Background Information:

What are the other Names for the Procedure?

• Hemi Thyroidectomy
• Isthmectomy
• Near-Total Thyroidectomy

What is Thyroid Gland Removal surgical procedure?

• Thyroid Gland Removal (or Thyroidectomy) is a surgical procedure that involves the removal of a part, or all of the thyroid gland
• In some instances (as in a thyroid cancer), a neck dissection (removal of lymph nodes) is also performed

There are several types of thyroid surgery depending on the extent of removal of the thyroid glands. These are referred to by different names including:

• Partial Thyroidectomy
• Subtotal Thyroidectomy
• Hemi Thyroidectomy
• Near-Total or Total Thyroidectomy
• Isthmectomy (removal of the isthmus, or middle part of the thyroid gland)

What part of the Body does the Procedure involve?

The Thyroid Gland Removal surgical procedure involves the thyroid gland.

• The thyroid gland is an endocrine (hormone-producing) organ that lies in the middle of the neck, below the Adam’s apple and in front of the windpipe
• The hormones produced by the thyroid, affect all organs and tissues and control the body’s metabolism

Why is the Thyroid Gland Removal surgical procedure Performed?

The Thyroid Gland Removal procedure may be performed for one or more of the following reasons:

• An enlarged thyroid gland (goiter) causing compressive symptoms
• Suspected or confirmed thyroid cancer
• Overactive thyroid (hyperthyroidism)

What are some Alternative Choices for the Procedure?

• The alternative choices depend on the reason (indication) for performing the Thyroid Gland Removal surgery.
• For patients with over-activity of the thyroid gland, radio-iodine ablation or other medical treatments are some alternatives
• For patients with an enlarged thyroid gland, a ‘watchful waiting’ policy is often a reasonable alternative
• For patients with suspected or confirmed thyroid cancer, surgery is strongly recommended in most cases
• It is best to discuss these issues in detail with the treating physician.

What are the Recent Advances in the Procedure?

• The Thyroid Gland Removal (or Thyroidectomy) surgery may be performed via a small incision on the neck. This is called a keyhole operation (minimally-invasive Thyroidectomy)
• In some centres, the operation is performed via an incision in the armpit or chest. This is done as some patients are very keen to avoid a neck scar
• A robot may also be used to perform the operation in some hospitals, although there is no evidence that robotic surgery is better than conventional operations
• Although these new procedures are considered to be advances, they are not necessarily more effective and may occasionally be associated with serious complications. Please discuss at length, the risks and complications involved with your operating surgeon, in order to determine, if these new procedures are appropriate for you.

What is the Cost of performing the Thyroid Gland Removal surgical procedure?

The cost of a Thyroid Gland Removal procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused by the information regarding Thyroid Gland Removal surgery on what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5^th Edition, New York, 2006

Prior to Thyroid Gland Removal surgical procedure:

How is the Thyroid Gland Removal surgical procedure Performed?

• The Thyroid Gland Removal procedure is usually performed via a horizontal incision over the lower part of the front of the neck (often called a ‘collar’ incision)
• The muscles over the thyroid gland in the front of the neck are separated (or divided), to get access to the gland
• The gland is then separated from several vital structures around it, taking care to divide the small blood vessels on the gland surface, and avoiding injury to these structures
• Occasionally, the operation may be performed via a small (keyhole) incision over the neck, or through an incision away from the exposed part of the neck (such as the underarm). This may be an important consideration for some individuals, who are keen to avoid a visible scar, to the extent possible.

Where is the Procedure Performed?

The Thyroid Gland Removal procedure is performed at a hospital, under a general anesthetic.

Who Performs the Procedure?

A general surgeon, or a head and neck surgeon with interest in thyroid disease, performs the Thyroid Gland Removal procedure.

How long will the Procedure take?

The time for the Thyroid Gland Removal procedure is very variable. It may range from 45 minutes to 3 hours, depending on the indication for surgery, the type, and extent of surgery, the size and vascularity of the gland, and the need for additional procedures.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Thyroid Gland Removal procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• If the patient is hyperthyroid, this condition will need to be treated with drugs, before the surgery is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Local anesthesia may be used at the time of surgery to reduce pain following the procedure. Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for at least 4-6 weeks, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 4 hours prior to the surgical procedure, depending on when the procedure is arranged. Please discuss this with the medical team at your hospital
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Thyroid Gland Removal procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Thyroid Gland Removal surgical procedure?

• Thyroid function tests and blood calcium should be checked before every thyroid surgery. Other tests depend on the reason for surgery in the first place
• In patients with an isolated or dominant nodule (lump) in the thyroid gland, a needle biopsy is often performed
• Most patients having surgery for an enlarged thyroid also have cross-sectional imaging, such as an ultrasound scan performed
• Patients may be advised to have further scans (such as CT or MRI scans) for other reasons. Typically, further scans are arranged in patients with suspected or confirmed thyroid cancers, to determine the extent of the disease
• Other blood and urine tests, chest x-ray and an electrocardiogram (ECG) may occasionally be required, to check if the patient can safely receive a general anesthetic

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Thyroid Gland Removal procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who is involved in performing this procedure?
• Where is the procedure performed?
• What are the complications that might take place, during and after the surgery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures do you perform on a regular basis?
• Are there any follow-up tests and/or periodic visits required after the procedure?
• What are the costs involved?

During the Thyroid Gland Removal surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia is usually employed during a Thyroid Gland Removal surgical procedure.

How much Blood will you lose, during the Procedure?

The amount of blood loss is usually minimal during a Thyroid Gland Removal procedure

However, for very large thyroid glands and for thyroid glands extending into the chest, blood loss may (very occasionally) be significant enough, to necessitate a blood transfusion

What are the possible Risks and Complications during the Thyroid Gland Removal surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes
• Specific risks of Thyroid Gland Removal surgery include the following:
• Laryngeal nerve injury: This can cause hoarseness, weakness, and a breathy voice, with or without swallowing difficulties. Occasionally, there is complete voice loss
• Very rarely, an injury to the nerve on both sides can result in the need for a tracheostomy (direct placement of a tube into the wind pipe). The injury is often temporary, with most patients reporting a full recovery
• Infection and bleeding: These are uncommon risks of a thyroid surgical procedure. Occasionally, a re-operation may be needed in patients, who either have significant bleeding or a serious infection after surgery

What Post-Operative Care is needed at the Healthcare Facility after the Thyroid Gland Removal surgical procedure?

• As part of routine postoperative care immediately after surgery, the patients are sent to an area of the hospital, called postoperative recovery room or PACU
• Here, the patient’s blood pressure, heart rate, and respiration, are closely monitored and any pain following the operation is treated
• After a short period of time in this area, patients may be sent to the ward for recovery
• Other care depends on the extent of surgery. In many centres, a routine postoperative check of the larynx (voice box) may be performed.
• Blood calcium levels are also checked routinely; although this is not required, when only a part of the thyroid gland is removed
• Although, a day surgery may be performed in many centres, the patients routinely stay in overnight
• A follow-up visit to the hospital is required to check the voice, site of surgery, thyroid hormone levels, and calcium levels. The timing and extent of these checks depend on the results of initial tests and vary between centres

After the Thyroid Gland Removal surgical procedure:

What are the possible Risks and Complications after the Thyroid Gland Removal surgical procedure?

Specific risks of the Thyroid Gland Removal surgery include the following:

• Low calcium: Surgery on both thyroid lobes may result in transient or permanent reduction in calcium levels, secondary to injury to the parathyroid glands (glands present on either side of the thyroid gland). This will need calcium and/or vitamin D supplementation, to treat low calcium level symptoms
• Hypertrophic scar and keloid formation: As with any operation, hypertrophic (prominent, thick) scars or keloid (prominent scars that tend to itch and can worsen with time) can develop at the site of surgery and may require treatment

What is the Prognosis after the Surgery?

• The prognosis for Thyroid Gland Removal is dependent on the indication for the surgery.
• For patients with thyroid cancer, further treatment is usually required. In general however, the prognosis for thyroid cancer is very good, especially in comparison to other organ cancers
• For those with benign forms of the disease and in the absence of any serious complications, there is usually little impact on long-term quality of life
• Both, patients who have had all of their thyroid gland removed, and patients who have had a partial excision, need treatment with thyroid hormones (thyroxine)
• Patients on thyroxine treatment need long-term monitoring of thyroid function

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Pain that worsens and swelling of the surgical wound
• Bleeding or fluid drainage from the surgical wound
• Symptoms of low calcium that include numbness, tingling or ‘pins and needles’ sensation in the tips of fingers and toes, or around the mouth; nausea and ‘feeling unwell’
• Difficulty in swallowing
• Feeling unwell for any other reason, in the first few weeks after surgery

What Post-Operative Care is needed at Home after the Thyroid Gland Removal surgical procedure?

At home, the following post-operative care is recommended, after a Thyroid Gland Removal procedure:

• Slowly resume regular/daily activities, as early as possible; this aids in faster recovery
• Resume showering 48 hours after surgery, but keep the wound clean and dry before and after showering. Gently wash the surgical wound with a mild, unscented soap
• If there was a wound dressing in place at the time of discharge, replace dressing after showering
• Complete the course of prescribed medication, as advised by the physician
• Take thyroidal hormone medications regularly, if prescribed
• Avoid all activities that are physically strenuous for about 6 weeks after the surgery
• Resume driving 2 months after being discharged from the hospital, or when advised by your physician
• Avoid sex till a complete healing has taken place (or as advised by the physician)

How long does it normally take to fully recover, from the Procedure?

• The time for recovery from a Thyroid Gland Removal procedure is variable
• It depends on the extent of the surgery and indication for (reason for performing) the procedure
• Most individuals are able to fully recover in around 4-6 weeks

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later disposed as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• The slide(s) are prepared once the tissue is processed, and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case and local facilities, issue of the report may take anywhere between 72 hours to a week’s time

Who will you receive a Bill from, after the Thyroid Gland Removal surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• A hospital
• An anesthesiologist (if anesthesia was administered)
• A pathologist
• General surgeon

The patient is advised to inquire and confirm the type of billing, before the Thyroid Gland Removal is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA