Thyroid Surgery & Minimally Invasive Thyroidectomy
Surgery on the thyroid gland - a thyroidectomy - involves the removal of all or part of the thyroid gland. This is now achieved with small cosmetic scars usually and just one night in hospital.
A thyroid lobectomy or hemithyroidectomy involves the removal of one half of the thyroid gland. The affected thyroid lobe and isthmus that connects it to the opposite lobe are removed along with the upward projection of the thyroid – the pyramidal lobe. This operation is performed mainly for the diagnosis of suspicious nodules, to exclude cancer, for unilateral thyroid swellings (goitres) and overactive thyroid nodules. Most patients will not require thyroid hormone (thyroxine) replacement following this procedure but patients are monitored after surgery in case it becomes necessary. Operations less than a lobectomy are outmoded and should not be performed.
A thyroid isthmusectomy is sometimes performed when just the isthmus (central part of the thyroid) requires removal.
A total thyroidectomy is a procedure where all the thyroid gland is removed. This is the operation of choice in multinodular goitres, patients with Graves’ disease where surgery has been chosen over radioiodine, and it is mandatory in all thyroid but the smallest cancers. In the case of thyroidectomies for thyroid cancer the operation may also involve removal of tissue surrounding the thyroid gland and lymph nodes that may have been involved in the cancer.
Minimally invasive thyroidectomy is the term used to describe thyroidectomies performed endoscopically, with video assistance, via a small lateral incision or even with the assistance of a robot. Only small thyroid glands can be removed in this way (a 6cm thyroid lump cannot be removed via a 2cm incision except in pieces!). International literature and recent literature from the authors suggests that at most 15% of patients are suitable for this approach. Some surgeons use the term minimally invasive thyroidectomy inappropriately to describe a conventional thyroidectomy performed through a normal small incision where no muscle is cut and no drains used. In modern specialist thyroid surgery the incisions are much smaller than before, muscle is rarely cut and drains almost never used. If the incision is more than 2.5cm, the surgeon uses no endoscope and the approach is in the central neck it is not a minimally invasive thyroidectomy!
Risks of thyroid surgery. Thyroid surgery is safe when performed by experienced and appropriately trained specialist surgeons. Complications in thyroid surgery are infrequent and less likely to occur when surgery is undertaken by specialists in a team that regularly undertake thyroid surgery. The principle permanent problems that may be encountered after thyroid surgery are voice change or hoarseness and a low calcium leading to the need to take calcium and vitamin D supplements either short term or sometimes for life. Intraoperative nerve monitoring may be adopted during surgery but does not replace the need to identify and preserve the key nerves that control the voice during surgery. Bleeding, bruising and infection are all uncommon and should occur in less than 1% of cases.
Choosing your surgeon. There is a strong link between training, practice volume and the experience of the surgeon and the best outcomes in thyroid and parathyroid surgery. Large studies from Germany the USA have demonstrated that surgeons performing less than 30 thyroidectomies per year are more likely to have complications following thyroid surgery. A study from the USA reinforces these findings suggesting that surgeons performing cumulatively more than 100 thyroidectomies and parathyroidectomies per year are most likely to achieve the benchmarks set by the world’s leading centres. We recommend that patients requiring thyroid surgery find a specialist consultant surgeon that regularly undertake thyroid surgery in high volume. Such data is now available on national websites such as that of the British Association of Endocrine & Thyroid Surgeons. Our Surgeons at LEC.