ENDOCRINE SURGERY
Thyroid Cancer.2 In some low-risk patients with follicular cancer
Thyroidectomy
EG Kane
S Shore
Abstract
Thyroidectomy requires meticulous dissection and the technique has
changed over time. We discuss the gold standard and evolving new
methods of performing a thyroidectomy and the common complications
and difficulties associated with these. Retrosternal goitres present
slightly different challenges. The preoperative assessment and character-
ization of these retrosternal goitres and the associated increased compli-
cation rates are discussed. New techniques to minimize these
complications such as nerve monitoring are now more routinely being uti-
lized and are described in this article.
Keywords Complications; retrosternal goitre; technique; thyroidectomy
Introduction
Throughout history, the surgical technique of thyroidectomy has
changed for the better. In 1850 thyroidectomy was banned by the
French Academy due to its high mortality. However since the
work of Theodore Kocher, recognized by the award of the Nobel
prize (1909) for demonstrating a mortality of less than 1% for
extra-capsular dissection and arterial ligation of the thyroid,
conventional thyroidectomy has become a well-accepted, safe
procedure.1 It falls under the remit of the endocrine surgeon,
head and neck surgeon and general surgeon with a specialist
interest. Techniques are still advancing; with extra-cervical ap-
proaches including endoscopic, lateral and face lift incisions and
robot-assisted methods, which have developed from the standard
cervical Kocher incision thyroidectomy. However the cervical
incision continues to provide a safe, and good cosmetic result
and is most widely used.
Indications
Benign indications for total thyroidectomy include recurrent
thyrotoxicosis and compression symptoms (dysphagia or dysp-
noea); a total thyroidectomy is also indicated for papillary car-
cinoma (>1 cm), follicular carcinoma and medullary thyroid
carcinoma. If follicular carcinoma is suspected (by obtaining a
Thy3F cytology) a thyroid lobectomy and isthmusectomy is
indicated. A total thyroidectomy can also performed prophylac-
tically in those carrying a germline RET mutation. Completion
thyroidectomy is advised for histologically confirmed follicular
cancer greater than 1 cm with vascular invasion by the British
Thyroid Association in the Guidelines for the Management of
E G Kane MB ChB BSc is a CT1 in General Surgery in the Department of
Endocrine Surgery, Royal Liverpool and Broadgreen University Teaching
Hospitals, Liverpool, UK. Conflicts of interest: none declared.
S Shore MB ChB FRCS MD is a Consultant Endocrine Surgeon at the Royal
Liverpool and Broadgreen University Teaching Hospitals, Liverpool, UK.
Conflicts of interest: none declared.
SURGERY 32:10
between 2 and 4 cm, a completion thyroidectomy may not be
mandatory, but discussion in multidisciplinary team meetings
would be advisable. Recurrent thyroid cysts, solitary thyroid
nodules increasing in size and asymmetrical thyroid enlargement
causing compressive symptoms are also indications for thyroid
lobectomy  isthmusectomy. Thyroid lobectomy is indicated in
patients with repeated Thy1 (non-diagnostic) on fine needle
aspiration cytology (FNAC) to enable a firm diagnosis to be
obtained.
Types
Thyroid surgery usually consists of a thyroid lobectomy (one
thyroid lobe and isthmus), an isthmusectomy (the isthmus
alone) or a total thyroidectomy. Variations on a total thyroidec-
tomy include: a near total thyroidectomy in benign often thyro-
toxic disease (which leaves a tiny residual piece of thyroid
usually to preserve the blood supply of a parathyroid or to pre-
serve the recurrent laryngeal nerve (RLN)); subtotal thyroidec-
tomy (historically designed to reduce the risk of
hypoparathyroidism, RLN injury and hypothyroidism) e how-
ever in thyrotoxic patients, thyrotoxicosis can reoccur. We are
also seeing an increase in recurrent benign goitres in the elderly
in those where subtotal thyroidectomy was performed for benign
disease. Re-operation is associated with a higher risk to the RLN
and parathyroids. Subtotal thyroidectomy is therefore no longer
recommended. Other variations of thyroid surgery have also
been described (e.g. Dunhill’s procedure e total lobectomy on
one side and subtotal on the other). In those with cancer,
clearance of the central (level VI/VII) or lateral neck (IIe V)
lymph nodes dissection may also be required depending on the
type of cancer and the stage of disease.
Preoperative management
Preoperatively patients must be adequately assessed, prepared
and consented for the procedure. Due to the changing focus on
methods used to reduce cosmetic outcomes, it is recommended
that options of surgical approach be discussed with the patient in
line with available expertise. Assessment includes a full history
and examination focussing on symptoms of thyroid function and
compression and changes in gland or nodule size. Preoperative
investigation should include thyroid function tests and thyroid
antibodies, ultrasound, and FNAC for assessment of nodules.3
CT is utilized in those patients with compressive symptoms or
suspected retrosternal extension. In advanced disease CT/MRI
may help with assessment of vascular invasion into internal
carotid/internal jugular vein; oesophageal or tracheal invasion
or invasion of vertebral fascia: these are all factors which may
make a thyroid cancer inoperable or may change the extent of
surgery required. These advanced tumours are however only a
small percentage of most differentiated thyroid cancers. Tech-
netium scans should be used for assessment of thyrotoxic pa-
tients especially in the presence of a nodule, where a lobectomy
on the side of the hot nodule may be sufficient. The preparation
of the hyperthyroid patient is discussed in an earlier chapter so
will not be discussed again here.
The British Association of Endocrine and Thyroid Surgeons
(BAETS) recommends routine pre- and postoperative vocal cord
543 Ó 2014 Elsevier Ltd. All rights reserved.
 ENDOCRINE SURGERY
assessment with laryngoscopy. Preoperative assessment helps to
rule out pre-existing RLN injury, which can often be
asymptomatic.4
Consent
As with all consent processes clinicians should discuss the
indication for surgery and other treatment options, explanation
of the procedure and the side effects of treatment proposed.
Written information leaflets supplement this process. The con-
sent process starts at the first clinic visit and complication rates
should be quoted as per the unit or surgeon’s own figures.
Recognized specific complications are bleeding (around 1%
requiring re-operation), change in voice/singing voice (6.1%),
RLN injury (1.8%) and a need for calcium and vitamin D post-
operatively (temporary (25%) or permanent (12%)).4 Hormone
replacement with levothyroxine should also be discussed.
Complication rates are higher in re-do surgery, in patients with
retrosternal disease and malignancy. The risk of temporary
hypocalcaemia is increased in younger patients, females, Grave’s
disease and level VI dissection. Length of stay is normally one or
two nights for total thyroidectomy; hypocalcaemia accounts for
the majority of prolonged stays.
Preparation
The patient can be marked on the ward preoperatively or after
positioning on the operating table. The patient is anaesthetized
with a general anaesthetic and an endotracheal (ET) tube is used.
Nerve monitoring can be undertaken by using a stimulator probe
during surgery that responds to electrodes on the end of
specialized ET tube. These electrodes may be integrated in the
tube or wrapped around a normal ET tube and the tube is posi-
tioned so that the electrodes are in contact with the vocal cords.
Increasingly, nerve monitors are recommended to identify and
avoid injury to the recurrent laryngeal and external branch of the
superior laryngeal nerve. Recent audit shows that uptake of use
of nerve monitoring is not yet routine across the UK4. It does
require a skilled anaesthetist and surgeon in using the equip-
ment. In order for nerve stimulation to be used, a short-acting
paralysing agent is used for the anaesthetic. Following intuba-
tion, the patient is positioned supine on the table with a shoulder
support and head ring allowing neck extension. This allows good
access but care is required to avoid hyperextension and thereby
reduce postoperative pain and paraesthesia. Once positioned, the
neck is prepared and draped.
Incision
In conventional thyroidectomy, a skin-crease collar incision
(Kocher incision) is used approximately two fingerbreadths
above the sternoclavicular joint in neck extension. A higher
incision generally gives a better scar than a low incision; the
latter also has a higher risk of hypertrophy or keloid scar for-
mation. The site of incision is marked, the midline identified
and an incision 4e6 cm is used. The size and position of the
incision can be adapted based on the size of the thyroid or
indication for surgery. In the conventional approach, the
scalpel is used for the skin, followed by scalpel, diathermy,
ligasure or ultrasonic scalpel to divide the subcutaneous tissue
plane deep to the platysma down to the avascular deep
investing layer of fascia.
SURGERY 32:10
Alternative approaches: since the achievement of safe and
established good outcomes in conventional thyroid surgery,
alternative approaches have been developed that continue to be
under investigation. There are two principles to the alternative
approach: the use of minimally invasive techniques and remote
access techniques.
Endoscopic neck surgery was first described in 1996 by Michael
Gagner for parathyroidectomy but the technique for thyroidec-
tomy followed shortly after, but as of yet as not been widely
accepted in the UK. The aims of minimally invasive procedures are
improved cosmetic results while reducing postoperative discom-
fort, parasthesia and discomfort during swallowing.5 Many would
argue that the conventional approach has minimal postoperative
discomfort and the scar generally heals well. Miccoli et al. use a
minimally invasive video-assisted procedure that employs a
smaller incision and reduced dissection that in Italy is thought to
facilitate day case surgery.6 Patient selection for these procedures
is important as they are limited by the nodule size and thyroid
volume that can be removed. There is some evidence to support its
use in small papillary thyroid cancer nodules in the absence of
palpable neck involvement, no evidence of thyroiditis, a relatively
normal thyroid gland and no previous history of neck surgery or
radiation.7 Many surgeons are still sceptical of its widespread
acceptance, especially in suspected cancers and in large nodules.
Non-cervical approaches to the thyroid include axillary in-
cisions, areolar incisions, postauricular approaches, transoral,
infraclavicular and a ‘face-lift’ approach.8 These approaches take
longer and are more invasive than the conventional thyroidec-
tomy, have a longer recovery time and have also been shown to
have a steep learning curve.9
Robot-assisted thyroidectomy is perceived as a novel
approach to thyroidectomy for reducing scar and neck paraes-
thesia and is usually performed through a trans-axillary scar. It is
limited currently to those patients with a body mass index below
32 kg/m2, with a small thyroid gland (<5 cm), unilateral nodule,
non-malignant disease and in the absence of thyroiditis. A
feasibility study in 15 patients in the UK has demonstrated suc-
cess with robotic-assisted thyroid lobectomy.10 The average size
of the nodule was 2.5 cm with one report (6.6%) of temporary
brachial plexus neuropraxia that resolved by day 5. Patient se-
lection appears important with great care taken for correct arm
position to reduce brachial plexus damage; average operating
time was 200 minutes. Non-cervical approaches have also been
associated with postoperative breast tissue anomalies, arm pa-
ralysis and unpublished reports of oesophageal perforation,
transaction, prolonged shoulder discomfort, chest wall hyper-
aesthesia, retained thyroid tissue and excessive blood loss.4 The
use of the robot in thyroid surgery is controversial in Britain; as
yet it has not shown any significant advantages over the con-
ventional technique, except for cosmesis, but has other signifi-
cant risks.
Exposure
In conventional thyroidectomy, the incision is followed by
raising subplatysmal flaps. This is aided by counter-traction by
the assistant using skin hooks or cat’s paw retractors. Extension
of the flaps superiorly is required to the upper border of the
thyroid cartilage and inferiorly to the sternal notch. Care must be
taken to avoid the anterior jugular veins. By keeping to the
544 Ó 2014 Elsevier Ltd. All rights reserved.
 ENDOCRINE SURGERY
subplatysmal plane, postoperative anaesthesia can be reduced by
avoiding damage to the cutaneous nerves.
A self-retaining retractor (Joll’s retractor) can be used to
retract the skin flaps; in larger thyroid goitres a second retractor
can be used to create a square operating field. The strap muscles
are separated by incising the median raphe with diathermy and
separated from the thyroid capsule with diathermy/sharp
dissection and counter traction. The middle thyroid vein is
identified and divided to allow access to the carotid gutter.
Mobilization of the upper pole
This is achieved by careful extra-capsular dissection on the thy-
roid gland, ligating individual vessels as opposed to ligation of
the pedicle on mass, thus protecting the external branch of su-
perior laryngeal nerve that runs medially to supply the crico-
thyroid muscles. Clips, ties, bipolar diathermy, LigaSure or
harmonic scalpel can be employed for vessels depending on
surgeon preference.
Identification of the parathyroid glands
Postoperative hypocalcaemia occurs due to damage to the para-
thyroid glands or their blood supply.11 By ensuring that the
glands are visualized and handled with care, hypocalcaemia can
be prevented or reduced. They are commonly found within a
1e2-cm circle around the intersection of the inferior thyroid
artery and the RLN. The superior parathyroid may be found
Recurrent laryngeal nerve monitoring
Pre-dissection
Stim 1: 1.00/1.01 mA 03/05/2011 12:20
Event Threshold: 100 µV Stim Rej. Period: 2.1 ms Event Threshold: 100 µV
1 Vocalis Left 830µV
2 Vocalis Right 1295µV
500µV 25ms
Comments:
Figure 1 Recurrent laryngeal 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.
SURGERY 32:10
superior to the artery and posterior to the nerve on the posterior
border of the thyroid; the position of the inferior pair tends to be
more variable but they are more commonly located inferior to the
inferior thyroid artery and anterior to the nerve in the thyro-
thymic tract. Devascularization of the glands is prevented by
dividing the inferior thyroid artery on the capsule of the gland. If
vascular compromise does occur, the parathyroid glands can be
re-implanted into the sternocleidomastoid at the end of the
operation.
Identification of the RLN
The RLN runs in the trachea-oesophageal groove where it can be
visualized by rolling the thyroid lobe medially. It enters the lar-
ynx via the cricothyroid muscle at the meeting of the muscle and
the ligament of Berry at the inferior cornu of the thyroid cartilage.
The right RLN may be encountered higher and more laterally
than on the left. When it is difficult to visualize, the possibility of
a non-recurrent nerve must be considered.
The gold standard approach to preventing nerve injury is
visual nerve identification but this may be complemented with
intraoperative neural monitoring (IONM) (Figure 1). The uptake
of IONM has been seen more in younger surgeons or those
with a higher case load.12 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.
Post-dissection
Stim 1: 1.00/1.01 mA 03/05/2011 13:04
Stim Rej. Period: 2.1 ms
1 Vocalis Left 837µV
2 Vocalis Right 1050µV
500µV 25ms
Comments:
545 Ó 2014 Elsevier Ltd. All rights reserved.
 ENDOCRINE SURGERY

Predicting postoperative function confers benefit in preventing
bilateral vocal cord paralysis requiring a tracheostomy. For
IONM, the ET tube is sited so that its electrodes are at the level of
the vocal cords and the largest tube possible is selected. A
stimulation probe with approximately 1e2 mA is used against
the identified nerve which creates an arc between the RLN and
the probe (a ground electrode is also present). This arc provides
visual and auditory signals on a monitor and this signal can be
identified pre- and post-dissection. Signal following a probe to
the vagus nerve provides absolute evidence of non-injury. Na-
tional Institute for Health and Care Excellence (NICE) guidelines
support the use of IONM in cases of re-do surgery or thyroid
cancer13 but there has been concern regarding false-positive re-
sults with the use of IONM. However, there are now clear
guidelines on how to avoid both false-positives and -negatives.
The NICE steering group also agreed that IONM had a place in
training and provides hard evidence in cases of litigation.
Mobilization of the lower pole and the rest of the thyroid
While the thyroid is retracted medially, the surgeon can mobilise
the lower pole with capsular dissection. Care is taken to preserve
the inferior parathyroid glands. Sharp dissection or diathermy is
used to detach the thyroid from the ligament of Berry.
Haemostasis
The patient is placed head down and a Valsalva manoeuvre
performed to assess haemostasis. This increases venous return
and demonstrates any sites of bleeding. It is crucial to identify
any bleeding especially in the region of the nerve. A drain may be
placed, based on surgeon preference, although an empty drain
must NOT be interpreted as evidence of no bleed.
Closure
The strap muscles are brought together by suturing the midline
fascia. A space is often left inferiorly when closing this layer so
that if bleeding or haematoma occurs it is not in a closed
compartment at risk of causing rapid airway compromise. Pla-
tysma is closed with an absorbable suture ensuring that the su-
ture does not shorten the subcutaneous tissues leading to
postoperative bunching and a poor cosmetic result. The skin
edges need to be opposed perfectly and this can be achieved
through glue, subcuticular suture (absorbable/non-absorbable),
clips, interrupted sutures or steristrips.
undergoing a thyroidectomy at a UK tertiary referral centre over a
5-year period had a retrosternal goitre,14 however the incidence
varies depending on the definition used. Proposed definitions of
the retrosternal goitre range from a goitre descending below the
thoracic inlet to more than 50% of the goitre lying beneath the
thoracic inlet. Variation in the definition poses a difficulty in
assessment and surgical planning.
Retrosternal goitres can also be defined as primary or sec-
ondary. Primary goitres are thought to arise from ectopic thyroid
tissue in the anterior or posterior mediastinum; separated from
the cervical gland and have an intrathoracic blood supply. Sec-
ondary goitres are growths extending down from the neck and
can also occur following previous surgery. Medical management
of goitres is usually unsuccessful. Indications for surgery for
retrosternal goitre include tracheal compression (see Figure 2)
and the concern of being unable to adequately biopsy the thyroid
and exclude malignancy. The former has been overcome by the
use of CT scans to accurately assess compressive symptoms.
Most surgeons are able to remove a retrosternal goitre through
a neck incision in 98% of cases, although this can be predicted by
the position of the lower limit of the thyroid in relation to the
aortic arch. In a retrospective analysis of 537 thyroidectomies, 26
(4.8%) had retrosternal goitres and 96% were removed by collar
(cervical) incision.15 In this particular series, one patient required
a sternotomy following presentation as an emergency with res-
piratory distress and the goitre descended down to the level of
the pulmonary trunk.
Classification systems have been devised to aid risk assessment
for surgery and requirement for extra-cervical surgical approach.
These approaches include manubriotomy, sternotomy of thora-
cotomy and need to be included in the consent process wherever
appropriate. Goitres can be classified using CT cross-sectional
imaging.16 In the cranio-caudal dimension, goitres may be grade
1 (above aortic arch), grade 2 (at level of aortic arch) and grade 3
(below aortic arch). In the A-P cross-section, type A is pre-

Postoperative care
Adjusted calcium and parathyroid hormone levels are performed
between 6 and 24 hours postoperatively for total thyroidectomy.
The patient must be observed for signs of swelling and respira-
tory distress and this should be acted upon promptly. The British
Thyroid Association recommends adoption of a local protocol for
early recognition and management of postoperative bleeding. If a
drain has been sited, it is usually removed prior to discharge.
Postoperative laryngoscopy is increasingly used to assess vocal
cord function in all patients.

Retrosternal goitre
The retrosternal goitre is a challenge both diagnostically and
surgically. The incidence varies from 3 to 20% of those having
thyroid surgery. In a recent case series 34/573 patients Figure 2 Grade 3 retrosternal goitre on chest X-ray with tracheal deviation.

SURGERY 32:10 546 Ó 2014 Elsevier Ltd. All rights reserved.

 ENDOCRINE SURGERY
vascular, type B is retrovascular-paratracheal and type C are ret-
rotracheal. Goitres of grade 2 or above with type C extension were
more likely to require an extra-cervical approach. Recommenda-
tions from an earlier systematic review were to adopt a cervical
approach for thyroids above the aortic arch (grade 1), manu-
briotomy for thyroids between the aortic arch and pericardium
(grade 2) and full sternotomy for thyroids below the right atrium.17
The risks of surgery are higher in these patients with rates of per-
manent hypoparathyroidism up to 8.1% and permanent RLN
injury up to 14.3%.18 Tracheomalacia is an infrequent complica-
tion but should be considered in patients with tracheal compres-
sion and a retrosternal goitre over 5 years. A Neck Surg 2012 Aug; 147(suppl 2): 177.
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