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1. Subtotal Thyroidectomy
What is thyroidectomy?
A thyroidectomy is an operation that involves the surgicalremovalof all or part
of the thyroid gland.
What is the thyroidgland?
The thyroid gland is a butterfly-shaped endocrine gland that is normally
located in the lower frontof the neck. The thyroid’s job is to make thyroid
hormones, which are secreted into the blood and then carried to every tissue
in the body. Thyroid hormones help the body useenergy, stay warm and keep
the brain, heart, muscles, and other organs working as they should.
What are the five types of thyroidectomy?
Thyroidectomy can be classified into 5 distinct parts depending on the part of gland
or whole of gland to be removed, the spread of the disease and type of disease. The
different types of thyroidectomy are:-

3.  Hemithroidectomy
A Hemithyroidectomy is the removal of half of the thyroid gland. This
procedure, also referred to as a thyroid lobectomy or partial
thyroidectomy, is performed to removesymptomatic or cancerous
nodules.
 Subtotal thyroidectomy
Subtotal thyroidectomy is a surgicalprocedure, in which the surgeon
leaves a small thyroid remnant (3-5g) in situ to preservethyroid
function, thereby preventing lifelong thyroid hormonesupplementation
therapy.
 Partial thyroidectomy
Partial thyroidectomy involves the surgical removalof one lobe of the
thyroid gland, usually the cancerous portion.
 Near total thyroidectomy
Near‐total thyroidectomy is an operation that involves the surgical
removal of both thyroid lobes except for a small amount of thyroid
tissue (on one or both sides less than 1.0 mL).

4. Total thyroidectomy
Total thyroidectomy involves the
removal of the entire thyroid gland.
Despite all the above classifications of the
surgery, this article will mainly be focused to
review, analyse and summariseSubtotal Thyroidectomy.
However, the principles discussed may be applied to all Thyroidectomy
procedures.
Why is Subtotal Thyroidectomy performed?
The thyroid gland releases thyroid hormone, which controls many critical
functions of the body. Subtotal Thyroidectomy is usually performed to treat
Grave’s disease, thyroid nodules, thyroid cancer, autoimmune (lymphocytic
and hashimoto) thyroiditis, chronic lymphocytic thyroiditis etc. In simple
words, this procedureis used to surgically cut out cancerous lumps and
nodules on the thyroid gland. Other indications for surgery includecosmetic
(highly enlarged thyroid), or symptomatic obstruction (causing difficulties in
swallowing or breathing).
Subtotal thyroidectomy is also used to treat the thyroid gland when there is an
excess secretion of thyroid hormoneor hypothyroidism. Grave’sdiseaseis one
of the most common cause of this. Goiters which cannot be adequately
managed with antithyroid medications (e.g., patients with toxic adenoma or
toxic multinodular goiter) can also be removed with this procedure.
Thyroidectomy can also be considered as primary therapy in refractory cases
of amiodarone-induced hyperthyroidism.

5. What are the contraindications for this procedure?
There are few true contraindications to thyroidectomy. Given that thyroid
cancer is generally a slowly progressivedisease, the risk/benefitprofile
changes with age and this should be discussed with patients who are
considering undergoing thyroidectomy.
Anaplastic carcinoma represents a treatment dilemma due to its poor
outcomes and propensity for rapid progression. Surgicalresection may be
offered if gross totalresection can be achieved with minimal morbidity and
there is no evidence of metastases. Surgicalintervention may otherwisebe
contraindicated.
Surgicalfactors considered relative contraindications to outpatient surgical
management include massivegoiter, extensive substernalgoiter, locally
advanced carcinoma, challenging hemostasis, and a difficult thyroidectomy in
the setting of Hashimoto's or Graves'disease.
How to prepare for a subtotal thyroidectomy surgery?
Once it is determined that you need surgery, thedoctor do a physicalneck and
head check and run tests on you like a CT scan and PET scan and blood tests.
He will makesure to check your vocalcords by indirect laryngoscopy to rule
out any unsuspected pre-existing unilateral nervepalsy, this is particularly
important if the patient has undergoneany previous thyroid surgery. These
tests will confirmthe location and type of cancer. They will also indicate if the
patient is healthy enough to pull through with the surgery. Patients should be
rendered euthyroid with antithyroid drugs beforesurgery.
If you have hyperthyroidism, your doctor may prescribemedication — such as
an iodine and potassium solution — to control your thyroid function and lower
the bleeding risk after surgery.
Generally, patients should not eat or drink anything except essential
medications after midnight before the surgery. This is because when the
anaesthetic is used, your body's reflexes are temporarily stopped. If your
stomach has food and drink in it, there's a risk of vomiting or bringing up food
into your throat which can cause complications during the surgery. Patients
should informtheir doctors in casethey feel sick, nauseous or uncomfortable.

6. How many people are required for the surgery in the operating room?
Essential personnelfor this procedureinclude the primary surgeon, 1 or 2
surgicalassistants, a circulating/operating roomnurse, a surgicaltechnologist,
and an anesthesiologistand mostimportantly, the patient. Airway
management should be discussed with the anesthesiologistprior to starting
the procedure. The personnelcan also depend on kind of procedure,
availability etc.
What is the procedure ofa subtotal thyroidectomy?
An uncomplicated subtotal thyroidectomy should take less than 2 hours to
perform. If you arehaving a less extensive operation, it will be quicker. During
the surgery, your surgeon may usethe NIM® Nerve Integrity Monitoring
SystemfromMedtronic to help reduce the risk of nerveinjury to the nerves
controlling your voice. The NIMallows the surgeon to locate the nerves that
run close to your thyroid and also to test their functioning during surgery,
thereby reducing the risk of damage.
In a subtotal thyroidectomy, the surgeon will make an incision
What are the complications that can occur during and after a subtotal
thyroidectomy?
Thyroidectomy is a common surgicalprocedurethat has severalpotential
complications or sequelae including: temporary or permanent changein voice,
temporary or permanently low calcium, need for lifelong thyroid hormone
replacement, bleeding, infection, and the remote possibility of airway
obstruction due to bilateral vocal cord paralysis. Complications are uncommon
when the procedureis performed by an experienced surgeon. But, like every
surgery, subtotalthyroidectomy can have severalcomplications. The most
important complications of thyroidectomy are listed as follows:

7. Recurrentlaryngealnerveinjury Injuryto the recurrentlaryngeal
nerve has the potential to cause unilateral vocal cord paralysis. Patients
with this typically complain of new-onsethoarseness, changes in vocal
pitch, or noisy breathing.
 External Branchof superior laryngealnerveinjury
Damage to the laryngealnerve can resultin loss of voice or obstruction to
breathing. Laryngeal nervedamage can be caused by injury, tumours, surgery,
or infection. Damageto the nerves of the larynx can causehoarseness,
difficulty in swallowing.

8.  External Branchof superior laryngeal nerve injury
Damage to the laryngealnerve can resultin loss of voice or obstruction
to breathing. Laryngealnervedamage can be caused by injury, tumours,
surgery, or infection. Damage to the nerves of the larynxcan cause
hoarseness, difficulty in swallowing or breathing, or the loss of voice.
 Hypoparathyroidism
Hypoparathyroidism is an uncommon condition in which your body
produces abnormally low levels of parathyroid hormone(PTH). PTH is
key to regulating and maintaining a balance of two minerals in your body
— calcium and phosphorus.
 Laryngealoedema-airway obstruction
Laryngealoedema is a common causeof airway obstruction after
extubation in intensive care patients and is thoughtto arisefrom direct
mechanical trauma to the larynxby the endotracheal tube. The oedema
results in a decreased sizeof the laryngeallumen, which may present as
stridor or respiratory distress (or both) following extubation.
 BleedingHaematoma
Hematoma is generally defined as a collection of blood outside of blood
vessels. Mostcommonly, hematomas are caused by an injury to the wall
of a blood vessel, prompting blood to seep out of the blood vesselinto
the surrounding tissues.
 Hypothyroidism
Itis a condition in which the thyroid gland doesn'tproduce enough
thyroid hormone. Hypothyroidism's deficiency of thyroid hormones can
disruptsuch things as heart rate, body temperature and all aspects of
metabolism.

10. Hyperthyroidism
Hyperthyroidism(overactivethyroid) occurs when your thyroid gland
produces too much of the hormonethyroxine. Hyperthyroidism can
accelerate your body's metabolism, causing unintentional weight loss
and a rapid or irregular heartbeat.
 Surgical Site infection
Surgicalsite infections (SSI) affected 2% of patients. The risk of infection
depended mainly on the quality of pre-operative and post-operative
care and on whether there was a break in sterile technique.
 Keloid scar
A Keloid scar is a raised scar after an injury has healed. A keloid is caused
by an excess of a protein (collagen) in the skin during healing. Keloids are
often lumpy or ridged. The scar rises after an injury or condition has
healed, such as a surgicalincision or acne. Keloids aren't harmfuland
don't need treatment. If a person finds them unattractive, a doctor can
sometimes minimise the scars.
 Suturegranuloma
Suturegranuloma is a mass forming benign lesion that develops at the
site of surgery as a foreign body reaction to non-absorbablesuture
material.
What risks shouldone lookout for?
 Hemorrhage: severecases may causeairway compression and be life-
threatening
 Hypocalcemia which may become symptomatic and life-threatening if
unrecognized/untreated. Up to 1/3 of patients undergoing total
thyroidectomy will have at least transienthypocalcemia postoperatively.
Itis important to maintain a consistentprotocol for calcium
management after total or completion thyroidectomy to minimize
related complications.

11.  Injury to the recurrentlaryngeal nerve: results in hoarseness and
potentially aspiration. This is most commonly temporary but may be
permanent <1% of cases.
 Injury to the superior laryngealnerve: results in voice pitch change.
Reported rates of injury range from 0% to 58%.
 Post-surgicalinfection: approximately 6% of cases.
 Esophagealinjury
 Chyle leak
 Dysphagia
 Tracheal injury
 Horner syndrome
What is the recovery and after care of the surgicalprocedure?
The recovery time for a subtotal thyroidectomy is anywherefrom 2-3 days,
more in case of additional surgeries due to complications. The patient is
usually fed via a tube in the recovery period. Ample of restis advised as long as
it is not painful. There may be a changein diet and your care team will give you
thorough instructions on how to care for your incision sites and what to do in
case of emergencies.
Patients are asked to take 1000 mg of calcium 4 times a day for the firstweek
after surgery and then 500 mg of calcium twice a day for the next 2 weeks until
their post-operativevisit to help avoid the symptoms of low calcium levels.
After the removal of a thyroid, patients usually take a prescribed oral synthetic
thyroid hormone, levothyroxine (Synthroid) to prevent hypothyroidism.
Patients may havea gauze pressuredressing around your neck. Thedoctor will
give instructions on when to remove it. The stitches in the incision will need to
be removed in 5-7 days, or patients may havedissolvablestitches that do not
require removal. If the incision has been closed with dissolvablestitches, the

12. patient will likely haveeither skin glue or paper tapes (Steri-Strips) covering the
incision. Some people may need to have a drain placed under the incision in
the neck. This drain is usually removed the morning after surgery. After
thyroidectomy, a few people may experience neck pain and a hoarseor weak
voice. This doesn't necessarily mean there's permanent damage to the nerve
that controls the vocal cords. Thesesymptoms areoften short-term and may
be due to irritation fromthe breathing tube that's inserted into the windpipe
during surgery, or be a result of nerve irritation caused by the surgery.
You'll be able to eat and drink as usualafter surgery. Depending on the type of
surgery you had, you may be able to go home the day of your procedureor
your doctor may recommend that you stay overnight in the hospital. When you
go home, you can usually return to your regular activities. Wait at least 10 days
to two weeks before doing anything vigorous, such as heavy lifting or
strenuous sports. Ittakes up to a year for the scar from surgery to fade. Your
doctor may recommend using sunscreen to help minimize the scar from being
noticeable.
What is the clinical significance of the surgical procedure?
Thyroidectomy is an importantsurgicalprocedurewith high-quality evidence
for the management of benign and malignant thyroid disease. Due to the close
proximity of several critical anatomic structures, safethyroidectomy required
detailed anatomic knowledge and careful patient selection is paramount
detailed anatomic knowledge and careful patient selection is paramount.