Thyroid Surgery

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Today I’d like to welcome to the PodMd studio Dr Suren Jayaweera is an Australian trained endocrine and general surgeon, with a special interest in benign and malignant disease of the thyroid and parathyroid glands, endoscopic trans-axillary thyroid surgery and workup and management of adrenal disease. He also performs elective and emergency surgery for gallbladder disease and hernias.

Question 1

The topic of today’s discussion is thyroid surgery.
Whilst it sounds pretty straightforward, is it the same as it’s always been?

Well, thyroid surgery has changed over the past few decades and perceptions of what thyroid surgery entails might be a little bit dated. I have patients who ahh, have scars from ear to ear and uh I have story of them telling me about requiring a week or more in hospital 30 or 40 years ago. I’m happy to say that that is no longer the case. And I think it’s a good time to talk about what thyroid surgery entails for patients in the modern era.

Question 2

What then are the indications that surgery would be applicable?

So, there’s a range of thyroid conditions that require surgery which are both benign and malignant indications. So, these include solitary nodules, toxic nodules, multi-nodular goitres, auto-immune conditions such as Graves’ Disease or occasionally Hashimoto’s thyroiditis and of course thyroid cancer.

Question 3

What operations are commonly performed?

Some operations where only part of the thyroid are removed have really fallen out of favour include. What what used to be referred to as nodulectomy which is just removing a nodule or a sub-total thyroidectomy um leaving part of the thyroid gland intact. These operations are no longer performed due to the potential for recurrent disease and increased risks associated with reoperating ah within scar-tissue in the neck. So, the operations that we largely perform nowadays revolve around hemithyroidectomies- removing the entirety of one lobe or a total thyroidectomy involving both lobes. And in the case of thyroid cancer this might also include ah central neck dissections ah or lateral neck dissections to remove potentially involved lymph nodes. If a nodule is right in the middle of the isthmus of the thyroid gland so that’s that little portion of thyroid tissue connecting the two lobes. Occasionally it may be appropriate to remove just the isthmus which is a very low risk procedure um ah but we don’t perform it very often. And finally, we also operate on final glosial cysts, sometimes removing a portion of the hyoid bone to to reduce the chance of recurrence and that’s known as a cyst truck procedure.

Question 4
How can a patient then be prepared for an operation like this in the thyroid?

Patients undergo a full clinical assessment in total, including a thorough history and full examination. Um all patients have a baseline ultrasound ah to assess the structure of the thyroid gland, as well as bloods, as well as thyroid function tests. And I always perform a parathyroid screen ah to make sure, if I’m going to operate on the neck, I don’t want to be missing um other treatable conditions. So that involves calcium, vitamin D levels and ah PTH levels. Um they may need further tests as well say as anti-TSH antibodies or anti-thyroid globulins and anti-thyroid peroxidase um and further imaging tests as requires such as a CT scan of the neck if there’s ah concern about retrosternal extension. Or a thyroid nuclear scan if the patient is biochemically hyperthyroid. Ah I frequently ah um perform a vocal cord check as well with a fibre optic laryngoscope particularly if patients are symptomatic with a hoarse voice or if they’ve had previous thyroid surgery.
Ok, so that’s a nice outline of what goes on before surgery can you now tell us what’s actually entailed in thyroid surgery?
So, most thyroidectomies are performed in a hospital in an overnight setting um and involves a general anaesthetic with an incision across the lower part of the neck. Ah this transverse incision is extended to raise ah flaps beneath the platysma muscle and expose the strap muscles ah sometimes separated in the midline and sometimes they’re divided if the gland is particularly large. Um and that exposes the thyroid gland which is then removed and the key to thyroid surgery is identification and preservation of the recurrent laryngeal nerve ah to the voice box and the parathyroid glands.

Question 5
Right, so what are the risks that could be involved in thyroid surgery?

Ah when I’m consenting patients, I let them know about three important risks. The first is one is bleeding which is a an immediate complication which manifests as a swelling of the neck and can compromise the airways so it is a potentially life threatening complication. Um the second potential complication is nerve injury and a lot of um surgeons … will inform patients of the risk to the recurrent laryngeal nerve so patients can end up with a hoarse voice but there’s also a secondary nerve called the external branch of the superior laryngeal nerve. Which sometimes runs across the top of the upper lobe of the thyroid gland on each side and if that nerve is injured. That can change the voice in a different way, that can affect volume and it can also affect pitch. So, this may be important to people who use their voices and particularly people who are professional singers or who just love to sing in the shower. The third main complication really applies ah only to total thyroidectomies because during a total thyroidectomy all 4 glands ah are at risk. And the parathyroid glands have a very delicate blood supply which if interrupted can lead to hypocalcaemia which is reasonably commonly seen in a transient setting. Permanent or long term calcinemia is reasonably rare and occurs in around 1% of patients.

Question 6

Right so there are a few, what can be done to minimise these risks?

Each of these risks have been um carefully analysed and presented at many conferences throughout the years and steps have been taken to try and minimise each of them. So, in the terms, in terms of bleeding great surgical technique is the key involving meticulous haemostasis. We no use vessel-sealing devices such as; the LigaSure or the Harmonic Scalpel
Which has largely replaced the need for tedious hand ties and clips. At the end of the procedure, before closing the neck I also get the anaesthetist to perform a Valsalva manoeuvre which involves increasing the intra-thoracic pressure and results in distending the neck veins so it actually causes bleeding in any vessels that haven’t been sealed off properly so it finds a problem and hopefully fixes it before it becomes an issue on the ward. With regards to nerve injury ah I use an intraoperative nerve monitor- and it is becoming more, more towards standard of care. The nerve monitor helps to identify the current laryngeal nerve and the external branch of the laryngeal nerve. The makers of the machine will have you believe that it decreases nerve injury. I’m not sure if that’s necessarily the case because you really have to find the nerve before you can use the nerve monitor. But what the nerve does allow is for us the test at the end of the case and to be able to reassure patients that if they have a bit of a rough voice that that’s something that will recover reasonably quickly. Or in fact, if we have caused an injury we can identify early and approp or um instigate appropriate management thereof. With regards to hypocalcaemia ah when I perform a total thyroidectomy, I’ll often reimplant a parathyroid gland intraoperatively. Which can be seen as a little bit of an insurance policy and what this involves is: removing a parathyroid gland parathyroid gland, chopping it up and ah injecting it into the sternal colloidal muscle um and we know this works because when we do ah operations for renal ah hyperparathyroidism we sometimes remove all four parathyroid glands and reimplant a little in the neck and you’ll find by monitoring their post-operative PTH levels ahh the PTH can be seen as rising after a few weeks. So, it’s a good little technique to minimise the risk of permanent post-operative hypocalcaemia. Further to that, all patients get put on a post-operative calcium protocol. Which needs to be discussed with their GPs and it’s managed in conjunction with them to make sure ah that they don’t have any symptoms of hypocalcaemia in the immediate post-operative period.

Question 7

Ok, very interesting- so, what is post-operative recovery like for patients when undergoing thyroid surgery?

So, as I mentioned at the at the start, we’re no longer talking about a week in hospital, we’re no longer talking about a massive incision. Post-operative recovery has significantly improved as often just a 5- or 6-centimetre incision across the lower part of the neck and cervical plexus blocks at the end of the operation um is, gives really good post-operative analgesia. Sometimes patients only need Panadol after surgery, but of course if there’s more significant pain, there’s a a large array of analgesic available to them. I tell most of my patients that they should be able to eat, drink, walk, and talk on the day of surgery. And they’re sometimes surprised when I tell them that they should be able to go home day one post op or sometimes after two days. We’re now even moving towards day surgery thyroidectomy which we we may well see over the coming years. The main restriction that I tell patients about is no driving for 10-14 days post-operatively. And that’s more an issue of safety, that they’re less likely to want to turn their neck for head checks and the likes when they’ve just had surgery.

Question 8

What then is the role of the GP post-operatively?

Depending on the operation- for post ah heavy thyroidectomies, once the pathology has been sorted out and once we’ve determined that the remaining lobe is functioning well ah the GPs are closely involved in the surveillance of the contra-lateral lobe with yearly ultrasounds. With total thyroidectomies it is a little more involved, we need to work very closely with the GPs to manage thyroxine dosing once stable levels are achieved and also ah post-operative calcium replacement.

Question 9

What’s the likelihood of recurrence of thyroid conditions after surgery?

Previously the likelihood of reoccurrence was quite high when you had those subtotal operations where part of the gland was left in situ. Now that’s less likely with good surgical technique and removing the entirety of the lobe or the whole gland

Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on thyroid surgery.

1. Things ain’t what they used to be. The recovery after thyroid surgery is far less traumatic than it was in times past
2. The risks of surgery whilst potentially serious are thankfully few and far between
3. Risks can be further introduced by utilising good surgical technique and for GPs to refer to trusted surgeons who perform a high volume of thyroid surgery

Well thanks very much for giving us a comprehensive understanding of thyroid surgery. And for our listeners- do listen to Suren’s Scarless Thyroid Surgery podcast which will outline a new surgical technique.

Thank you very much for having me