Thyroid Surgery - Indications & Expectations
Thyroid Surgery - Indications
Thyroid nodules that have been diagnosed as cancerous on needle biopsy
Thyroid nodules that are suspicious for thyroid cancer on biopsy or ultrasound
Some nodules show atypical cells on biopsy or show ‘high-risk’ ultrasound features that make the risk of cancer in that nodule much higher than for a non-cancerous nodule (see section on ‘Fine Needle Aspiration Biopsy’)
- Large nodules can press on surrounding neck structures to cause symptoms
- Pressure on the esophagus (swallowing pipe) can cause swallowing difficulties
- Pressure on the vocal nerves or muscles can cause hoarseness
- Pressure on the airway (trachea) can cause a choking sensation and/or shortness of breath
- Pressure on the skin and muscles can cause neck discomfort and a visible mass
Progressive nodule growth
Despite being non-cancerous, some nodules grow more rapidly than they should can become symptomatic. These nodules rarely stop growing and intervention can be considered.
Growth of the nodule into the chest
Nodules can grow downwards into the chest (termed ‘substernal extension’). These nodules generally require treatment, often surgical over non-surgical.
To treat hyperthyroidism
Hyperthyroidism can be caused by an overactive nodule (termed a ‘toxic’ nodule) or an overactive gland (frequently due to an autoimmune condition called Graves’ disease). Surgery is one of a range of treatment options for these diseases.
Large nodules or goiters can be unsightly and cause self-consciousness and anxiety
Thyroid surgery - Expectations
Although a commonly performed procedure, thyroidectomy does have some unique risks and possible postoperative outcomes that are should be understood before deciding to proceed.
The extent of the thyroid surgery is determined by three factors:
- The indication for the surgery – cancer versus non-cancer
- The size of the thyroid nodule
- Patient and surgeon preference
Pre-surgical expectations: Individualization of treatment
Dr Sinclair practices minimally invasive thyroid surgeries whenever possible and prefers to adopt a conservative surgical approach if feasible (provided it is safe to do so) in order to retain normal thyroid tissue. For example, small thyroid cancers that have not spread outside the thyroid can often be adequately treated with a partial thyroidectomy. Small cancers under 1-1.5cm in size may even be suitable for observation alone (see section on “Active Surveillance) or minimally invasive radiofrequency or laser ablation. Larger cancers or those that have spread outside the thyroid gland and/or to lymph nodes in the neck may require a total thyroidectomy with or without lymph node removal for adequate treatment. With respect to non-cancerous thyroid nodules, partial thyroid surgery is often possible and, occasionally, the majority of each thyroid lobe can actually be left in place. However patients with multiple large nodules on both sides of the thyroid gland are usually best treated with total thyroid removal or radiofrequency ablation. People who have their whole thyroid removed will need to be on lifelong thyroid hormone replacement. This comes in the form of a small tablet taken every day in the morning on an empty stomach. People who are eligible for partial thyroid surgery have a 0-30% chance of requiring post-operative thyroid hormone replacement depending on the extent of the partial surgery. Dr Sinclair will speak to you in detail about the planned extent of surgery based on her ultrasound findings done during your office consultation. She will also advise whether you are likely to need post-operative thyroid hormone replacement based on the planned extent of surgery and an estimation of her ability to preserve normal thyroid tissue during the surgery. Dr Sinclair performs minimally invasive thyroidectomy whenever possible. The size of the incision is determined by the size of the lesion to be removed and can often be 1-3cm smaller than the largest dimension of the thyroid lobe to be removed.
There is a small risk of bleeding after thyroid surgery. If removing the thyroid leaves a large space in the neck, Dr Sinclair may place a drain tube that will come out the next day. If bleeding does occur after thyroidectomy, you may need a second operation to remove the blood so that it does not affect your breathing.
You will need to fast from midnight on the day prior to the procedure. When you arrive at the hospital you will be admitted and directed to the preoperative area. You will be seen by nursing staff, your anesthetist and Dr Sinclair. During the surgery, you will be under a general anesthetic. This means that you will be asleep and will not remember any of the surgery or feel anything while the surgery is occurring. You will have a breathing tube placed into your airway by the anesthesia doctor. This breathing tube is specifically designed for thyroid surgery as it allows the nerves to the voice box to be monitored during the procedure. Dr Sinclair is a world expert in intraoperative continuous neuromonitoring (see separate section on this topic) and, your vocal nerves will be monitored continuously every 4 seconds during the entire procedure. This helps ensure that you do not wake up with a hoarse voice. After the surgery when you wake up, you will be moved to the recovery bay where you will remain until you are able to be transferred to a ward bed. Some patients can be discharged home on the same day as the surgery and Dr Sinclair will discuss whether you may be a candidate for this approach. For routine thyroid surgery, you will spend one night in hospital. If you have had a cancer surgery with lymph node removal, you will spend 2-3 days in hospital. You may have a drain tube in your neck when you wake up from surgery. This will be removed before you leave the hospital. You will be provided with pain medications on an as needed basis. Many patients need no pain medication other than paracetamol and ibuprofen however pain thresholds are very subjective and Dr Sinclair encourages you to use pain medications as needed to be comfortable.
For the first one to two weeks after surgery, heavy physical activity should be avoided to facilitate the healing process. This includes heavy lifting and heavy exercise. Depending on the extent of surgery, Dr Sinclair will instruct you as to when you can return to these pursuits. For the first week after surgery, you will need to keep your wound dry. It will be covered with Steri-strips and these should remain intact and dry until Dr Sinclair removes them at the one week post-surgery visit. The wound is closed with dissolvable stitches so there will be no stitches to remove after the surgery. Dr Sinclair will give you detailed instructions on how to care for your thyroid incision in order to maximize the cosmetic appearance of the incision.