Pre-operative preparation Pre-operative management for a thyroidectomy revolves around reducing risk for post-operative complications.
Operation While
surgeons may adapt their approach based on the
pathology, amount of tissue to be removed, and specific patient
anatomy, the classic open thyroidectomy (OT) generally follows a similar sequence of events. The surgeon first makes a transverse (horizontal)
incision through the skin in the front of the neck and
dissects through
subcutaneous tissue and
muscle until the thyroid gland is exposed. The thyroid lobes are then
retracted to expose
vascular supply, which is
ligated to help release the gland. During this process, the surgeon identifies and takes special care to avoid important nearby structures, such as the
jugular veins,
superior laryngeal nerve,
recurrent laryngeal nerve, and
parathyroid glands. Finally, the specimen is carefully removed from the underlying
trachea before the skin is closed and
dressed.
Trans-axillary approach (TAA) Following an OT, patients will likely have a small but visible scar on the front of the neck, which can be unsatisfactory for some. As a result,
Japanese surgeons developed the trans-axillary approach to thyroidectomy. This is an
endoscopic method, which involves the creation small incisions (port sites) in the
axillae on either side of the patient. The surgeon will then blow
CO2 gas into the body to create space to work, a process termed "
insufflation". He is then able to insert cameras and other endoscopic instruments through these incisions to access the thyroid. This approach leaves the patient with a small scar in the axilla that is covered when the arm is in a natural position, eliminating the cosmetic drawback of OT. Over time, endoscopic variations have arisen to provide better operative visualization and reduce complication risk. Instead of working on one side of the patient at a time, the bilateral axillo-breast approach (BABA) involves inserting ports in both axillae and beneath both
areolas simultaneously to provide a symmetrical view of the thyroid throughout the procedure. As mentioned previously, CO2 gas is utilized for endoscopic approaches and, while the gas is usually absorbed by the body during recovery, it can occasionally cause
subcutaneous emphysema and/or
pneumothorax. To minimize this risk, gasless approaches have been developed that use a special tool for visualization instead of gas.
Post-operative management For the majority of patients, a thyroidectomy is an outpatient procedure, meaning they are discharged home the same day as the surgery. However, patient status may necessitate hospital admission for observation and additional management. Since removal of the thyroid gland usually results in lower than normal
thyroxine (T4) and
triiodothyronine (T3), patients are often prescribed an oral synthetic thyroid hormone to address the deficiency, usually in the form of
levothyroxine (Synthroid). Patients are also generally discharged with oral calcium supplementation to prevent
hypocalcemia, which may present as
paresthesias,
tetany,
hyperreflexia, and
ECG changes. If these symptoms arise, additional oral calcium and
calcitriol (Vitamin D) supplementation will usually resolve them, but more severe cases may require
intravenous calcium and prolonged hospital admission. If thyroidectomy was indicated for
thyroid cancer, patients may undergo post-operative
radioactive iodine therapy to destroy tissue left behind during the operation. == Complications and risks ==