Outpatient surgery benefits patients and surgeons alike, as it is convenient, safe and cost-effective. We sought to assess the safety and feasibility of daycare thyroid surgery in a stand-alone Daycare Surgery Center in South India.

1. Daycare thyroidectomy surgery – Our experience

2. Original Article
Daycare thyroidectomy surgery – Our experience
M. Babu Manohar a
, P.S.J. Vikram b,
*, V. Vidhya c
, Raees Abdurahiman d
a
Senior Consultant ENT, Head and Neck Surgeon, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21,
Greams Lane, Off Greams Road, Chennai 600006, India
b
Associate ENT, Head and Neck Surgeon, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21,
Greams Lane, Off Greams Road, Chennai 600006, India
c
Senior Registrar, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21, Greams Lane, Off Greams Road,
Chennai 600006, India
d
Registrar, Department of ENT, Head and Neck Surgery, Apollo Hospitals, 21, Greams Lane, Off Greams Road,
Chennai 600006, India
1. Introduction
The advent and betterment of outpatient surgery has
dramatically changed the landscape of the profession.
Just as other innovations such as antibiotics and improved
anaesthetics have led to better outcomes for surgical patients,
outpatient surgery has undoubtedly benefited patients and
surgeons alike, as it is convenient, safe and cost-effective.
However, many surgeons and institutions are hesitant to
perform day surgery for some procedures. There are scant
reports of daycare thyroid surgeries (DTS) in the literature.
Many of the published studies on this topic have a small cohort
of patients; others are highly selective and exclude total
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 9 March 2015
Accepted 23 July 2015
Available online xxx
Keywords:
Daycare thyroidectomy
Case series
a b s t r a c t
Background: Outpatient surgery benefits patients and surgeons alike, as it is convenient, safe
and cost-effective. We sought to assess the safety and feasibility of daycare thyroid surgery in
a stand-alone Daycare Surgery Center in South India.
Aim: Our aim is to identify the difficulties, to formulate a protocol for daycare thyroidecto-
mies and also to discuss its feasibility.
Study design: Case series.
Methods: We performed a prospective study of 71 patients who underwent total or
hemithyroidectomy with or without neck dissection between January 2012 and March
2014 at Apollo Daycare Surgery Center, Chennai.
Results: Seventy-one patients met our inclusion criteria. Most patients were women (77%)
and men were 23%. Only 1 patient developed haematoma, 1 patient developed tetany, and
there was no incidence of stridor or recurrent laryngeal nerve injury.
Conclusion: Daycare thyroidectomies are safe and associated with low complication rate
provided a strict inclusion and exclusion criteria is followed along with meticulous surgery.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author.
E-mail address: Vikrampsj@yahoo.com (P.S.J. Vikram).
APME-306; No. of Pages 5
Please cite this article in press as: Babu Manohar M, et al. Daycare thyroidectomy surgery – Our experience, Apollo Med. (2015), http://dx.doi.
org/10.1016/j.apme.2015.07.010
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.07.010
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. thyroidectomies or procedures performed to treat cancer.
Finally, in several studies, the procedures are being performed
in 23-hour stay units. It may not be that safe to discharge
patients on the same day these procedures are performed.
Hence, we sought to review the outcomes of patients who
underwent thyroidectomies in an ambulatory centre. The
procedures were performed to treat benign diseases and
cancer and included hemithyroidectomies and total thyroid-
ectomies with or without neck dissection.
2. Methods
We conducted a prospective study of DTS performed at Apollo
Hospital, Chennai between January 2012 to March 2014.
Inclusion criteria for our study are outlined in Box 1.
Patients considered for this venue are made to meet an
anaesthesiologist in the preoperative clinic and the patients
are asked to remain in the city (within a 1-hour drive from the
hospital) for 48 h after the operation. It is made mandatory
that the patients remain in the presence of a second adult for
the same period of time.
2.1. Inclusion criteria
The following aspects are considered criteria for inclusion:
both benign and malignant thyroids, goitre of any size,
euthyroid status, hypothyroid status corrected, patient resid-
ing in town, within a 1-hour drive from the hospital, for at least
48 h, patient seen in preadmission assessment clinic (by an
anaesthesiologist) and cleared for day surgery (ASA grade I and
II patients). Every patient was observed in the surgical day care
unit for at least 4 h.
2.2. Exclusion criteria
The following aspects are considered criteria for exclusion:
ASA Grade III and above patients, goitre with compressive
symptoms, restrosternal extension, coagulopathy and age
more than 65 years.
2.3. Preoperative work up
Thyroid function tests: serum calcium, neck ultrasound/CT
scan, FNAC, indirect laryngoscopy, chest X-ray including neck,
preanaesthetic check up, councelling for day surgery and
endocrinologist opinion.
2.4. Procedure
Neck extension
Superficial cervical plexus block given
Local anaesthetic infiltrated
Standard skin crease incision given
Strap muscles retracted
Bipolar cautery only
Both the recurrent laryngeal nerves always identified and
preserved
At least 2 parathyroids identified and preserved
Minivac suction drain placed
3. Results
A total of 71 patients underwent procedures during our study
period. Most patients were women. The number of total thyroid-
ectomies is 48, which includes 3 one side modified radical neck
dissection (MRND), 1 bilateral MRND and 6 central neck node
dissections. The number of hemithyroidectomies is 23.
N Minimum Maximum Mean Std.
deviation
Age (years) 71 18 61 38.33 10.029
Valid N
(listwise)
71
N Minimum Maximum Mean Std.
deviation
Clinical size 71 3 10 4.92 1.918
Valid N
(listwise)
71
0 Frequency Percent Valid
percent
Cumulative
percent
Valid Euthyroidism 86.1 86.1 86.1
Hypothyroidism
(corrected)
13.9 13.9 100.0
Total 100.0 100.0
Frequency Percent Valid
percent
Cumulative
percent
Valid Benign 57 80.29 80.29 80.29
Malignant 14 19.71 19.71 100.0
Total 71 100.0 100.0
Frequency Percent Valid
percent
Cumulative
percent
Valid Total
thyroidectomy
48 67.61 67.61 67.61
Hemithyroidectomy 23 32.39 32.39 100.0
Total 71 100.0 100.0
Benign thyroids – 57
Malignants – 14
Papillary carcinoma – 10
Follicular carcinoma – 3
Medullary carcinoma – 1
Mean N Std.
deviation
Std. error
mean
Pair 1 Pre op-CA 9.508 71 0.5315 0.0886
Post op-CA 8.894 71 0.6210 0.1035
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
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4. Paired differences t df Sig.
(2-tailed)
Mean Std.
deviation
Std. error
mean
95% confidence
interval of the
difference
Lower Upper
0.614 0.4051 0.0675 0.477 0.751 9.093 35 0.000
3.1. Postoperative hypocalcaemia
Different studies showing low postoperative morbidity and
mortality (RLN transient and permanent injury) in daycare
thyroidectomy.
3.2. Postoperative haematoma
Different studies showing low postoperative morbidity and
mortality (postoperative haematoma) in day care thyroidecto-
my.
3.3. Postoperative haematoma timing interval
Different studies showing low postoperative morbidity and
mortality (postoperative cervical haematoma timing interval)
in day care thyroidectomy.
3.4. Postoperative RLN injury
Different studies showing low postoperative morbidity and
mortality (postoperative RLN transient and permanent injury)
in day care thyroidectomy.
4. Discussion
Even though DTS has been performed since the early 1980s, it
remains a controversial topic with two distinct schools of
thought. Most of the controversy revolves around the time
duration the patients should be observed for life-threatening
complications following the procedure. Many agree that this
depends on the type of thyroid surgery performed, as
procedures performed to treat cancer, completion or total
thyroidectomies have a greater potential for complications
given the extensive dissection involved. The existing literature
on short-stay thyroid surgery exhibits a great deal of variability
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3
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5. in definitions, inclusion criteria and results. Some
authors define same-day surgery, whereas others admit
patients before their surgeries for optimisation. Other authors
exclude patients with cancer because of the theoretical
implications of greater complications related to more exten-
sive dissection.
Finally, a large study from the Philippines did not include
total thyroidectomies. Airway compromise due to haematoma
formation is an immediately life-threatening complication
that requires close monitoring. These situations may require
immediate evacuation of the haematoma and sometimes a
second operation to obtain haemostasis. This complication
typically occurs early in the postoperative period, and it did not
occur in our study, suggesting that an observation period
ranging from 4 to 10 h is appropriate. Hypocalcaemia is more
common, usually occurring within 14–72 h after surgery.
Hypocalcaemia rates are reported to range from 6% to 30%.
Most of the higher rates have been observed in patients who
had total thyroidectomies. Many authors report on methods
used to predict which patients will experience hypocalcaemia.
Despite useful predictors of hypocalcaemia such as measure-
ment of parathyroid hormone that permit early discharge of
certain groups of patients, most methods are expensive, time-
consuming and not readily available in all centres. In our
study, we instructed patients to document and report
symptoms of paraesthesia, which is indicative of hypocalcae-
mia. The incidence of hypocalcaemia in our series was only
1.4%, which is substantially lower than in other series. We did
not examine the potential financial benefits of DTS. As with
other types of outpatient surgeries, hospital costs are reduced
when patients are safely discharged home on the day of their
surgeries. Outpatient thyroid surgeries are no exception. In
fact, many studies have shown financial benefits to OTS. Some
American studies have shown a savings of as much as 22–56%
compared with the same procedures performed on an
inpatient basis. It is unclear what the cost benefit would be
in an Indian centre.
5. Conclusion
Our review of ambulatory thyroidectomy demonstrates that
the feasibility of daycare surgery depends on the following
factors such as proper patient selection, mandatory preanaes-
thetic check-ups, preoperative patient counselling, short
acting anaesthetic drugs, standardised surgical technique,
good pain management, proper control of postoperative
nausea and vomiting, less expenditure, very alert and trained
recovery team.
Our review of OTS demonstrates that a short period of
observation (4–10 h) is safe and that thyroid surgery can be
performed as an outpatient procedure with an acceptable
complication rate. However, due diligence is essential, as it will
undoubtedly serve to establish quality controls and safeguards
to potential complications, which in turn will improve the
safety of such procedures. Patient education is an essential
first step in establishing such a program. Careful patient
selection and preoperative assessment provide important
safeguards. The facility of Accessible emergency services is
also critical for such procedures. Further studies assessing
patient satisfaction with day surgery will reinforce the benefits
of this approach.
Conflicts of interest
The authors have none to declare.
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