from drawing a conclusion about the nature of a nodule. Sampling errors, processing errors or interpretive errors may occur. Sometimes conclusions are impossible. Each case is individualized. Sometimes repeat biopsy is appropriate. Sometimes surgery is recommended. Sometimes, observation and repeat ultrasound in a few months is the best approach. Which of these approaches is the most appropriate depends on the individual circumstances of the patient and the potential causes of the indeterminate biopsy. Each case is individualized. A second pathologic opinion or thyroid lobectomy for diagnosis may be recommended. If surgery is recommended we usually have to wait for the final report from the pathologist. This may take several days. If a benign adenoma is found then nothing else is required. If cancer is found the we have to go back to surgery to remove the remaining thyroid lobe. This is called a “completion thyroidectomy”
If the FNA is negative then, generally, observation is appropriate. Surgery may still be considered if the lesion is very large (greater than 4 cm) or causing local symptoms or if the patient is very anxious about the nodule.
A subsequent page shows a slide show of a FNA procedure.
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Laryngoscopy is a procedure performed in the office to evaluate the function of the vocal cords and adequacy of the airway in anticipation of thyroid or parathyroid surgery.
One risk of thyroid and parathyroid surgery is injury to nerves that control the vocal cords (recurrent laryngeal nerve). A small percentage of patients may have pre-existing vocal cord problems. This could due to prior surgery (thyroid, parathyroid, anterior cervical spine), neurologic issues, or other pre-existing conditions. Significant pre-existing vocal cord or airway problems may be present without the patients knowledge. Establishing that the vocal cords are functioning normally before surgery is important to ensure maximum safety and optimal outcomes for the patient.
We perform screening laryngoscopy to assess global vocal cord function and airway adequacy. If our exam suggests an abnormality we may have to alter our surgical approach or obtain a more detailed exam by a voice specialist. If necessary, we will arrange this referral.
Understandably, the procedure creates some anxiety for our patients. You will be administered a numbing agent and instructed on what to expect and what to do during the procedure. The entire scope procedure usually less than a minute to evaluate the integrity of the vocal cords.