This document discusses the surgical management of benign thyroid disease. It covers:
1) Evaluation of thyroid enlargement including clinical examination, FNAC, ultrasound, and TSH levels.
2) Surgical principles including pre-operative, per-operative, and post-operative care.
3) Surgical options for thyroid enlargement including lobectomy, isthmusectomy, and total thyroidectomy.
4) Potential complications of thyroid surgery including recurrent laryngeal nerve injury, hypocalcemia, and bleeding.
2. Facts
1.
Palpable nodules – 5% women, 1% Men (High
Resolution US 19 – 67%)
2.
Risk of Cancer 5 -15%
3.
Non-neoplastic diseases of the thyroid affect
nearly 3/4 of a billion worldwide
4.
Iodine deficiency common worldwide Iodine
excess common in US (and in SL?) – contribution
to thyroiditis – Jod-Basedow phenomena
5. Clinical Evaluation
●
History childhood head and neck
irradiation
●
Family history of thyroid
carcinoma or thyroid cancer
syndrome
●
Rapid growth
●
Hoarseness
●
VC Palsy
●
LN enlargement
●
Fixation of nodule to the skin
7. Thy
Thy 1
Non-Diagnostic for cytological diagnosis
Thy1c
Non-Diagnostic for cytological diagnosis Cystic Lesion
Thy 2
Non - Neoplastic
Thy 2c
Non – Neoplastic Cystic Lesion
Thy 3a
Neoplasm Possible
Atypia/Non-diagnostic
Thy 3f
Neoplasm Possible
Suggesting follicular neoplasm
Thy 4
Suspicious of malignancy
Thy 5
Malignant
8.
9. Action Based on Thy
Thy 1
Thy 2
Thy 3
Thy 4
Thy 5
1+c
a +c
a+f
Repeat FNS
Consider USS
guidance
Describe as
cystic if no
epithelial cells
present
Repeat FNA if
no surgery
planned
Discuss at MDT
Discuss at MDT
Discuss at MDT
Diagnostic
Lobectomy
usually
recommended
Diagnostic
lobectomy +/on table frozen
section to
proceed to total
thyroidectomy
+/- central node
clearance in
high risk
patients
Radiotherapy/ch
emotherapy or
surgery where
indicated
Consider total
thyroidectomy in
larger lesions
>4cm where
incidence of
malignancy is
high
Appropriate
further
investigations
for staging when
indicated
Total
thyroidectomy
+-central node
clearance in
appropriate high
risk patients
13. Surgical Decision Making
●
Nature of the goiter
–
Degenerative
–
Neoplastic
–
Physiological
●
Function of the goiter
●
Compression and Extension
●
Cosmetic
●
Patient comorbidities
14. Indications
●
Compressive symptoms esp. with sub-sternal
goitre
●
Concerned about the risk of malignancy –
diagnostic lobectomy and isthmusectomy
●
Controlling hyperthyroidism
●
Cosmetic – 5cm
Laryngoscope, 121:60–67, 2011
The Surgical Management of Goiter: Part I. Preoperative Evaluation
Jennifer J. Shin, MD; Hermes C. Grillo, MD*; Doug Mathisen, MD; Mark R. Katlic, MD; David
Zurakowski, PhD; Dipti Kamani, MD; Gregory W. Randolph, MD
Laryngoscope, 121:60–67, 2011
32. Complications
●
RLN – 7%, permanent 3.6%
●
Hypocalcaemia – 10-20%, permanent 1-5%
●
Bleeding – Haematoma formation – 5%
●
Scar
Assessment of the Morbidity and Complications of Total Thyroidectomy
Neil Bhattacharyya, MD;Marvin P. Fried, MD
•
Conclusions Postoperative hypocalcemia is the most common immediate surgical
complication of total thyroidectomy. Other complications, including recurrent laryngeal nerve
paralysis, can be expected at rates approximating 1%.
JAMA Network | JAMA Otolaryngology–Head & Neck Surgery | Assessment of the Morbidity
and Complications of Total Thyroidectomy
33. Controversies
●
Drain or not to drain
●
Wound Closure
●
Routine Calcium Supplementation
●
DL examination of VC function at recovery
●
Post op T3 or T4
●
Contrast in CT in imaging
35. Endoscopic Thyroidectomy
What is the Evidence for Endoscopic Thyroidectomy in the
Management of Benign Thyroid Disease?
E. Th. Slotema, F. Sebag, J. F. Henry
World J Surg. 2008 July; 32(7): 1325–1332
42. William Halstead
• Sterile Operating Room
Concept
• Invented Surgical Gloves
• Introduced Radical
Mastectomy
• Performed first emergency
blood transfusion
• Intestinal Suturing
43. William Halstead
“The extirpation of the
thyroid gland for goitre ……
provide(s) perhaps more
than other operations the
supreme triumph of the
surgeons art”
William Halstead