Thyroidectomy

Thyroidectomy is a surgical procedure to remove one of the most important endocrine glands in the body – the thyroid gland (glandula thyreoidea). The extent of the surgical intervention – removal of part or all of the gland – depends on the specific diagnosis. [ 1 ]

Indications for the procedure

This operation is shown:

• in malignant tumors, i.e. thyroid cancer – differentiated, medullary, follicular, papillary, anaplastic, as well as adenocarcinoma; [ 2 ]
• in case of metastases to the thyroid gland from tumors of other localizations;
• in the presence of diffuse toxic goiter (Graves' disease) of a multinodular nature, leading to the development of thyrotoxicosis. Excision of the goiter is also called strumectomy;
• patients with follicular adenoma of the thyroid gland or a large cystic formation that makes breathing and swallowing difficult.

Preparation

Preparation for such operations begins from the moment the decision is made about its necessity. It is clear that in order to establish the appropriate diagnosis, each patient underwent a comprehensive examination of the thyroid gland (with aspiration biopsy) and examination of regional lymph nodes.

It is also important to determine the location of the parathyroid glands, since their localization may be non-orthotopic (they may be located at the top of the back of the thyroid gland or far from the neck - in the mediastinum). An ultrasound or CT scan of the neck is performed.

Before the planned thyroid removal (complete or partial), the condition of the heart and lungs should be checked - using an electrocardiogram and chest X-ray. Blood tests are taken: general, biochemical, coagulation. The doctor gives recommendations regarding the medications taken by the patient (some medications are temporarily canceled).

The last meal before surgery, as recommended by anesthesiologists, should be no less than 10 hours before it begins.

Technique thyroidectomy

Depending on the indications, a radical or total thyroidectomy may be performed – removal of the entire gland, performed for the surgical treatment of cancer. The operation is performed under general (endotracheal) anesthesia, and lasts on average about two to three hours.

Technique of traditional subfascial thyroidectomy: a transverse incision (7.5-12 cm long) is made in the skin, subcutaneous tissues, sternohyoid muscles and parietal leaf of the cervical fascia - along the anatomical horizontal fold in front of the neck (above the jugular notch); by crossing and ligating the corresponding vessels, the blood supply to the gland is stopped; the thyroid gland is exposed and separated from the tracheal cartilages; displacement of the gland allows for the isolation of the recurrent laryngeal nerve; the parathyroid glands are identified (to protect them from accidental damage and not to disrupt the blood supply); after isolating the gland from the fascial capsule, it is excised; the edges of the capsule are connected with sutures; the site of the gland is covered with the visceral leaf of the internal fascia of the neck; the surgical wound is sutured with drainage (which is removed after 24 hours) and the application of a sterile bandage.

In the presence of a malignant tumor, radical extrafascial thyroidectomy is used - complete extracapsular removal of one lobe, isthmus and 90% of the contralateral lobe (leaving no more than 1 g of gland tissue). Patients with a large tumor, as well as medullary thyroid cancer, may require thyroidectomy with lymph node dissection or lymphadenectomy, that is, removal of the lymph nodes of the neck affected by metastases. Depending on their location, bilateral excision is performed - thyroidectomy with lateral lymph node dissection or with removal of the upper and anterior mediastinal nodes - thyroidectomy with central lymph node dissection.

If not the entire gland is removed, but more than half of each lobe, including the isthmus, then this is a subtotal thyroidectomy (resection), used in cases of goiter or the presence of single benign nodes. When the tumor is small (for example, isolated papillary microcarcinoma) or the node is single (but raising suspicion regarding its benignity), only the affected lobe of the gland and the isthmus can be removed - hemithyroidectomy. And removal of tissues of the isthmus between the two lobes of the gland (isthmus glandulae thyroideae) with small tumors located on it is called isthmusectomy.

The so-called final thyroidectomy is performed in cases where the patient has undergone thyroid surgery (subtotal resection or hemithyroidectomy) and there is a need to remove the second lobe or the remaining part of the gland.

In some cases, an endoscopic procedure may be performed, using a special thyroidectomy instrument set. During this procedure, an endoscope is inserted through a small incision in the neck; carbon dioxide is pumped in to improve visibility, and all necessary manipulations (visualized on a monitor) are performed with special instruments through a second small incision. [ 3 ]

Contraindications to the procedure

If the patient has acute infectious diseases, relapse of a chronic disease, or coagulopathy (poor blood clotting) that cannot be compensated with medication, removal of the thyroid gland is contraindicated.

Consequences after the procedure

Both the general condition after thyroidectomy and its short-term and long-term consequences largely depend on the patient's diagnosis and the extent of the surgical intervention performed.

Although this procedure is considered safe (the mortality rate after it, according to some data, is no more than seven cases per 10 thousand operations), many patients note that their lives after thyroidectomy have changed forever.

And it is not that a scar or a cicatricial mark remains on the neck after thyroidectomy, but that when the entire thyroid gland is removed, the body still needs thyroid hormones, which regulate many functions, metabolic processes and cellular metabolism. Their absence causes hypothyroidism after thyroidectomy. Therefore, treatment after thyroidectomy will be required in the form of lifelong replacement therapy with a synthetic analogue of the T4 hormone - the drug Levothyroxine (other names - L-thyroxine, Euthyrox, Bagotirox ). Patients should take it daily: in the morning on an empty stomach, and the correct dosage is checked by a blood test (6-8 weeks after the start of use).

As endocrinologists note, the development of secondary hypothyroidism after subtotal thyroidectomy is observed much less frequently: in approximately 20% of those operated on.

It is also important to know how thyroidectomy affects the heart. First, postoperative hypothyroidism causes a decrease in heart rate and an increase in blood pressure, causing pain in the heart area, atrial tachyarrhythmia, and sinus bradycardia.

Secondly, during surgery, the parathyroid glands may be damaged or removed together with the thyroid gland: the incidence of their accidental extirpation is estimated at 16.4%. This deprives the body of parathyroid hormone (PTH), which causes a decrease in renal reabsorption and intestinal absorption of calcium. Thus, calcium after thyroidectomy may be insufficient, i.e. hypocalcemia occurs, the symptoms of which may persist for six months after surgery. In case of severe hypocalcemia, heart failure with a decrease in the left ventricular ejection fraction and ventricular tachycardia is observed.

Another question: is pregnancy possible after thyroidectomy? As is known, with hypothyroidism, the menstrual cycle and ovulation in women are disrupted. But taking Levothyroxine can normalize the level of thyroid hormones T3 and T4, so there is a chance of getting pregnant after thyroid removal. And if pregnancy occurs, it is important to continue replacement therapy (adjusting the dosage of the drug) and constantly monitor the level of hormones in the blood. [ 4 ]

More information in the material - Thyroid gland and pregnancy

Complications after the procedure

The most likely complications after this surgery include:

• bleeding in the first hours after surgery;
• hematoma of the neck, which occurs within 24 hours after the procedure and is manifested by compaction, swelling and pain in the neck under the incision, dizziness, shortness of breath, a wheezing sound when inhaling;
• airway obstruction, which can lead to acute respiratory failure;
• temporary hoarseness of the voice (due to irritation of the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve) or permanent (due to damage to them);
• uncontrollable coughing when talking, difficulty breathing or the development of aspiration pneumonia are also caused by damage to the recurrent laryngeal nerve;
• pain and sensation of a lump in the throat, difficulty swallowing;
• pain and stiffness in the neck (which can last from several days to several weeks);
• development of infectious inflammation, in which the temperature rises after thyroidectomy.

In addition, after thyroidectomy in patients with Graves' disease, fever with a body temperature of up to +39°C and increased heart rate may occur as a result of a thyrotoxic crisis requiring intensive care.

Care after the procedure

After the operation, patients are kept in the ward under observation by medical staff; to reduce swelling, the head of the bed should be raised.

If you have a sore throat or painful swallowing, food should be soft.

It is important to maintain hygiene, but the incision area should not be wetted for two to three weeks until it begins to heal. Therefore, you can take a shower (so that the neck remains dry), but you should avoid taking baths for a while.

Recovery will require at least two weeks, during which patients should limit physical activity as much as possible and avoid lifting heavy objects.

Because the area around the incision is at increased risk of sunburn, it is recommended to use sunscreen when going outdoors for a year after surgery.

Patients undergo the following tests after thyroidectomy: blood test for

The level of pituitary thyrotropin (TSH) - thyroid stimulating hormone in the blood, the serum content of parathyroid hormone (PTH), calcium and calcitriol in the blood.

Determining the TSH level after thyroidectomy allows one to avoid the development of hypothyroidism by prescribing hormone replacement therapy (see above). The established norm of TSH after thyroidectomy is from 0.5 to 1.5 mIU/L.

Relapse after thyroidectomy

Unfortunately, thyroid cancer recurrence after total thyroidectomy remains a serious problem.

Recurrence is determined based on clinical signs of the tumor, the presence/absence of tumor signs on X-ray imaging, radioactive iodine scanning, or ultrasound after thyroidectomy, as well as blood thyroglobulin tests, which are considered an indicator of disease recurrence. Its level should be determined every 3-6 months for two years after thyroidectomy, and then once or twice a year. If thyroglobulin increases after thyroidectomy for cancer, it means that the malignant process has not been stopped.

According to the Instruction on the establishment of disability groups (Ministry of Health of Ukraine, Order No. 561 dated September 5, 2011), patients are assigned disability after thyroidectomy (Group III). The criterion is defined in the following wording: "total thyroidectomy with subcompensated or uncompensated hypothyroidism with adequate treatment."