Thyroidectomy or Hemithyroidectomy

Indications 

  • Hemithyroidectomy is usually performed for diagnosis of a possible thyroid malignancy in one thyroid lobe (see Thyroid Lumps). If malignancy is confirmed, a “completion thyroidectomy” is usually carried out as a separate stage. It may also be performed for removal of a large benign nodule or cyst, if it is causing pressure symptoms or cosmetic issues.
  • Total thyroidectomy is performed for confirmed/very likely thyroid malignancy, or to treat Graves’ disease which is not responding to medication. It may also be performed for a very large or retrosternal multinodular goitre causing pressure symptoms.

 

Procedure

A nerve monitor can be used to check integrity of the recurrent laryngeal nerve (RLN; see below). A horizontal incision is made in a skin crease overlying the thyroid gland. Subplatysmal flaps are raised, and the strap muscles divided vertically to expose the thyroid. The thyroid lobe(s) is dissected around laterally, taking great care to identify and preserve the RLN and parathyroid glands. For hemithyroidectomy, the gland is divided at the isthmus.

 

Length of procedure

Variable, but usually 60-90 minutes per lobe.

 

Complications

Pain 

Bleeding/haematoma  A drain is used to prevent haematoma, which can be life-threatening (see below).

Infection

Scar  Usually quite good long-term cosmesis.

Need for further treatment  Depending on histology.

Hypothyroidism A certainty in total thyroidectomy; in hemithyroidectomy some patients may eventually require some T4 replacement.

Recurrent laryngeal nerve damage  Hoarseness or weak voice. Permanent damage probably occurs in <1% of patients. Temporary damage due to traction or heating is more common. Even permanent damage may be compensated spontaneously over time, or may be treated with injection techniques.  Rarely, bilateral partial injury can lead to airway obstruction, necessitating urgent tracheostomy.

Hypocalcaemia  More common in total thyroidectomy. Damage to, or removal of, parathyroid gland(s) may cause a significant drop in serum calcium. This usually occurs in the first 24 hours post-operatively, so patients will usually have at least one calcium check during this time. Check the operation note for details – some surgeons will also do this in hemithyroidectomy. (See below for management).

 

Post-operative management 

  • Patients usually stay overnight (sometimes two nights in total thyroidectomy). 
  • Drain output should be monitored closely. Swelling at the operative site indicates haematoma; this can cause airway obstruction due to laryngeal oedema. If haematoma is present, call your senior immediately.  If the patient has difficulty breathing, immediately remove the skin suture, open the wound and evacuate haematoma or blood. Sit the patient up and give high-flow oxygen, and fast-bleep an anaesthetist/crash team and call your senior.
  • For the above reason, a stitch cutter or staple remover should be close to hand at all times (eg taped to the wall behind the bed).
  • Calcium should be monitored postoperatively in all total thyroidectomies, and after hemithyroidectomy if the surgeon wishes. The timing varies according to preference. If a patient becomes significantly hypocalcaemic, or symptomatic from hypocalcaemia, give IV calcium gluconate (infusion over 20-30 minutes with cardiac monitoring). Discuss this with your senior and the medical/endocrine team. The patient may need to continue on oral calcium and vitamin D supplements, as may patients who have moderate hypocalcaemia.
  • Removal of suture in 1 week at GP.
  • Clinic in 2-3 weeks for histology results.

 

TTO

  • Analgesia
  • Oral calcium/vitamin D if indicated
  • Total thyroidectomy: for Graves’, 100-150 mcg levothyroxine (T4) od; for malignancy, 20 mcg liothyronine (T3) tds but check the operation note.

 

 

 

 Page last reviewed: 23 September 2016