Total Thyroidectomy

Procedure Description: 

Based on your condition, the otolaryngologist (a surgeon who performs thyroid surgery) will take one of the following surgical approaches for your surgery:

1. Hemithyroidectomy (lobectomy thyroidectomy): The surgeon will remove one entire lobe and isthmus in this method. This method is performed for indeterminate nodules.
2. Total thyroidectomy: The surgeon will remove both lobes and isthmus in this method. This method is performed in cases of cancer.
3.  To perform thyroidectomy, the otolaryngologist will:

Make a five-centimetretimetre cut in the skin's Langer's line and create two skin flaps 

1. Secure the flap by using stitches.
2. Divide the strap muscles in the midline present in the neck to reach the thyroid capsule (the covering over the thyroid gland). 
3. Dissect the left lobe of the thyroid gland and expose the thyroid gland's front part.
4. Carefully withdraw the strap muscles so that the veins in the thyroid gland are not affected. After this, the external branch of the superior nerve present in your voice box is exposed. 
5. Use criss-cross stitches to ligate (tie) the upper vessels.
6. Remove the isthmus by doing a blunt dissection.
7. Expose the hilar structures by dividing the superior vessels completely. The surgeon ensures that the inferior thyroid blood vessel and its branches are preserved as much as possible since they are essential for supplying blood to the two parathyroid glands.
8. Cut the vessels running to the lower pole after properly exposing a nerve present in your voice. 
9. Expose the veins from the superior anterior mediastinum (between the lungs) and divide them.
10. Dissect the left lobe away from the trachea during the final steps of the thyroidectomy. At this time, the nerve in your voice box is still exposed but kept intact. However, there is a risk of thermal injury to that nerve; hence, the surgeon avoids any cautery or other thermal dissection equipment at this point. 
11. Close the wound using an intradermal running suture (applied within the layers of the skin) made of 5-0 absorbable thread. A post-operative drain will not be able to replace correct haemostasis (stoppage of bleeding) and will be of little or no use if there is extensive post-operative bleeding.
12. Thyroidectomy procedure will take anywhere from 45 minutes to three hours, depending on whether the surgeon removes one or both the lobes.[8] During the first 24 hours following thyroidectomy, a smooth collar may be used. You will be instructed to keep a head-up position of around 30 degrees to avoid swelling of the soft tissues around the wound because of venous congestion.

What to Ask and Tell Your Doctor?

You can ask the following questions to your otolaryngologist during the appointment: 

1. Why do I need a thyroidectomy?
2. Is there any alternative to the surgery? 
3. What will happen if I choose not to undergo thyroidectomy? 
4. What is the benefit of thyroidectomy?
5. How long will the surgery take?
6. Do I have to stay overnight in the hospital?[10] 
7. What are the risks and complications of this surgery? 
8. How much time will I take to recover after surgery?
9. Can I continue my routine medications?
10. While you are at your appointment, you must inform your otolaryngologist if you are: 
11. Currently using any prescription, non-prescription, or herbal medications.
12. Currently using any medications to relieve pain. 
13. Having any health condition (e.g., pregnancy, diabetes, high blood pressure, breathing problems, heart problems, etc.). 
14. Having allergies to food and medications.
15. A smoker.

What to Expect Before Surgery?

You can plan the following before surgery:

1. In the case of blood-thinning medications, you must contact your physician to discuss stopping them before your surgery.
2. The anesthesiologist will see you at least one week before your surgery for a preoperative examination.
3. It is challenging to detect thyroid disorders early because their symptoms are similar to other illnesses. However, specific tests can help determine whether a thyroid issue causes your symptoms. These tests include:
4. Blood tests: These tests can determine TH levels in your blood. Low TH can signal hypothyroidism, while high TH can signal hyperthyroidism.
5. Thyroid profile: This blood test helps check the levels of thyroid-stimulating hormone (TSH), T3, and T4. The levels of TSH help to detect the imbalance of TH, T3 levels are used to check the presence and severity of hyperthyroidism, and T4 levels detect hypothyroidism and hyperthyroidism.[2,10]
6. Calcitonin: This test can diagnose two uncommon diseases- medullary thyroid cancer and C-cell hyperplasia.
7. Ultrasound imaging: This imaging test uses high-frequency sound waves to produce images and videos of the body tissues. Radiation is not used in this test. Your neck is treated with gel before a probe is placed on it, and a thorough thyroid examination is performed.
8. Radioactive iodine test: You will need to swallow radioactive iodine in this test. The thyroid gland takes iodine from the bloodstream to produce enough of the hormone T4. Further diagnosis is carried out based on the amount of radioactive iodine absorbed from the blood by the thyroid gland. Uptake is very high if the thyroid gland is overactive (hyperthyroidism). However, the uptake is low when the thyroid gland is underactive (hypothyroidism).
9. Technetium scan: Technetium-99m is used to analyse the size of the nodules, remnant thyroid tissue, distant and nodal metastases before 131 Iodine therapy.
10. The doctor will discuss the planned procedure with you. You will need to sign the consent form before the surgery.

What to Expect on the day of Surgery?

Preoperative measures:

The surgeon will use a permanent marker to mark the tentative skin incision (cut) on your neck preoperatively when you are awake. This will be done symmetrically, along the Langer's skin lines (wrinkle lines of the skin) or in a skin crease between the medial borders of the sternocleidomastoid muscles (muscles on the neck).[7]

What to Expect During the Surgery?

You can expect the following: 

1. When you are ready, you will receive general anaesthesia (to make you unconscious so that you do not move or feel pain during the surgery) before the surgery.[16] 
2. Positioning and draping: You will rest on your back with the neck extended. The healthcare staff will place rolled towels under your shoulders to allow enough neck extension. The head of the table will be raised to 30 degrees. An alcohol-based agent (without iodine) is used for the disinfection. The surgical area (the neck area below the chin) will be draped (covered with a cloth) to reduce the risk of infection.

What to Expect After Surgery?

At the hospital:

Your doctor will continuously monitor your vital signs, food and drinks consumption, pain levels and surgery site until you are discharged from the hospital, depending on the procedure you have undergone. For example, if you have undergone total thyroidectomy, you will be monitored for longer because the procedure is more invasive (involves larger cuts). 

In most cases, you will have to remain in the hospital for observation and be discharged according to the surgeon's recommendation.

Calcium levels in your blood may drop after a total thyroidectomy or parathyroidectomy. The drop in calcium levels is because your parathyroid glands, which regulate your blood calcium levels, may not temporarily function properly after surgery. Until they are appropriately regulated again, you will have to stay at the hospital for observation. Your surgeon may also recommend calcium supplements to regulate calcium levels.

Wound care:

After surgery, the incision of your neck will be covered with a light bandage made of a gauze pad surrounded by a clear plastic covering. You can take this bandage off 48 hours after you leave the hospital. 

Do not soak or scrub your surgery site for at least seven days after surgery. Let your surgery site heal completely.[18]

Diet: Most people can eat, drink, and stroll around the night of their surgery. You can consume soft meals and drink liquids after the procedure. 

Medications:

1. Work, activity, restrictions:
2. You can return to work after two weeks post-surgery.
3. You should avoid lifting heavy objects or performing any tasks that strain your neck. Do not perform such activities for three weeks post-surgery.[18]

First Follow up Appointment 

1. You will have a follow-up appointment nearly two to four weeks after the surgery.[13] If you experience any of the following major changes, you require a post-operative check-up:
2. Haemorrhage (blood loss due to injury to a blood vessel during surgery)
3. Upper airway obstruction caused due to bleeding
4. If there is any damage to the superior laryngeal nerve, it can lower the tension of the vocal folds, impairing the production of high-frequency sounds, especially in women, teachers, singers, and telemarketers.

When to Consult a Doctor?

After the surgery, you can experience the following changes that are temporary and resolve over time: 

Stiffness in the neck

Sore throat or cough

Hoarseness of voice/changes in the pitch of the voice

Tension headaches

Swelling, slight bruising, and slight elevation at the incision site 

Numbness under the chin

Use sunscreen to avoid darkening of the area near the scar, as all incisions are sensitive to sunlight.

You should contact your otolaryngologist immediately if you notice signs of infection like:

Sudden swelling, redness, warmth, delayed healing, or bleeding in your neck

Raised body temperature.

Tenderness, or pus at your surgical site.

Tingling sensation or numbness in your lips, feet, or hands.

You should keep the following in mind:

You will typically be given medication right after surgery to ease your symptoms. However, TH will still circulate throughout your body even after removing your thyroid. Therefore, in the months following thyroid removal, you will be given medications to restore your body's hormone levels. Contact your healthcare provider if you are still experiencing fatigue and other symptoms of thyroid disease after the surgery.

If further treatment is needed, it will be addressed at your post-operative appointment with the surgeon. Your referring endocrinologist may discuss additional treatment options with you.