I think I may have skipped a month on the “surgery of the month” series, but we’ll get back into it this month! The topic today is thyroidectomy, or removal of the thyroid gland. Removal of half of the thyroid gland is called hemithyroidectomy (or thyroid lobectomy sometimes), whereas removal of all of the thyroid is called total thyroidectomy.
You can remind yourself of what the thyroid gland is and where it is located by reading my post on thyroid nodules HERE.
Many thyroid disorders can be treated entirely with medications, especially hypo- and hyperthyroidism (meaning the thyroid makes too little or too much hormone, respectively). Surgery to remove part or all of the thyroid is most commonly necessary in the case of thyroid cancer or large benign nodules which are causing symptoms such as pressure sensation, difficulty swallowing, or shortness of breath.
For any thyroid cancer, the first order of treatment is total thyroidectomy. Even if a tumor is only in one side of the gland, it is important to remove the entire thyroid because small areas of tumor are common in other parts of the gland. For benign nodules limited to one side, hemithyroidectomy is preferred so that the patient will still have a functioning lobe on the other side and thus won’t need to take thyroid replacement medication for the rest of their life.
So, how is the surgery done? I make a horizontal incision in the lower neck in a skin crease. The incision is carried down to the muscle layer overlying the larynx and thyroid gland, which is then divided vertically. At this point, the thyroid isthmus is visible crossing in front of the trachea. I’ll then dissect around the periphery of the thyroid gland, taking care to divide and cauterize any blood vessels. On the back side of the gland, there are fibrous attachments to the trachea called Berry’s ligament which must be divided carefully. After this is done, the entire lobe can be removed. For total thyroidectomy, the process is repeated on the other side. I’ll then close the incision after verifying there is no bleeding in the area where the thyroid was sitting.
The two specific risks in thyroid surgery are injury to the parathyroid glands or to the recurrent laryngeal nerve. There are 4 parathyroid glands which are rice-sized structures which live in the tissue behind the thyroid. They produce parathyroid hormone which helps regulate calcium levels in the blood. The recurrent laryngeal nerve provides innervation to the vocal cord on that side, and can cause hoarseness and swallowing problems if injured. I take care to visually identify and preserve these important structures while dissecting around the thyroid gland.
After surgery, most patients can go home the same day. For total thyroidectomy patients, I will have a calcium blood level checked in the recovery room after surgery and then again the following morning (the patient goes to a local lab to have the blood drawn).
The recovery after surgery is usually not terrible. Patients usually have a moderate level of pain for several days after but this mostly resolves within a week. The scar tends to heal very well and usually blends in nicely with the natural creases in the neck.