HOSPITAL PUTRAJAYA

Putrajaya
Capital Administrative City
Malaysia
 THYROID CANCER SURGERY:
SURGEON’S APPROACH TO THE THYROID
GLAND AND THE IMPORTANCE OF
TECHNIQUE

HISHAM AN
DEPARTMENT OF BREAST & ENDOCRINE SURGERY
PUTRAJAYA HOSPITAL,
PUTRAJAYA, MALAYSIA
Introduction
In the 1850s thyroid surgery was often
associated with a high mortality of up to 40%
Cause of death: Uncontrollable bleeding
Wound infection

Kocher redefined the technique of thyroid

Year Kocher’s mortality
1884 14% Emil Theodor Kocher
(1841-1917)
1889 2.4%
1898 0.18%
Introduction

In 1970’s

• Bilateral subtotal thyroidectomy was the standard

procedure for multinodular goitre and Graves’ Ds
• Surgery for recurrence of nodular goitre was common
(25%) and persistence of symptoms was a problem
• Graves’ patients still had recurrence (5%) and long-
term hypothyroidism was very common (72%)
• Total thyroidectomy was virtually only performed for
thyroid cancer
 Evolution of technique
1970s Now
Thyroidectomy Bilateral subtotal Total
*(completeness of surgery)

Technique Lateral dissection Capsular dissection

- RLN “encountering”
- routine ELN identification
Parathyroids Preservation Autotransplantation
- in situ - ready
- routine
*Completeness Anatomical Embryological
- Tubercle of Zuckerkandl
- descent remnants
Embryological Descent

Descent from the

foramen of caecum
• thyroglossal
• pyramidal
• thyrothymic

lateral migration from 4th

branchial pouch &
ultimobranchial body

continued descent
Completeness of surgery: Pyramidal Area
– The pyramidal area up to the laryngeal
cartilage should be a routine part of
dissection in every total thyroidectomy

– even minimal recurrence in this area is

very apparent to the patient
Embryological Descent

Embryological descent of
thyroid tissue continues
towards and into the
mediastinum alongside
thymus
Completeness of surgery: Thyro-thymic Area

– if not removed then these

remnants may appear later as
retrosternal recurrence

– routine dissection of the thyro-

thymic area down to the
thoracic inlet should be part of
every total thyroidectomy
Classification of Thyro-thymic rests

Failure to remove all the

thyrothymic rests will lead
to recurrent retrosternal
goitre:

Type 1

Sackett WR, Reeve TS, Barraclough B, Delbridge L

J Am Coll Surg 2002 Nov;195(5):635-40
Classification of Thyro-thymic rests

Failure to remove all the

thyrothymic rests will lead
to recurrent retrosternal
goitre:

Type 2

Sackett WR, Reeve TS, Barraclough B, Delbridge L

J Am Coll Surg 2002 Nov;195(5):635-40
Classification of Thyro-thymic rests

Failure to remove all the

thyrothymic rests will lead
to recurrent retrosternal
goitre:

Type 3

Sackett WR, Reeve TS, Barraclough B, Delbridge L

J Am Coll Surg 2002 Nov;195(5):635-40
Thyro-thymic rests Type III
Thyro-thymic rests Type III
Madam SA, 59 year old
Neck swelling > 30 years
No compressive symptoms

Type I B
Anterior
Substernal extension
Thyro-thymic rests Type III

Type I B
Anterior substernal goiter
 Thyro-thymic rests Type III

Type I B Anterior substernal goiter.

Total thyroidectomy with median
sternotomy: Goiter – 850 grams
 Follow up
Type I B Anterior substernal goiter

2 years post-op

1- year post-op
Classification of Thyro-thymic rests

Failure to remove all the

thyrothymic rests will lead
to recurrent retrosternal
goitre:

Type 4

Sackett WR, Reeve TS, Barraclough B, Delbridge L

J Am Coll Surg 2002 Nov;195(5):635-40
Thyro-thymic rests Type IV

Madam MZ, 56 years old

Asymptomatic

Substernal goiter found on

screening CXR
Thyro-thymic rests Type IV

Type I A: Anterior Isolated

mediastinal goiter
Thyro-thymic rests Type IV

Type I A: Anterior Isolated

mediastinal goiter
Incomplete removal of all the thyrothymic rests

Madam YNN, 53 year old

Had a previous Left hemithyroidectomy
Presented with 6 month of chest pain.

CT scan
anterior & middle mediastinal mass
on right side, straddling & compressing
Left Brachiocephalic vein
Recurrent thyro-thymic rest Type 4

Sackett WR, Reeve TS, Barraclough B, Delbridge L

J Am Coll Surg 2002 Nov;195(5):635-40
Anatomic Classification of Substernal goiter

TYPE SUBTYPE DESCRIPTION

I ANTERIOR
A Isolated anterior mediastinal thyroid
B Substernal extension

II POSTERIOR
A Isolated posterior mediastinal thyroid
B Ipsilateral posterior mediastinal extension
C Contralateral posterior mediastinal extension
1 Retrotracheal
2 Retroesophageal
Shahian DM
Posterior retrosternal
goitre Type II B
Posterior retrosternal
goitre Type II B
Posterior retrosternal goitre Type II C
Posterior retrosternal
goitre Type II C
Completeness of surgery: Zuckerkandl tubercle

Failure to remove enlarged

remnants of Tubercle of
Zuckerkandl is a significant
cause of persistent symptoms

Hisham et al
Aust NZ J Surg.2000;70:251-3
Incomplete surgery

Recurrence or persistence
from Zuckerkandl Tubercle

Hisham et al
Aust NZ J Surg.2000;70:251-3
Incomplete surgery
Case study
Recurrent from Zuckerkandl Tubercle
Completeness of Surgery
Recurrence from
Zuckerkandl tubercle
 Conclusions

1. The concept of “completeness” or “total thyroidectomy”

has evolved from anatomical to embryological approach
giving detail attention to the surgical technique to ensure
safe dissection and minimize the morbidity related to the
surgery.
Thank You