Thyroidectomy

Thyroidectomy is the surgery done to remove all or part of the thyroid gland. The thyroid is a butterfly-shaped gland present in the lower front of the neck. It produces hormones that control the rate of metabolism.

Thyroidectomy is a treatment option for conditions like thyroid cancer, overactive thyroid (hyperthyroidism), thyroid nodules and goitre. Depending on the cause for surgery, either a part (partial thyroidectomy) or the whole (total thyroidectomy) thyroid gland may be removed. If only a partial thyroidectomy is performed, your thyroid may function normally after surgery. If a total thyroidectomy is done, you will need to take thyroid hormone tablets daily to make up for the gland’s function.

Thyroidectomy may be performed by one of the following methods:

• Conventional open surgery
• Endoscopic surgery using smaller incisions
• Robot-assisted surgery 

A novel technique to perform thyroidectomy is scarless thyroid surgery (transoral method). This is a laparoscopic technique that is performed through small incisions on the inner surface of lower lips. The incisions heal completely without leaving behind any scars.

Doctors generally recommend thyroidectomy for the following conditions:

• Thyroid cancer 
• Goitre 
• Hyperthyroidism
• Thyroid nodules that are suspected to be cancerous

Thyroid cancer has the following symptoms:

• Swelling in neck
• Trouble in breathing or swallowing
• A lump in neck that grows fast
• Pain in the front of the neck that may extend to ears
• Persistent hoarseness or other changes in voice 
• A constant cough without a cold

The following are the symptoms of goitre:

• Enlarged throat
• Voice changes like hoarseness
• Difficulty in breathing or difficulty swallowing
• Coughing 
• A feeling of tightness in the throat

Generally, thyroid nodules do not manifest any symptoms. However, sometimes a lump may be felt or seen in front of the neck. The lump may cause difficulty swallowing or pain. If the nodule releases excessive thyroid hormone (hyperthyroidism), you may have:

• Fatigue 
• Nervousness
• Fast heartbeat
• Muscle weakness
• Intolerance to heat
• Trouble falling asleep or staying asleep
• Absent periods
• Hair loss 
• Increased bowel movements
• Weight loss

Thyroidectomy is recommended in people with the following conditions:

• Hyperthyroidism: Thyroidectomy is an option if you do not want radioactive iodine therapy or have problems taking anti-thyroid drugs. 
• Thyroid cancer: Removing most or all the thyroid gland is an ideal treatment option for cancer. 
• Goitre: Thyroidectomy is performed if the goitre is causing discomfort, difficulty in breathing or swallowing or, in some cases, hyperthyroidism. 
• Suspicious or indeterminate thyroid nodules: Despite microscopic testing of a tissue sample (biopsy), some nodules cannot be identified as cancerous or non-cancerous. The doctor may recommend thyroidectomy for these nodules if they have a high risk of being cancerous.

Thyroidectomy is contraindicated in uncontrolled Grave’s disease (an immune system disorder that causes hyperthyroidism). Although not contraindicated in pregnant women, it is preferable to postpone thyroidectomy until after delivery to minimise the risks to the mother and the unborn baby.

A few weeks before the surgery: 

• You may need to get an ultrasound, computed tomography (CT) or other imaging tests so that the doctor can determine the exact location of the abnormal thyroid growth. A complete exam of the head and neck may be performed along with a chest x-ray. 
• Your doctor may perform a fine needle aspiration biopsy to check if the thyroid cells are cancerous or non-cancerous. 
• The functioning of your vocal cords will also be checked. 
• Blood tests may be done to check the level of thyroid hormone. Read more: Thyroid function test
• Your doctor may give you thyroid medicine or iodine one to two weeks before surgery.

A few days before the surgery:

• Discuss with your healthcare provider about all the medicines you are taking, including herbs, supplements and non-prescribed medicines, and if you need to discontinue any of them. 
• Your doctor may request you to stop taking blood-thinning medicines that include aspirin, warfarin, clopidogrel, ibuprofen and naproxen, among others.
• Buy the pain medication and calcium that you will require after the operation as per your doctor’s prescription. 
• You will also need to stop smoking, if you are in the habit.
• If you are pregnant, you must tell your doctor.
• You will need to sign an informed consent form to allow the doctor to perform the surgery.

Before the operation:

• Your healthcare provider may give you antibiotics if you have weak immunity or any condition that makes you prone to infections. 
• You may receive medications to prevent nausea and vomiting. 
• If you have hyperthyroidism, your doctor will give you medicines to control your thyroid hormone levels during and after surgery.
• You must avoid drinking/eating anything after midnight the night before the surgery. 
• On the day of the surgery, keep jewellery and valuables at home and arrange for transport to the hospital and back home.

Thyroidectomy is usually performed under general anaesthesia. A breathing tube is put into the patient’s windpipe to help in breathing during surgery. 

Just before the surgery, several monitors will be placed on your body to check your blood pressure, blood oxygen and heart rate throughout the procedure. An intravenous line will be placed in one of your veins to deliver medicines and fluids. 

The surgery may be performed by one of the two following methods:

• Conventional thyroidectomy: The procedure for this method is as follows:
  • The surgeon will make a 3- to 4-inch incision in the skin on the lower front part of your neck. 
  • He/she will cut through the muscles under the skin and spread the muscles apart to reveal the thyroid gland. 
  • Depending on the requirements, all or part of the thyroid gland will be removed. If the surgery is performed to treat thyroid cancer, the surrounding lymph nodes may also be removed. These lymph nodes will be checked to see if the cancer has spread. 
  • The surgeon will try to avoid injury to the parathyroid glands, which are located next to the thyroid gland. 
  • After removing the thyroid gland, the surgeon will bring the muscles to their original position and secure them with one to two stitches. 
  • They will then close the skin cut with stitches or sterile paper tapes. 
• Endoscopic thyroidectomy: The procedure for this method is as follows:
  • Three or four incisions, each about 3-5 mm long, will be made in your neck. 
  • Through these incisions, small surgical instruments and an endoscope will be inserted. 
  • Using the tiny camera of the endoscope, the surgeon will guide the instruments to remove the thyroid tissue. 
  • Once the surgery is done, the incisions will be closed with stitches or surgical tape.
• Scarless thyroidectomy: The surgery is performed laparoscopically as follows:
  • The surgeon will make three small incisions on the inner side of your lip through which they will pass the surgical instruments and a high-resolution camera.
  • With the help of the camera and instruments, the surgeon will remove the thyroid gland and close the incisions without leaving any visible scars.
• Robotically-assisted surgery: The procedure for robotically assisted surgery is as follows:
  • You will be asked to lie on the operating table. 
  • The surgeon will perform the surgery with the help of a console. This console will have an endoscope with a camera attached to it and three other arms with special laparoscopic instruments attached to them.
  • The surgeon will remove a part of or the entire thyroid gland and close the incisions with stitches.

After removing the gland, the surgeon may insert a small tube (drain) near the incision to drain any blood that may accumulate in your neck. 

Thyroidectomy usually takes around one to two hours, but the duration may vary depending on how much of the thyroid gland needs to be removed. 

After the surgery

After surgery, you will be kept in a recovery room. The hospital staff will constantly monitor your vitals and recovery until you regain consciousness and will move you into a hospital room once you wake up. If a drain was put in your neck, it would be removed in the morning after the surgery. 

You can drink and eat normally after the surgery. However, you may experience temporary pain in your neck or have hoarseness after the surgery. Both these are usually temporary and caused by irritation from the breathing tube inserted during the surgery.  If you find it difficult to swallow solid food, it is better to start with liquids soft foods like mashed potatoes or yoghurt.

Depending on the type of surgery you had, you may be discharged from the hospital on the same day or one night after the surgery.

The following steps are advised to care for yourself after thyroidectomy:

• If the wound was closed with skin glue or surgical tape, you may shower the day after surgery. Wash over the incision gently with soap and water, and pat dry. If the wound was closed with stitches, your surgeon will tell you when you can shower. Do not apply ointments, creams or powders over the incision until you follow up with your doctor. 
• If there is a drain in place, keep track of the amount of fluid drained. Follow your nurse’s instructions on changing the dressing. Your doctor will inform you when it is time to remove the drain. 
• Take plenty of rest. While sleeping, keep your head raised for the first week. Avoid strenuous activities like heavy lifting during the first few weeks. Resume your normal activities gradually as you feel ready. Do not drive if you are on narcotic pain medicines.
• To manage pain, you may be prescribed a pain medicine or may be advised to take over-the-counter pain medicines, like ibuprofen or acetaminophen. You can apply a cold compress over the area to ease the pain, but do not place ice directly on the wound. 
• To prevent constipation caused by narcotic pain medicines, have foods that are rich in fibre and plenty of fluids. If these do not help, you may take medication for constipation after discussing with your doctor.
• Keep the incision area covered or use a strong sunscreen when you step out for the first year after surgery.
• If you have had a total thyroidectomy, your doctor will put you on thyroid hormone replacement tablets, which you must take as instructed.
• Try to perform gentle neck exercises like tilting your neck from side to side, turning the head from one side to another, looking up and down and shoulder shrugs. Perform these exercises about twice or thrice a day for five to 10 minutes for three months after surgery. These exercises help in recovery and prevent stiffness of the neck.

The benefits of a thyroidectomy are as follows:

• Thyroid cancer can be treated
• You may get relief from symptoms of hyperthyroidism
• Removal of goitre that may be blocking the airway

When to see the doctor?

If you have any of the following symptoms, notify the doctor immediately:

• Excessive or progressive fatigue
• Tingling or numbness in lips or extremities
• Difficulty in breathing, swallowing or talking
• Twitching or muscle spasms
• Signs of infection like chills and fever
• Redness, increased pain, swelling, excessive bleeding or any discharge from the wound
• Chest pain, shortness of breath or cough
• Persistent nausea or vomiting that cannot be controlled by medicines
• Uncontrolled pain despite medication
• Hoarse, husky or weak voice

Although thyroidectomy is relatively safe, there are some risks, including:

• Bleeding beneath the neck wound
• Thyroid storm: A sudden release of thyroid hormones in very large amounts. When the thyroid gland is manipulated during the surgery, it releases a large amount of hormones. A thyroid storm may show up suddenly after surgery or after a while.
• Infection of the wound. 
• Hypoparathyroidism: Damage to the parathyroid glands during surgery may cause a decrease in parathyroid hormone levels which could lead to low calcium levels. Read more: Hypoparathyroidism causes
• Changes in the voice due to damage to the nerve supplying the vocal cords
• Scarring at the incision site

You will probably have a follow-up a week after surgery. At this visit, your doctor will check the healing of your incision. If you have stitches or a drain, he/she will remove them. The thyroid hormone levels in your blood will be checked. Additionally, the levels of phosphorus and calcium will also be determined to assess the functioning of the parathyroid glands. Your doctor will also inform you about any further follow-ups or treatments that you may need.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.