ENDOCRINE SURGERY
Thyroidectomy
MP Rowland
Susannah L Shore
Abstract
This article discusses the procedure and technique for performing a
thyroidectomy: explaining complications, potential pitfalls and
methods of avoiding them. We also discuss the indications for surgery
and the preparation required especially for thyrotoxic patients and
those with retrosternal goitres. We also discuss the ever increasing is-
sues with consent and how thyroid surgeons are monitored in the UK.
Keywords Complications; consent; indications for thyroidectomy;
lobectomy; thyroid; thyroidectomy
Introduction
Thyroidectomy refers to the surgical excision of part of or all of
the thyroid tissue; currently most surgeons would understand a
thyroidectomy to take the form of one of the following e
isthmectomy, lobectomy (hemi-thyroidectomy), total thyroidec-
tomy or near-total thyroidectomy. Many patients presenting to
clinics have previously had sub-total thyroidectomies, but this is
not a common operation in the UK, given the risk of recurrent
disease and the difficulties with re-operation1 (for definitions see
Table 1).
Thyroidectomy has evolved considerably from a 100 years
ago where the mortality and morbidity was unacceptably high to
the current stage where mortality is negligible and morbidity is
low, with transparent audit and governance procedures in place.2
Thyroidectomy continues to evolve with new techniques such as
robotic and minimally invasive thyroidectomy growing in
popularity.3 A thyroid resection remains a challenging but usu-
ally elegant operation; all those who wish to perform it should be
adequately trained and maintain a log of their outcomes.
This article will give an overview of the important facets to
thyroidectomy in general, including indications, techniques,
risks and the consent process.
Indications for surgery
A thyroidectomy may be performed for benign or malignant
pathology. Benign pathology includes a goitre with pressure
symptoms and/or cosmetic concerns, toxic nodule(s)/toxic-multi
nodular goitre and recurrent or treatment resistant Graves dis-
ease. Thyroidectomy may be performed on recurrent cysts or a
retrosternal goitre that is enlarging or is associated with signifi-
cant tracheal deviation or compression.
MP Rowland MB ChB MA FRCS is an ST8 Endocrine and Breast
Surgical Trainee at Royal Liverpool and Broadgreen University Trust,
Liverpool, UK. Conicts of interest: none declared.
Susannah L Shore MB ChB MD FRCS is a Consultant Endocrine
Surgeon at Royal Liverpool and Broadgreen University Trust,
Liverpool, UK. Conicts of interest: none declared.
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Please cite this article in press as: Rowland MP, Shore SL, Thyroidectomy, Surgery (2017), http://dx.doi.org/10.1016/j.mpsur.2017.06.020
From a malignant perspective, indications for thyroidectomy
include biopsy proven thyroid carcinoma, indeterminate lesions
(Thy3f cytology) and prophylactic thyroidectomy for those with
the RET genetic mutation, predisposing to medullary thyroid
carcinoma. The type of resection and need for lymph node
dissection will vary with the clinical, radiological and cytological
findings. In the UK, recent trends are towards more limited
resection (hemithyroidectomy instead of total thyroidectomy) in
and avoidance of prophylactic lymph node dissection in low risk,
well differentiated cancer.4
Extent of resection
Thyroid surgery encompasses a variety of resection types (Table 1).
This may be based on pathology (for example, total thyroidectomy
for Graves disease) or tailored to the anatomy of the goitre (isth-
mectomy or hemi-thyroidectomy in asymmetrical goitre) or prog-
nosis of disease (limited resection in good prognosis thyroid
cancer). The need for and extent of lymph node dissection in thy-
roid cancer depends on the presence of proven lymph node disease
and overall risk of recurrence. When describing lymph node dis-
sections, it is most accurate to describe the precise anatomical
compartments dissected (i.e. levels IIeV) rather than using un-
clear terminology such as lateral dissection.4
Perioperative assessment and planning
All thyroidectomies should be planned to reduce the morbidity
involved. It is uncommon for thyroidectomy be performed ur-
gently other than for tracheal compression with stridor.
Assessment includes a full history and examination, focus-
sing on symptoms of thyroid dysfunction, compression of
neighbouring structures and changes in gland or nodule(s)
size. A family history of endocrinopathy and exposure to pre-
vious radiotherapy can influence the risk of malignancy,
threshold for surgery and extent of resection. If a previous neck
operation has been performed, assessment of voice and laryn-
geal function and ongoing calcium and/or vitamin D supple-
ments are important.
Preoperative investigations should include thyroid function
tests (TFTs), thyroid antibody levels and ultrasound with or
without fine needle aspiration cytology (FNAC) for assessment of
any nodules.5 Any patient with non-Graves thyrotoxicosis
should undergo a technetium scan, as technetium uptake by
hyper-functioning (hot) nodule(s) will allow the surgeon to
decide between a total or hemithyroidectomy for cure of thyro-
toxicosis. Where hyper-functioning nodules are encountered,
cytology is generally unhelpful; as frequently give atypical results
are obtained.4 A CT scan may help in patients with compressive
symptoms or suspected retrosternal extension. To evaluate
distortion or narrowing of the trachea and to predict the likeli-
hood of the need for manubriotomy or formal sternotomy. In
patients with suspected locally advance thyroid cancer, CT and
MRI staging may be helpful4 for assessment of major vascular
invasion, extent of lateral lymph node involvement, oesophageal
and tracheal invasion or invasion of vertebral fascia (thus indi-
cating inoperability). Advanced tumours are, however, only a
small percentage of most differentiated thyroid cancers. Preop-
erative discussion at a thyroid cancer MDT is highly desirable4 in
all cases of suspected and confirmed cancer.
1 Crown Copyright 2017 Published by Elsevier Ltd. All rights reserved.
 ENDOCRINE SURGERY
Definitions for thyroid resections and thyroid-related
lymph node dissections
Term Definition
Thyroid lobectomy Complete resection of a
(hemi-thyroidectomy) lateral lobe of the thyroid
including the isthmus
Isthmusectomy Excision of the Isthmus
(any pyramidal tissue)
with preservation of both
lateral lobes of the thyroid
Total thyroidectomy Complete excision of both
lobes, the isthmus & any
pyramidal lobe
Near-total thyroidectomy Resection of >99% of the
thyroid tissue with
preservation of a non-
functional remnant(s) of
tissue preventing injury to
the RLN or parathyroid
Sub-total thyroidectomy Partial resection of the
thyroid (although no
specified amount) with the
aim to achieve functional
status, however this is no
longer an advisable
operative strategy in the UK.
Central neck dissection Excision of the lymph nodes
in Level VI  Level VII of the
neck
Lateral neck dissection Excision of the lymph nodes
in the neck e classically
Level IIeV
Selective neck dissection Tailored dissection of
the lymph nodes from levels
IeVII
Adapted from the UK 2014 Guidelines for the management of thyroid cancer:
Surgery for differentiated thyroid cancer tables 7.1 & 7.2
Table 1
The British Association of Endocrine and Thyroid Surgeons
(BAETS) and American Academy6 recommend routine pre- and
postoperative vocal cord assessment with laryngoscopy to rule
out pre-existing recurrent laryngeal nerve palsy, which may be
asymptomatic. Occasionally, flow-volume loops may help in the
assessment of the breathless patient with a possible obstructing
goitre to differentiate between lung disease and tracheal nar-
rowing by the goitre as the cause of breathlessness.
All patients should be euthyroid for the day of surgery. Even
in patients intolerant or allergic to common anti-thyroid medi-
cations, control can be achieved with beta blockers, cholestyr-
amine, Lugols iodine and high-dose steroids. Perioperative
Lugols-iodine solution 10 days before surgery will also reduce
the vascularity of a Graves disease.7 It is helpful to ensure the
patient is vitamin D replete so as to reduce the risk and severity
of hypocalcaemia in the postoperative phase.
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Consent
As with all consent processes, clinicians should discuss the in-
dications for surgery, alternative treatment options, explanation
of the procedure and the side effects of the proposed treatment;
written information leaflets and drawings should supplement this
process. The patient will need time to consider information so it
may be better to avoid consenting on the day of surgery. Clini-
cians broadly discuss risks such as bleeding with return to
theatre (w1.0%); infection, RLN injury causing change to voice
and/or swallowing (w1e2%); the need for postoperative cal-
cium and vitamin D supplements (this may be temporary or
permanent); hypertrophic scarring (additional warnings about
keloid scarring if appropriate); and potential for hormone
replacement with levothyroxine. Complication rates may be
higher in re-do surgery, retrosternal disease and malignancy.
Recently, consent law in England has changed; following the
case of Montgomery v Lanarkshire Health Board [2015] UKSC
11, the focus of consent has changed from a clinician driving
what the patient should be consented about, to what the patient
would want to know. The change in practical terms means a
patient should be consented regarding the risks that an indi-
vidual patient would want to know and would affect their deci-
sion making about this procedure, rather than with the risks that
a respectable body of thyroid surgeons would deem important to
patients. Although this may seem a subtle change, it suggests we
need to tailor the consent more closely to the individual, rather
than adopt a generic consent process to fit all. Examples would
be greater detail on change in voice especially in singers or
lecturers from EBSLN injury, and rare, but highly significant,
events such as need for tracheostomy, chyle leak and oeso-
phageal injury should be considered in patients having extensive
surgery.
Operative procedure
A description of a thyroidectomy via a low-transverse cervical
(collar) incision will follow; many elements of the approach will
reflect the senior authors preferences and experience. Other
surgical approaches, such a trans-axillary thyroidectomy will be
briefly discussed; but it should be borne in mind that most pa-
tients will not be suitable for minimally invasive surgery and
conventional thyroidectomy will remain the most common
procedure.8
Preparation
Before surgery, it is the responsibility of the operating surgeon
and anaesthetist to review relevant investigations and decide on
the surgical strategy. The consent should ideally be refreshed
with the patient on the day of surgery and the side marked, if
appropriate.
General anaesthesia with endotracheal (ET) intubation is
most commonly used, although occasionally local aesthetic
techniques have been employed. The use of an intermittent or
continuous nerve monitoring system will require a specialist ET
tube to be placed, with electrodes on the tube to capture move-
ment of the vocal cords intraoperatively (see Figure 1 for classic
EMGs); long-acting neuromuscular blocking agents should
therefore be avoided. Following intubation, the patient is posi-
tioned supine on the table with a shoulder support and head ring
2 Crown Copyright 2017 Published by Elsevier Ltd. All rights reserved.
 ENDOCRINE SURGERY
Recurrent laryngeal nerve monitoring
Pre-dissection
Stim 1: 1.00/1.01 mA 03/05/2011 12:20
Event Threshold: 100 V Stim Rej. Period: 2.1 ms
1 Vocalis Left 830V
2 Vocalis Right 1295V
500V 25ms
Comments:
RLN nerve monitoring recorded at first identification of nerve and after thyroidectomy completed. Note the voltage,
which can be used to aid diagnosis of nerve trauma.
Figure 1
allowing neck extension; this allows good access but care is
required to avoid hyperextension. The neck is prepared and
draped; no antibiotic prophylaxis is necessary and DVT pro-
phylaxis should be considered according to local policy.
Incision
In a conventional thyroidectomy, a collar incision (Kocher inci-
sion) is used, approximately 2 cm above the sternoclavicular
joints in neck extension. If the upper thyroid poles are high in the
neck or (paradoxically) if the goitre is retrosternal the incision
may be placed higher. The midline is identified and a transverse
incision of approximately 4e8 cm is made, symmetrically around
the midline. If the thyroid is large then the incision may need to
be longer. The skin is incised with a blade and the subcutaneous
tissue including the platysma is divided, often with monopolar
diathermy. Sub-platysmally there is an avascular plane; raising
the skin flaps with retractors will demonstrate this plane and
allow mobilization of sub-platysmal flaps with diathermy from
the muscles and anterior jugular vessels below. The flaps should
be raised cranially to the thyroid cartilages, caudally to the
sternum and heads of clavicles; and laterally to the sternoclei-
domastoid (SCM) muscles. A self-retaining retractor(s) such as
Jolls can be used to part the skin flaps and a Langenbecks
retractor can be used to retract the SCM muscle laterally.
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Postdissection
Stim 1: 1.00/1.01 mA 03/05/2011 13:04
Event Threshold: 100 V Stim Rej. Period: 2.1 ms
1 Vocalis Left 837V
2 Vocalis Right 1050V
500V 25ms
Comments:
Exposure
The strap muscles must be parted in the midline; in the majority
of cases they can be fully preserved by finding the avascular
raphe between them. When the thyroid is very large or a re-
exploration, it may help to divide the sternothyroid ( the ster-
nohyoid) muscle to expose anterior neck; divided muscles can be
re-apposed with interrupted sutures on closure. Division of the
middle thyroid vein is done before moving on to mobilize the
poles of the thyroid lobe.
Mobilization of the upper pole
The upper pole should be freed from the facia of the carotid
gutter laterally and the cricothyroid muscles medially. Once a
plane on thyroid capsule is established, the vessels should be
identified and taken individually on the thyroid with ties, clips
or energy devices. Each method has its own advantages and
disadvantages and the surgeon should use whichever method
they feel most adept with. Ligation of vessels onto the capsule
allows for a capsular dissection,9 reducing the chance of injuring
the external branch of the superior laryngeal nerve (EBSLN) as it
courses medially towards the cricothyroid muscle. Behind the
upper pole, the superior parathyroid may be identified and pre-
served. If not seen clearly, further dissection to identify it is not
necessary as long as the dissection is kept to a capsular plane.
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 ENDOCRINE SURGERY
Identication of the recurrent laryngeal nerve (RLN)
Once the upper pole is free it should be possible to medially rotate
the thyroid lobe, exposing and dissecting the rest of the carotid
gutter. The inferior cornu of the larynx can be palpated as the
landmark as to where the RLN enters the larynx. Identification of
the RLN at this early stage of the dissection is ideal, but may not
always be possible. Blunt dissection with the forceps will often
reveal the nerve, remembering its course will be more oblique on
the right side of the neck and more vertical on the left. Always
remain vigilant to the possibility of a non-recurrent laryngeal
nerve; this will course horizontally from the vagus towards the
inferior cornu and is more likely on the right side.10 A nerve can
be confirmed by a positive trace with a nerve monitor.
If the nerve cannot be found it may become necessary to
mobilize the inferior pole of the thyroid, keeping dissection
strictly to the capsule, while constantly looking for the nerve.
Mobilization of the lower pole of the thyroid and
identication of the lower parathyroid
Mobilization of the lower aspects of the gland is easier once you
have clearly defined the RLN, but the principle of capsular-
dissection should continue regardless. This will ensure that the
parathyroids along with their blood supply are preserved. The
lower pole vessels are isolated and ligated as per the upper pole.
For those thyroids reaching the thoracic inlet or extending ret-
rosternally, the vast majority of the vascular supply remains in
the neck. Therefore, once these vessels are ligated the lowest part
of the inferior pole may be drawn up into the neck with traction
on the upper parts of the thyroid.
The parathyroid glands may be encountered during the lower
pole mobilization. They are commonly found within a 1e2 cm
radius around the intersection of the inferior thyroid artery and
the RLN. The superior parathyroid may be found superior to the
artery and posterior to the plane of the nerve, often adherent to
the posterior border of the thyroid. The position of the inferior
gland tends to be more variable, more commonly located infe-
rior and anterior to the nerve in the thyro-thymic tract. Dissec-
tion on the thyroid capsule will preserve the majority of glands.
If a gland is inadvertently excised or devitalized it should be
preserved in saline for auto-transplantation at the end of the
procedure.
Managing the isthmus
The isthmus should be dissected free of the trachea superiorly
and inferiorly. In a thyroid-lobectomy it will need to be divided
near to the remaining lobe. In a total thyroidectomy, ligation of
the isthmus can help reduce bleeding from the already dissected
lobe that is still been supplied from the other side. The isthmus
can be lifted from the trachea with bipolar diathermy or energy
devise, taking care not to enter the trachea. The isthmus can be
divided with a knife (between clips) or energy device; the capsule
is over sewn and sometimes attached to the trachea for
haemostasis.
Haemostasis
At the end of the procedure the patient is placed head down, the
thyroid bed is irrigated with water (not saline) and a Valsalva
manoeuvre is simulated via the ET tube, to raise the venous
pressure, thus demonstrating any venous bleed. Small arteriole
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bleeding is best identified with the anaesthetist raising the sys-
tolic pressure to a systolic >100 mmHg.
Drain or no drain?
Drains may be placed after thyroidectomy, but should not be
seen as a haemostatic measure as they do not reduce the chance
of a neck bleed and return to theatre11,12 and can become
blocked, falsely reassuring the inexperienced. Drains do, how-
ever, reduce seroma collections. Neither drains nor haemostatic
products should be seen as a cover for poor haemostatic
technique.
Closure
The strap muscles are brought together by suturing the midline
fascia, thus preventing the sub-platysmal flaps adhering to the
trachea. An opening is often left inferiorly when the midline to
enable any bleeding in the deep compartment to vent superfi-
cially and cause visible swelling. Platysma is closed with an
absorbable suture taking care to avoid bunching of tissues and a
poor cosmetic result. The skin edges need to be opposed neatly
and this can be achieved with a subcuticular suture (absorbable/
non-absorbable) and/or glue.
Postoperative care
Ideally the anaesthetist should wake the patient with the minimal
of coughing and straining, with the surgeon available in case of
immediate bleeding. The patient should be recovered and
transferred to a dedicated ward experienced in managing patients
following neck surgery; overnight stay is advised to monitor for
bleeding which is most common in the first 6 hours but can occur
later.12 A clear policy should exist on whom to call, and what to
do if bleeding occurs. Nursing and medical staff should know
how to open the skin and platysma on the ward so as to
temporize a life-threatening neck haematoma. Adjusted calcium
(and parathyroid hormone levels if available) are performed
between 6 and 24 hours postoperatively after completion or total
thyroidectomy, to predict hypocalcaemia. Postoperative laryn-
goscopy can assess vocal cord function, especially if there is a
hoarse voice, ineffective cough or dysphagia.
Novel adjuncts and approaches
There are a variety of modifications to standard thyroidectomy
including the type of approach, use of nerve monitoring and
what to do with the devitalized parathyroid; these modifications
essentially all aim to reduce areas of morbidity in thyroid surgery
and are discussed below.
Alternative surgical approaches
There are two principal alternative approach types: the use of
minimally invasive cervical techniques and remote-access ro-
botic techniques. Endoscopic neck surgery was first described in
1996 by Michael Gagner for parathyroidectomy but the technique
for thyroidectomy followed shortly after. The aims of minimally
invasive procedures are improved cosmetic results, reduced
postoperative discomfort and paraesthesia; while maintaining
reduced rates of nerve injury and hypoparathyroidism.13 How-
ever, many surgeons would argue that the conventional
approach has minimal postoperative discomfort and the scar
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 ENDOCRINE SURGERY
generally heals well. Miccoli et al. use a minimally invasive
video-assisted procedure, with smaller cervical incision and
reduced dissection.3 Patient selection for these procedures is
important as endoscopic surgery is limited by nodule size. The
approach is viable in small papillary thyroid cancer nodules in
the absence of palpable neck involvement, no thyroiditis, a
relatively normal thyroid gland and no previous neck surgery or
radiation.14
Remote approaches to the thyroid include trans-axillary thy-
roidectomy, trans-areolar or infra-clavicular approaches, post-
auricular and trans-oral approaches.15 These approaches are
longer and more invasive than conventional thyroidectomy. Pa-
tients have longer recovery times and surgeons have a steep
learning curve.16 Robot-assisted thyroidectomy may facilitate the
application of these approaches. In the UK, this is limited to a
handful of centres and to patients with a BMI <32, with a small
thyroid gland (<5 cm), unilateral nodule, non-malignant disease
and in the absence of thyroiditis.17
Some complications unheard of with the conventional
approach have been reported and these include brachial plexus
damage, postoperative breast tissue anomalies, oesophageal
injury, prolonged shoulder discomfort, chest wall hyperaesthe-
sia, retained thyroid tissue and excessive blood loss. For this
reason, these approaches should be considered investigational.
Intraoperative nerve monitoring
There appears to be a widespread acceptance that visual identi-
fication of the RLN is the gold standard to prevent injury, but
this can be complemented by intraoperative neural monitoring
(IONM). American International Standards suggest that IONM
should be used for identification of the RLN, aiding dissection by
identifying adjacent non-neural tissue and prognostically for
predicting neural function postoperatively, preventing bilateral
vocal cord paralysis requiring a tracheostomy. The ET tube is
sited so that the electrodes are at the level of the glottis and the
largest tube possible is selected. A stimulation probe with
approximately 1e2 mA is used to stimulate the identified nerve,
which creates an arc between the RLN and the probe generating
an EMG recorded via the ET tube; the EMG provides visual and
auditory signals on a monitor (see Figure 1 for classic IONM
EMGs). National Institute for Health and Care Excellence NICE)
guidelines support the use of IONM in cases of re-do or thyroid
cancer surgery;18 and the steering group also agreed that IONM
had a place in training and provides hard evidence in litigation.
Continuous nerve monitoring is also possible e this requires the
placement of a probe on the vagus nerve to provide a continual
circuit; loss of amplitude of the nerve conductions intra-
operatively should warn the surgeon that the nerve is being
damaged by traction or other elements to the dissection, which
must be stopped or modified immediately.
Parathyroid auto-transplantation
Every effort is made to preserve the parathyroid glands with
capsular dissection; however, occasionally glands cannot be
preserved in-situ if they have been devascularized during
dissection. In this scenario, the parathyroid should be kept from
drying out in a small amount of sterile saline. At the end of the
case pockets in the anterior aspect of one sternocleidomastoid
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muscle are created, the parathyroid diced into small pieces and
inserted into the pockets which are closed with a dyed prolene so
it can be easily located if needed. Fine dicing should leave small
fragments of parathyroid that neo-vascularize overtime, but
function can take several months even if the transplant is suc-
cessful. Recent publication casts doubt on the effectiveness,19 but
in a non-cancer case there is minimal harm in attempting
transplantation.
Psychology of operating
Each thyroidectomy will present different challenges. The sur-
geon needs to appreciate this and the other environmental factors
that will influence surgery, such as the experience of the anaes-
thetist and surgical assistant. When the case is not progressing as
planned it is essential the surgeon has strategies to safely com-
plete the operation:
 Plan well and leave plenty of time for cases that can be
predicted to be long and difficult.
 The table can be tilted or surgeon change sides of the table
to help with view especially if the RLN, allowing safe
progress.
 Most bleeding comes from ooze from the thyroid, espe-
cially as the venous pressure rises with ligation of main
vessels; the ooze stops when the thyroid is out, so the
surgeon should keep securing the vessels in the neck and
keep the RLNs in view.
 An experienced assistant cannot be underestimated in very
complex/challenging cases. Surgeons should also not be
afraid to ask for colleagues opinion or help.
 If the RLN trace is lost with IONM on one side, the surgeon
should decide if they really need to perform the contra-
lateral lobectomy that day, or could it wait? Often traction
palsy on the nerve will recover allowing a completion-
thyroidectomy in the future with both nerves functional
again.
Summary
Thyroidectomy is an operation that has evolved from a high-risk
operation with life-long morbidity to a safe and fine-tuned pro-
cedure in experienced hands with robust clinical audit measures
in place. Surgeons from a variety of specialities of will learn
thyroidectomy and the importance of high quality mentorship
cannot be understated. This chapter demonstrates one method
for thyroidectomy, the associated risks and possible alternative
methods available. A
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