Evidence - Total thyroidectomy in bilateral nodular goiter

Thyroid surgery: Paradigm shift in surgical strategy and revamping of resection technique over the last 30 years

Thyroid surgery has undergone major changes in surgical strategy over the last 30 years. This was induced by a new endocrine understanding of the various thyroid disorders, progress in morphological, functional and immunological diagnostics and by the continued development of surgical technique, all of which have contributed to lowering the complication rate in this type of surgery (28).

For a long time, subtotal resection, leaving a small (end of thumb sized) remnant in situ, was considered the standard technique in benign goiter. Subtle exposure of the recurrent laryngeal nerve and parathyroids did not appear necessary because the line of resection was safely away from these structures. It was believed that this would avoid most of the RLN paralysis and postoperative hypothyroidism.

However, since subtotal resections suffer from a recurrence rate of up to 40%, the need for more radical resections became evident. Inevitably, this led to the development of modern surgical techniques with their exposure of the RLN and parathyroids, thereby avoiding the high rate of serious complications (1, 3).

Apart from perfecting the technique of nerve exposure, the improved diagnostic work-up of thyroid disorders has also demonstrated that they often require (near) total resection of the thyroid. In multinodular goiter the thyroid gland frequently has undergone such extensive nodular changes that the surgeon cannot leave any healthy remnant in place. Since in Graves disease the entire thyroid gland has been subject to increased stimulation, any remaining tissue often leads to renewed hyperthyroidism.

In thyroid cancer total resection quickly became the treatment of choice and therefore necessitated a subtle dissection of the RLN and parathyroids, which commonly involved microsurgical technique.

Dralle at Halle University in Germany demonstrated this trend toward more radical resections because in his department the percentage of total lobectomies in benign goiter rose from 20% in the mid-nineties to 70% 13 years later (20).

One direct consequence of these increasingly more radical procedures is the decreasing number of reoperations, which therefore could be regarded as proof of this paradigm shift.

Intraoperative neuromonitoring (IONM)

Intraoperative neuromonitoring, or IONM for short, is a reliable tool for RLN identification. Properly performed this intraoperative functional monitoring of the nerve correlates quite well with vocal cord function checked by postoperative laryngoscopy. Its negative predictive value (unremarkable nerve stimulation = no RLN paralysis) is between 92% and 100%, while its positive predictive value (prediction of RLN palsy) is 35% – 92%. IONM increases the rate of identification, spares the nerve, allows the radical (total instead of subtotal) resection demanded, improves the safety of dissection in demanding conditions (cancer, recurrence) and permits guideline driven surgery.

The introduction of IONM has decreased the rate of RLN paralysis in thyroid surgery. However, evidence-based improvement has only been noted in repeat thyroid procedures; here, in the last 15 years the rate of permanent RLN palsy has gone down from 6.6% to 2.2%. By now, the consistent exposure of the RLN in initial procedures has lowered the rate of RLN paralysis to very low levels.

References: 3, 4, 12, 21, 29, 30, 47

Outpatient thyroid surgery

Today’s age of shortened postoperative hospital stays has also seen efforts to perform thyroid surgery in an outpatient setting. The data regarding the „bleeding” complication typically encountered in this type of surgery argue against “one day surgery”.

Most bleeding occurs within the first 6 hours after the operation. Burkey (5) reported that 19% of their patients demonstrated the first signs of bleeding only after 24 hours; the prospective trial by Sonner (44) noted that 54% of all patients in thyroid and parathyroid surgery suffer from postoperative nausea and vomiting (PONV) and run a higher risk of secondary bleeding during this phase. Marohn (39) and McHenry (40) also emphasize the need for postoperative repeat surgery in secondary bleeding beyond the 24-hour limit. Clark (13) notes that 25% of secondary bleeding after thyroidectomies appears up to 24 hours and later after the operation. Data by Dralle (22) show that 20% of secondary bleeding will become manifest more than 24 hours after surgery.

Based on these data “one day thyroid surgery” is unsafe and not recommended.

A Multicenter, Randomized, Controlled Clinical Study on the Feasibility and Safety of Gasless Transaxillary Posterior Endoscopic and Open Thyroidectomy for Papillary Thyroid Cancer.

Study of Total Post-thyroidectomy Hypocalcemia After Preoperative Cholecalciferol Supplementation

Usefulness of ICG Angiography-Guided Thyroidectomy for Preserving Parathyroid Function. GuiArte Multicentric Randomized Study.

A Novel Technique for Endoscopic Transaxillary Thyroidectomy: a Preliminary Report and Comparison With the Open Procedure

The Use of Autofluorescence and Indocyanine Green to Avoid Hypocalcemia After Total Thyroidectomy: A Randomized Clinical Trial

Intraoperative Monitoring (Parathormone Values and Continuous Neuromonitoring) to Predict Postoperative Complications After Total Thyroidectomy

Effectiveness of Intraoperative Neuromonitoring to Identify and Preserve External Branch of Superior Laryngeal Nerve During Thyroid Surgery

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