Types of Thyroid Operations
In general, there are three types of thyroid resections:
Total thyroidectomy: removal of the entire thyroid
A total thyroidectomy may be done for a variety of diseases including thyroid cancer, Graves' disease (See Hyperthyroidism »), multinodular goiter, and substernal goiter, among others. In certain cases, the surgeon may choose to perform a near-total thyroidectomy in which a small piece of thyroid tissue is left behind usually in the area of the parathyroid glands and recurrent laryngeal nerve in order to avoid damaging these structures. After a total thyroidectomy, patients will need to take thyroid hormone replacement pills (one pill a day for the rest of their lives).
Thyroid lobectomy (aka hemithyroidectomy): removal of half of the thyroid
A thyroid lobectomy may be done for a variety of diseases including indeterminate lesions on fine needle biopsy (See Thyroid Nodules Diagnosis and Treatment »), a toxic nodule (See Hyperthyroidism »), substernal goiter, and an enlarging thyroid nodule, among others. In cases of indeterminate lesions, some surgeons refer to a thyroid lobectomy as a diagnostic lobectomy because the main purpose of the operation is to make a diagnosis – cancer or benign thyroid disease. The final pathology is ready approximately 1 week after the operation. Approximately 70% of patients who have half of a normal thyroid gland left in place will not require thyroid hormone replacement pills. This percent decreases in older women, patients with a personal or family history of Hashimoto's thyroiditis or hypothyroidism, and patients with a family history of autoimmune disease.
Completion thyroidectomy: removal of any remaining thyroid tissue.
A completion thyroidectomy is usually done after a thyroid lobectomy reveals cancer in the first half of the thyroid but may also be done for multinodular goiter or hyperthyroidism. After a completion thyroidectomy, patients will need to take thyroid hormone replacement pills (one pill a day for the rest of their lives).
The decision as to which thyroid operation to perform depends on a number of factors including the type of disease and the patient's preferences. It is critical to work with a team of thyroid specialists to choose the right operation for each individual patient.
Minimally Invasive Thyroid Surgery
The typical incision made for thyroid surgery is known as a "collar incision" in which a large incision (around 5 to 6 inches) is made stretching from one side of the neck to the other just above the collar bone. Minimally invasive thyroid surgery refers to certain types of surgery in which the thyroid is removed through very small incisions using special techniques. Columbia Thyroid Center surgeons perform minimally invasive thyroid surgery in over 95% of patients, typically using an incision measuring just an inch to an inch and a half in length. In addition to using very small incisions, our surgeons "hide" the incision in a natural skin crease which acts like camouflage. Most people will not be able to notice the incision once the redness fades away. See our Scar Gallery section for examples of minimally invasive thyroid surgery.
At the Columbia Thyroid Center, 95% of our patients are able to go home after a 4 hour observation period in the recovery room. In certain cases, a patient may be asked to spend the night in the hospital. Patients who are asked to stay overnight generally have very large goiters, advanced cancer, bleeding disorders, a history of taking anticoagulation, or have a personal preference to spend the night. Patients who spend the night in the hospital are typically discharged by 10AM the next morning.
Patients will receive general anesthesia. With this type of anesthesia, you are completely asleep during the operation, and you will have a breathing tube placed temporarily to protect your airway and lungs.
In the hands of an experienced thyroid surgeon, thyroid surgery is a safe procedure with few complications. The following possible complications are directly related to the operative experience of the surgeon, and these statistics are based on our own results here at Columbia:
Bleeding in the neck:
As with any operation, there is always a chance of bleeding. The average blood loss for this operation is less than a tablespoon and the chance of needing a blood transfusion is extremely rare. However, bleeding in the neck is potentially life-threatening because as the blood pools, it can push on the windpipe or trachea causing difficulty breathing. Fortunately, in the hands of Columbia Thyroid Center surgeons, the risk of bleeding is less than 1%. Due to this rare risk of bleeding, patients are observed for 4 hours by our highly trained recovery room staff. If there is no sign of bleeding and the patient feels well, he or she may go home. Once at home, patients and their friends/family should watch for signs such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon.
Hoarseness (Recurrent laryngeal nerve injury):
There are two nerves called the recurrent laryngeal nerves that run just behind the thyroid. These nerve control the vocal cords. If one of these nerves is injured, the voice may become hoarse. In the hands of our Columbia Thyroid Center surgeons, the chance of having a temporary hoarseness is 3% and the chance of having a permanent hoarseness is less than 1%. Temporary hoarseness usually gets better within a few weeks, but can take up to 6 months to resolve. Even in the rare chance of having a permanently hoarse voice, there are things that can be done to improve or fix the voice.
The parathyroid glands are 4 small, delicate glands each the size of a grain of rice that sit behind the thyroid and control the blood calcium levels. If all 4 glands are injured or removed during the operation, the blood calcium levels can become lower than normal called hypocalcemia. Hypocalcemia can cause symptoms such as numbness and tingling (especially around the lips and in the hands and feet) as well as cramping and even "locking" of the hands and feet. In the hands of Columbia Thyroid Center surgeons, the risk of having a temporarily low blood calcium level is about 5% and the risk of having a permanently low blood calcium level is less than 1%. It is important to note that numbness and tingling may be caused by something other than a parathyroid problem. If a patient has symptoms caused by low blood calcium, the surgeon may prescribe extra calcium and a vitamin D supplement.
Other risks of thyroid surgery include wound infections and seromas. Wound infections happen in about 1 out of 2000 operations (far less than 1%) and because of this low risk, the routine use of antibiotics is not needed. A seroma is a collection of fluid under the incision. Seromas happen rarely and usually disappear within a few weeks. If the seroma is large, the surgeon may drain it with a small needle. The risk of having any of these complications depends on the experience of the surgeon. Although the risk of these complications cannot be eliminated entirely, they can be minimized in the hands of an experienced thyroid surgeon.
Preparing for Surgery
Prior to the operation, patients will need certain pre-operative testing to make sure that they are healthy enough and properly prepared for an operation. The typical recommendations for pre-operative testing include:
- Blood tests done within 30 days of the operation
- CBC (complete blood count)
- BMP (basic metabolic profile)
- B-HCG (blood pregnancy test) for menstruating females
- Coagulation profile if the patient is on blood thinners or has a bleeding disorder
- EKG done within 3 months of the operation for patients older than 40
In addition, patients may require additional tests in certain situations to help plan the operation. It is not common to need these additional tests, but they may include:
Fiberoptic laryngoscopy: This test allows the surgeon to look at how well the vocal cords are moving by passing a thin flexible camera through the nose into the airway. This test is used in patients with hoarseness, a previous neck operation, or cases of advanced cancer.
CAT scan of the chest: This test allows the surgeon to evaluate if the thyroid disease is growing down into the chest and if so, how it is affecting the structures in the chest. The CAT scan will also allow the surgeon to see if the trachea is being moved to one side or the other and if it is being narrowed by the thyroid. This test is used in patients with large goiters, substernal goiters, and cases of advanced cancer.
Patients with other significant medical issues may be asked to visit with their medical team to obtain a letter of medical clearance. The medical clearance allows the patient's medical team the opportunity to optimize the patient's health prior to an operation and allow the specialists to make recommendations for how best to care for the patient's other medical issues during the peri-operative period.
In general, patients should be eating, drinking, walking around, and doing their normal activities the night of the operation. However, patients will be asked to do no heavy lifting, swimming, or soaking in a bathtub for 1 week after the operation. Patients should call their surgeon's office to make a follow up appointment 3 weeks after surgery.
Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. Some people experience a dull ache, while others feel a sharp pain. The Thyroid Center recommends taking Tylenol, Motrin, or Advil as the bottle directs around the clock for the first few days (as long as their overall health allows it). The vast majority of patients do not require narcotic pain medications. In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days.
Your incision is covered with a protective strip of clear glue called collodion. You can shower and wash your hair as usual, but do not soak or scrub the incision. After showering, pat the incision dry. The collodion will turn white and start curling up at the edges in about 5 to 7 days. When this happens, you can trim the edges or let the glue fall off on its own.
If you experience itching once the collodion is off, you may apply lotion to the scar. You might notice bruising around your incision or upper chest and slight swelling above the scar when you are upright. In addition, the scar may become pink and hard. This hardening will peak at about 3 weeks and may result in some tightness especially when swallowing or extending your neck. This will disappear over the next 3 to 6 months.
Bleeding is a rare complication and those few patients who do have a bleeding problem almost always have it during the 4 hour observation period in the recovery room. However, in the first 24 to 48 hours, patients and their family/friends should observe the incision and neck for signs of bleeding in the neck such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon.
In general, patients may resume taking their normal medications the day after the operation. The exceptions are blood thinners, aspirin, Plavix, and anti-thyroid medications like PTU and Methimazole. Patients should discuss with their doctors when and if they should restart these medications. Typically, patients will be given prescriptions for the following medications after the operation:
Calcium: Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000® tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. After the seventh day, reduce the calcium to one Tums Ultra 1000® tablet three times a day until your follow-up appointment. If symptoms of hypocalcemia develop, take an extra two Tums Ultra 1000® tablets and if the symptoms do not go away after 30 minutes, call your doctor. We also recommend a multivitamin for most patients.
Patients may also be given a prescription for thyroid hormone medication (Levothyroxine or Synthroid). If the patient was taking thyroid hormone before the operation, they should continue taking the same dose unless it was changed by the surgeon. If the patient was not taking thyroid hormone prior to the operation, the surgeon may prescribe these tablets following surgery. The dose of thyroid hormone is usually based on the person's weight. During the post operative visit, a blood test called TSH level may be checked to measure the levels of thyroid hormone in order to determine if the dose is correct. Thyroid hormone levels will then be measured about every 2 months until the hormone levels are stable (levels generally stabilize in 4 to 5 months).
Most patients (97%) will not notice any change in their voice after the operation. Rarely, a patient may have temporary changes in the voice such as fluctuations in volume and clarity (hoarseness). In these cases, the voice will often be better in the mornings and "tire" toward the end of the day. Hoarseness generally improves within the first 3 to 4 weeks after the operation but it may take up to 6 months. Patients should not be worried about hurting their voice by talking. If the voice is still hoarse after 3 to 6 months, the surgeon may prescribe voice-strengthening exercises or ask the patient to visit with a voice specialist for evaluation.
In about 5% of patients who have thyroid surgery, the parathyroid glands do not function properly immediately after thyroid surgery. This can also happen after parathyroid surgery. This is the result of the blood calcium level dropping below normal (hypocalcemia) and is usually temporary. Symptoms of hypocalcemia include numbness and tingling in your hands, soles of your feet and around your lips. Some patients experience a "crawling" sensation in the skin, muscle cramps or headaches. These symptoms appear between 24 and 48 hours after surgery. It is rare for them to appear after 72 hours.
Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000® tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. After the seventh day, reduce the calcium to one Tums Ultra 1000® tablet three times a day until your follow-up appointment. If symptoms of hypocalcemia develop, take an extra two Tums Ultra 1000® tablets and if the symptoms do not go away after 30 minutes, call your doctor. We also recommend a multivitamin for most patients.
More Information on Thyroid Surgery
- Finding a Surgeon: What should you look for?
- FAQs about Thyroid Surgery
- Day-Of-Surgery and Post-Surgery Guides
- Thyroid Scar Gallery: Know what to expect from our minimally-invasive procedures
If you are dealing with a thyroid issue, our team at the Columbia Thyroid Center is here to help. Call (212) 305-0444 or request an appointment online.