Overview of Thyroidectomy
A thyroidectomy is a surgical procedure that involves removal of part or all of your thyroid gland, which is located in your neck. There are two main types of a thyroidectomy: a total thyroidectomy, which is the complete removal of the thyroid gland, and a partial thyroidectomy which is when only a part of the thyroid is removed. This procedure is used to treat multiple conditions, including non-cancerous issues like an enlarged thyroid, or goiters, overactive thyroid nodules, and inflammation of the thyroid. It is also used for cancerous conditions such as differentiated thyroid cancer and a very aggressive form of thyroid cancer known as anaplastic thyroid cancer.
Before having a thyroidectomy, it is important to check your thyroid’s functioning to look for any low (hypothyroidism) or high (hyperthyroidism) thyroid hormone levels which may affect the plan for the surgery. Usually, a thyroid ultrasound is done first which helps to view the structure of the thyroid gland and identify any abnormal areas. If the ultrasound shows anything concerning, like potential lumps or growths, a fine-needle aspiration biopsy might be needed. This will help your doctor understand the nature of these abnormal parts and if they could be cancerous. The decision to proceed with a total or partial thyroidectomy would then depend on factors like the size and location of the abnormality and the nature of the cells (histopathology) found by the biopsy.
Like all surgeries, a thyroidectomy can also have complications. These include severe bleeding that might need another surgery to control, damage to the recurrent laryngeal nerve (a nerve that controls the vocal cords), which can cause voice changes, or accidental damage to the parathyroid glands (glands near the thyroid that control calcium levels in the body) that could lead to low calcium levels and symptoms related to that. Once the surgery is done, it is crucial to recheck the function of any remaining thyroid tissue, as you may need to take thyroxine (thyroid hormone) tablets if a lot of the thyroid gland has been removed. This all-around approach to managing your thyroid removal surgery is very important to ensure the best results and maintain your long-term health and wellbeing.
Anatomy and Physiology of Thyroidectomy
The thyroid gland, located in your neck, is shaped like a butterfly and is connected by a small bridge called the isthmus. The thyroid is found behind muscles in your neck, wrapping around your windpipe and around some cartilage in your voice box. It’s held in place by connective tissue that connects each side of the thyroid to your windpipe. Other structures in the neck like the parathyroid glands, parts of the food pipe, the voice box, and windpipe all share a compartment in the neck close to this thyroid gland.
Normally, your thyroid gland should have equal sides and a visible isthmus in the middle. Some people might have an extra bit stretching upward from the isthmus. This is a leftover from when we were developing as embryos and can range in size. The back of each side of the gland may also have a smaller extension. The thyroid gland can look different from person to person, but on average, it weighs around 15 to 25 grams in adults.
Your thyroid gland gets a lot of blood from two main sources, the superior and inferior thyroid arteries. The first, the superior thyroid artery comes from an artery in your neck, the external carotid artery, and takes care of the top part of the gland. The second, the inferior thyroid artery, branches from another artery in your neck and supplies the back of each side of your thyroid. Sometimes, a few people may have an additional artery, the thyroid ima artery, that helps the isthmus or the lower part of your thyroid.
The thyroid gland drains blood through similar named veins, the superior and middle thyroid veins go to the internal jugular vein, and the inferior thyroid vein heads to the vein in front of your windpipe. These thyroid veins can look different between people.
The lymph system of the thyroid gland is complex and can flow in many directions. This means that the thyroid can drain to many nearby lymph nodes, crucial for if you develop thyroid cancer as it can determine the way it might spread and how a surgery would be done.
The thyroid gland is found close to nerves that are important for voice and swallowing. Two sets of nerves, the superior and recurrent laryngeal nerves are branches of the vagus nerve and are situated close to the gland and play an important role in the surgery. The recurrent laryngeal nerve is very important to avoid in surgery as damage could lead to voice changes or breathing issues. The superior laryngeal nerve splits into two and one of them, the external branch, is responsible for voice pitch control. Any damage to this could lead to voice fatigue and difficulty in maintaining a high-pitched voice.
Finally, nerves from both the sympathetic and parasympathetic nervous systems are found in the thyroid gland. These nerves typically control the diameter of your blood vessels, potentially affecting the release of hormones in response to what your body needs. If you undergo thyroid surgery, these nerves need to be preserved as they are important structures. They do not directly control the secretion of thyroid hormones, but can affect the local blood flow.The nerves and parathyroid glands can complicate surgery, and care is needed to avoid harming them years.
In summary, the thyroid gland’s location and its relationships with surrounding structures pose unique challenges during surgery. The close proximity to important nerve and parathyroid structures requires a careful surgical technique to avoid complications.
Why do People Need Thyroidectomy
Surgery to remove your thyroid (thyroidectomy) is often needed for several reasons. These reasons could be related to non-cancerous and cancerous conditions. Common reasons for a thyroidectomy include growths on the thyroid gland (thyroid nodules and goiters), thyroid cancers, and overactive thyroid conditions (hyperthyroidism).
The most common reason for removing your thyroid is due to nodules, or growths on the gland. Doctors often use a method called the Thyroid Imaging Reporting and Data System to tell if these nodules are a cause for concern. If they are, a small piece of the nodule might be removed with a needle and looked at under a microscope. Depending on the results, surgery might be the next step. Bethesda 5 and 6 (meaning there is a high chance of or confirmed cancer in the nodule) usually require surgery. Bethesda 3 and 4, which are more uncertain, might also need surgery depending on further tests.
Another reason you might need surgery is if your thyroid gland is enlarged and causing problems like trouble swallowing, breathing problems, a chronic cough, feelings of pressure, or pressing on other body parts. This is often referred to as a goiter.
If tests show that a nodule on your thyroid is a certain type of cancer, surgery may be necessary. Papillary thyroid cancers larger than 1 cm, or those with high-risk features, should undergo surgery. Similarly, follicular thyroid cancers need surgery, but often, this type of cancer can only be confirmed after a part of the thyroid gland has been removed and examined. More aggressive types of thyroid cancer such as undifferentiated tumors, oncocytic, medullary, and anaplastic thyroid cancers, all require complete removal of the thyroid. Sometimes, even more extensive surgery might be needed based on the specifics of your situation.
An overactive thyroid (hyperthyroidism) that can’t be controlled with medication is another reason to consider surgery. This includes conditions like autoimmune thyroiditis, toxic multinodular goiter, or toxic adenomas.
Though it’s less common, the thyroid might need to be removed if there is a thyroid lymphoma, melanoma, or if another type of cancer has spread to the thyroid gland.
How much of the thyroid is removed (all or part of it) depends on your specific situation. Usually, smaller, lower-risk tumors can be effectively treated with removing just a part (a lobectomy) of the thyroid. More aggressive tumors, hyperthyroidism, or goiters usually require that all of the thyroid be removed (total thyroidectomy). Sometimes, if the results from removing a part of the thyroid show it’s necessary, the rest of the thyroid might need to be removed in a subsequent surgery (completion thyroidectomy).
When a Person Should Avoid Thyroidectomy
Sometimes, a person’s health issues might prevent them from undergoing a thyroidectomy, a surgery that is often necessary to treat thyroid cancer. It’s crucial to carefully assess the patient’s overall health before deciding on surgery. While there aren’t many absolute reasons not to have this surgery, there are cases where it could potentially be too risky. For example, if someone has severe blood clotting issues that cannot be corrected (uncorrectable coagulopathies) or uncontrolled medical conditions such as heart failure or severe chronic obstructive pulmonary disease (a type of lung disease). These conditions could make general anesthesia, which puts you to sleep during surgery, too dangerous.
In patients with thyroid cancer, the cancer usually grows slowly. This allows doctors to weigh the benefits and risks of surgery, particularly in older patients who might have other health conditions that could influence decisions about treatment.
A specific type of thyroid cancer, called anaplastic thyroid carcinoma, progresses rapidly and often has a poor prognosis. Surgery might be an option if the entire cancer can be removed without causing much harm and if the cancer hasn’t spread. However, the surgery is generally risky and may not provide much benefit, making it a less common choice.
There are also several factors that can make a thyroidectomy more complex. These factors include large or deeply located lumps in the thyroid (substernal goiters), advanced cancer, difficulties in stopping bleeding (hemostasis), and conditions like Hashimoto or Graves disease that can make the thyroid tissue more fragile and blood-rich. Doctors need to carefully plan for the operation and discuss with the patient whether the benefits of the surgery outweigh the potential risks. This is particularly important for complex cases where other treatment options might be considered.
Equipment used for Thyroidectomy
When performing a thyroidectomy, which is a surgical procedure to remove all or part of the thyroid gland, the surgeon needs a standard set of tools specifically designed for head and neck surgeries. Having a bright, high-quality lighting system is very important because it allows the surgeon to clearly see what they’re doing.
Depending on the hospital facilities, the surgeon might also have access to special equipment that can improve the results of the operation. For example, energy devices such as harmonic scalpels or bipolar diathermy devices are very useful. These devices help to control bleeding, speed up the surgery process, and aid in a quicker recovery and discharge after surgery.
In recent years, many surgeons have started using equipment that monitors the recurrent laryngeal nerve during the operation. The recurrent laryngeal nerve is a nerve in the neck which influences speech and swallowing. If this nerve is accidentally damaged during surgery, it can cause problems with the patient’s voice and swallowing. The monitoring equipment provides real-time feedback to the surgeon, which helps them to identify and protect this nerve, significantly reducing the chances of problems after surgery.
Who is needed to perform Thyroidectomy?
A thyroidectomy is a type of surgery where a part or all of the thyroid gland is removed. This procedure is carried out by a specialist doctor called a primary surgeon. This doctor has undergone special training to perform surgeries like this.
The primary surgeon is often supported by a surgical assistant. This is another medical professional who can help during the surgery, but their presence isn’t always necessary. The next important person in the operating room is the surgical technician or nurse. They have important tasks such as handing the primary surgeon their tools and ensuring all equipment is ready and working correctly.
There’s also a circulating nurse who ensures the operation goes smoothly. They might help by checking the patient’s vital signs or preparing the patient before the surgery. An essential part of the team who you won’t see because you’ll be asleep is the anesthesia personnel. They are responsible for ensuring you remain unconscious and pain-free during the surgery.
The whole team works together to ensure that your surgery is safe and effective, helping you to recover as quickly as possible.
Preparing for Thyroidectomy
Before having a surgery to remove the thyroid (a gland in the neck that produces hormones), doctors start with preoperative care to decrease the risk of complications. This involves making sure patients have balanced levels of thyroid hormones. If a patient’s thyroid is overactive (hyperthyroid), medications such as methimazole or propylthiouracil may be prescribed to stabilize these hormone levels. To help control any symptoms and heart rate issues, a medication called propranolol might be used. Close monitoring is needed with these patients, as hyperthyroidism can lead to severe hormonal imbalances or a critical condition called thyroid storm during or after surgery.
Some doctors also give an iodine solution like Lugol’s solution or potassium iodide to prepare the thyroid. Iodine helps to control the thyroid’s production and release of hormones. It could help to decrease the blood supply to the thyroid gland and could potentially reduce any blood loss during surgery. Although more research is needed, some doctors use iodine before surgery to help prevent a thyroid storm and excessive bleeding. Calcium and calcitriol may also be given before surgery to lower the risk of a common side-effect of thyroid surgery, hypoparathyroidism (low levels of parathyroid hormone), which affects calcium levels.
It is important to assess the patient’s voice before surgery since there’s a risk of damaging the recurrent laryngeal nerve (a nerve closely tied to the thyroid which controls the voice box). Damage could result in voice changes or difficulty speaking. A flexible fiber-optic laryngoscopy (a test using a flexible tube with a camera) can evaluate the function and integrity of the voice box, if needed. This helps to plan the surgery and lower risks, overall enhancing the surgical outcome.
Patient positioning is important to enhance the surgical procedure. The patient lies on their back with their neck extended, generally with a device under their shoulder to help expose the surgical area. In elderly patients with neck mobility issues, care is taken not to strain their neck. Body elevation or a special beach chair position may be used to improve blood flow. Key anatomical landmarks, such as the sternal notch (an indentation at the base of the neck), thyroid, and cricoid cartilages (rings of cartilage around the windpipe) are identified.
If the doctor decides to monitor the nerves during surgery, the patient is put to sleep under general anesthesia and a special tube is used to help the doctor check on the nerve function during surgery. This helps the doctors take care of these nerves and reduces the risk of nerve damage. Previous studies show that keeping track of nerves during surgery is helpful and lessens the risk of damage to the recurrent laryngeal nerve.
The surgical area is then cleaned and covered in a sterile way, preparing for the thyroid removal surgery.
How is Thyroidectomy performed
A total thyroidectomy is a surgery to remove all of your thyroid. Your thyroid is a gland located in your neck that helps your body use energy, stay warm, and keep the brain, heart, and other organs working as they should. Here’s a simple breakdown of the stages of this procedure:
Incision: The surgeon begins the procedure by making a horizontal cut (or incision) about an inch above the notch in your collarbone. This is adjusted based on the size of your thyroid and how much needs to be removed. Making the cut in a natural skin fold helps reduce visible scarring. A fluid that decreases bleeding is often injected before the cut.
Raising flaps under the skin: The surgeon then lifts up the skin flaps carefully. This helps expose the surgical area more clearly. It’s necessary to avoid damaging the veins that run in the neck during this part. If a vein is injured, it is tied off to stop any bleeding.
Exposing the thyroid gland: The muscles overlying the thyroid gland are moved aside so the thyroid can be clearly seen. Keeping to a specific path helps to avoid injury to surrounding blood vessels. Depending on the situation, the surgeon may start the operation on the side with confirmed cancer or, if benign, on the bigger side. The gland is then carefully separated from the tissue around it.
Superior pole dissection: The top ends of the thyroid lobes are then carefully detached. This requires careful surgical precision to avoid injuring small glands called the parathyroid glands that are behind the thyroid.
Identifying the recurrent laryngeal nerve: This nerve controls the vocal cords, so it is important that the surgeon identifies it to avoid causing voice problems. It generally runs behind the thyroid and along the windpipe. If it is difficult to find, the nerve can be located where it enters the windpipe.
Identifying the parathyroid glands: It’s important to identify the parathyroid glands to avoid damaging them and causing problems with blood calcium levels. They are small glands found at four places near the thyroid.
Inferior pole dissection: Finally, the lower ends of the thyroid lobes are detached. The surgeon must carefully cut the blood vessels that feed the gland without injuring the nearby laryngeal nerve.
In all these steps, the most important thing for the surgeon is to maintain clear visibility and avoid damage to the surrounding structures.
Possible Complications of Thyroidectomy
Thyroid surgery is usually safe, but it can sometimes cause complications:
Hemorrhage or heavy bleeding: The area where your thyroid used to be has many blood vessels, and after surgery, heavy bleeding can occur. Although this is rare, it can be dangerous and potentially affect your airway, making it difficult to breathe. Patients with larger or more vascular thyroid glands are more at risk. Rapid bleeding may result in the formation of a blood clot, known as a hematoma, which might need urgent attention to control bleeding under anesthesia. In severe cases, when heavy bleeding blocks the airway, the surgeon might need to open up the wound immediately or perform an emergency procedure to secure the airway.
Hypoparathyroidism or low parathyroid hormone levels: A third of patients who have their entire thyroid gland removed may temporarily suffer from low calcium levels due to the parathyroid glands (that regulate calcium levels) being temporarily affected. Doctors control calcium levels carefully after surgery to avoid complications. Most patients recover within a few weeks, but 1% to 2% of patients may have permanent hypoparathyroidism, requiring life-long calcium and vitamin D supplements. Severe cases of low calcium levels might need treatment with intravenous calcium.
Injury to the recurrent laryngeal nerve: Using intraoperative monitoring (checking during surgery) helps avoid damage to these nerves. If these nerves get injured, the symptoms can be immediately or later noticed, like a hoarse voice, swallowing problems, and a weak cough. Most such injuries are temporary due to stretching or bruising, but if the symptoms persist, doctors might need to check vocal cord function. Permanent injuries might require further treatment to improve voice quality.
Superior laryngeal nerve injury: Surgery near the upper part of the thyroid gland can potentially damage nerves that control a muscle involved in voice production. Identified by subtle voice pitch changes, these injuries are often unnoticed. Due to this, reported rates of such an injury vary.
Postoperative infection: Infection after thyroid surgery occurs in about 6% of cases, although it varies depending on the patient and surgery-related factors.
Esophageal and Tracheal injury: In rare cases, these injuries can occur during thyroid surgery, which needs immediate attention to avoid further complications.
Horner syndrome: This rare problem is due to damage to the nerves controlling specific facial features and can result in drooping eyelids, small pupils, and loss of sweating. This can happen if there is excessive stress during surgery near these nerves.
Dysphagia: After surgery, you might have difficulty swallowing due to temporary swelling, scar tissue, or irritation. If this continues, you might need additional tests.
Chyle leak: This rare complication happens when certain neck vessels get injured during extensive surgery in the lower neck. Management of this complication varies from diet changes to surgical intervention in severe cases.
Gentle surgical techniques and monitoring during surgery help reduce the risk and severity of these issues. After surgery, more careful watching particularly in the first 24 hours aid in catching and managing any complications early.
What Else Should I Know About Thyroidectomy?
A thyroidectomy is a surgery that removes all or part of your thyroid gland. This procedure is crucial for various thyroid conditions and can impact your hormones and quality of life. Doctors usually recommend a thyroidectomy to treat thyroid cancers, troublesome goiters (enlarged thyroid), and severe hyperthyroidism (overactive thyroid) that don’t respond to medication.
In the case of thyroid cancer, removing the whole or nearly the whole thyroid is often the main treatment method. This helps doctors examine the entire gland, aids in determining how advanced the cancer is, and could even improve survival rates. After the surgery, blood tests are carried out to check for a protein called thyroglobulin, which can indicate if thyroid cancer is still present or has come back. Additionally, you may be given radioactive iodine to destroy any remaining thyroid tissue, which can further improve the outlook.
If you have a large or symptomatic goiter that’s causing difficulties with breathing or swallowing or even distorting the shape of your neck, a thyroidectomy can alleviate these issues. Once the goiter is removed, the symptoms usually improve immediately.
In the case of hyperthyroidism not well controlled with medication, surgically removing the thyroid can serve as an immediate and definite solution. This can be crucial for patients with severe symptoms or those planning to become pregnant.
However, having your thyroid gland taken out has serious after-effects. In particular, if your entire thyroid is removed, you’ll have to take thyroid hormones for the rest of your life to make up for the lost gland. The amount you’ll need to take can be tricky to figure out and will need to be adjusted according to regular blood tests.
This procedure also carries a risk of complications. These include injury to nerves in the neck, injury to the parathyroid glands (which control calcium levels) and damage to surrounding blood vessels. While these risks are low when the surgery is performed by a skilled surgeon, they’re something you and your doctor will need to discuss and plan for prior to the operation. For patients with thyroid cancer, continued monitoring after surgery is required, as elevated thyroglobulin levels in the blood can indicate a recurrence of the cancer.
