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14 Thyroidectomy Procedures
425
14.8.2.2 Advantages inComparison
toEndoscopic Surgery
– No incision in the neck.
– Less cumbersome: Robotic thyroidectomy
can be performed without CO2 insufation,
which may cause neck swelling postoperatively. The regular endoscopic instruments are
straight and do not give the range of motion
one gets with open or robotic surgery.
– Better view: Endoscopic surgery uses a 2D
camera. It shows the surgeon at images,
while the 3D camera used in robotic thyroidectomy shows a much more accurate and trueto- life image.
– The recovery time for robotic thyroidectomy
is about the same as it is for open or endoscopic surgery; a patient usually spends one
day in the hospital following surgery.
14.8.2.3 Disadvantages ofRobotic
Thyroidectomy [169, 183]
– Limited indications: The main disadvantage
of robotic thyroidectomy right now is that it
cannot be used on every patient.
– Longer operative time.
– High (additional) cost: Cabot et al. reported
that the costs associated with robotic approach
are higher than the costs of conventional open
thyroidectomy ($13,670 versus $9028) and
that this signicant difference in cost was pri-
marily due to high equipment depreciation
costs and longer operative times [183].
– Steep learning curve: A steep learning curve
of 40–45 cases has been described for trans-
axillary robotic thyroidectomy [184, 185].
This illustrates the difculty in learning the
procedure even for surgeons that are experi-
enced in conventional open thyroid surgery. A
decrease in total operative time and complica-
tions rates is found after these initial 40–45
cases.
14.8.3 Indications ofRobotic
Thyroidectomy
Regardless of the chosen approach, the successful outcome of robotic thyroidectomy largely
depends on careful patient selection and the skills
of the surgeon. The ideal robotic candidates for
robotic thyroidectomy are those patients who (1)
are not overweight, (2) have a small thyroid gland
(not >4cm), (3) have unilobar, small nodules (not
>2cm) contained within the thyroid gland without evidence of thyroiditis, and (4) have a good
neck and arm mobility without history of previous neck surgery or irradiation.
14.8.4 Techniques (Approaches)
ofRobotic Thyroidectomy
The most commonly used approaches are transaxillary, retroauricular, and the combination of
both approaches. The newest approach is the
trans-oral approach. The selection of approach is
largely dependent on the training, skill, and preference of the surgeon and/or patient. Both the
trans-axillary and retroauricular approaches are
performed in a “gasless” fashion, while the transoral technique requires CO2 gas insufation for
the procedure. Many recommend that the intraoperative nerve monitoring (IONM) is used for
robotic thyroidectomy cases. The surgical techniques of the three aforementioned approaches
use the Da Vinci robots. Regardless of the
selected approach, there are 3 consistent steps to
robotic thyroidectomy: (1) working space formation, (2) docking, and (3) console stages.
14.8.4.1 Trans-Axillary Approach
Steps oftheProcedure
1. Working Space Formation
Under general anesthesia with the patient
in the supine position and slight extension of
the neck, the ipsilateral arm is extended and
rotated cephalad fully exposing the axilla
[174, 186, 187]. A 5–6cm curved-vertical line
is drawn just posterior to the anterior axillary
fold, well hidden in the axillary crease for the
maximal cosmetic outcome. It is important to
make sure that no extra-tension is placed on
the extended arm to avoid brachial plexus
injury. This arm is padded and secured using
tape.
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M. Sakr
Once the ideal position is achieved, the
patient’s arm, neck, and chest is prepped and
draped exposing the axilla, neck, and upper
chest. The incision is made using a 15 blade,
and the subcutaneous (SC) ap is raised using
electrocautery. Once the pectoralis major is
exposed, a careful dissection over the clavicle
is performed until the SCM muscle is exposed
and dissection then proceeds by opening the
avascular plane between the clavicular and
sternal heads of the SCM.Dissection is then
carefully proceded directly underneath the
strap muscles exposing the thyroid gland. The
working space is considered to be safe and
adequate if a sufcient space is created exposing the superior pole of thyroid and central
neck. Once dissection is completed, “Chung
retractor” or an equivalent retractor is placed
holding the SC ap, anterior SCM and strap
muscles upward to keep the working space
exposed. In case of TT, the contralateral lobe
should be completely exposed and the position of the retractor should be appropriately
modied to allow safe resection of the contralateral lobe.
2. Docking Stage
Once adequate working space is achieved,
the robot is advanced toward the patient from
the contralateral side in preparation for the
docking of the arms. In this approach, all 4
robotic arms are used. For the right-sided
approach, the arm closest to the head of the
patient carries the Maryland dissector, followed by the second arm holding the 30° endoscope. On the arm next to the endoscope arm,
the “ProGrasp forceps” is inserted. The arm
closest to the patient’s feet carries the “harmonic scalpel”. The order is reversed when the
procedure is approached via the left side. This
docking method ensures that the surgeon operates using the harmonic scalpel using his right
hand, similarly to the open procedures [188].
3. Console Stage
The superior pole is rst dissected by
addressing the superior vessels. This rst step
is crucial in order to identify the superior PTG
and safely preserve it. Attention is then turned
to the inferior pole. If central neck dissection
(CND) is indicated, then this is performed en-
bloc prior to inferior pole dissection. The
RLN is identied inferiorly and dissected
superiorly towards the ligament of Berry with
careful dissection of the thyroid gland off
adjacent structures. The isthmus is then
divided to complete “hemi-thyroidectomy”.
The entire CND content and thyroid gland are
removed en bloc. Hemostasis is achieved.
Advantages oftheTransaxillary Approach
The main advantages of the transaxillary
approach are (1) the ease of console stage, (2)
easy detection of RLN, (3) ability to perform TT
with central and lateral neck dissection, and (4)
well-established safety and excellent outcomes
[169, 172, 189, 190].
Disadvantages oftheTransaxillary
Approach
Some of the main disadvantages of this approach
are the possible risks of anterior chest paresthesia
and brachial plexus injury. Brachial plexus injury
is considered to be preventable with proper arm
positioning with extra-padded support. Anterior
chest paresthesia over the clavicular area, however, occurs with unavoidable injury to the sensory
nerves of cervical plexus chain during the working
space formation. There have also been reports of
high-volume hemorrhage and injury to esophagus
[187, 191, 192], but these complications may be
decreased as the surgeon becomes used to the lateral approach to thyroidectomy with experience.
14.8.4.2 Retroauricular (Face-Lift)
Approach
Steps oftheProcedure
1. Working Space Formation
The patient is intubated under general
anesthesia and positioned supine with the
head turned gently to the contralateral side
from the approach, exposing the posterior
auricular sulcus with the posterior portion of
the neck facing the surgeon. The incision is
marked along the posterior auricular sulcus
extending over the mastoid and inferiorly parallel to the occipital hairline. The patient is
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14 Thyroidectomy Procedures
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prepped and draped exposing the incision
line, neck, and the ipsilateral half of the face.
Once the incision is made, the SC retroauricular ap is raised anteriorly exposing the
parotid tail and SCM.Care must be given to
preserve the greater auricular nerve (GAN)
and marginal mandibular nerve (MMN). The
subplatysmal ap is then dissected toward the
midline of neck exposing the inferior border
of the mandible and strap muscles down to the
sternal notch. Dissection is done underneath
the strap muscles to expose the thyroid gland.
A modied Chung retractor is inserted underneath the strap muscles.
2. Docking Stage
Once an adequate working space is estab-
lished, the robotic system is docked. If the
working space allows, it is preferable to use
all 3 robotic arms (30ₒ-endoscope with 3
instrument arms) to facilitate the surgery. If
working space is limited, surgery can still be
done using only 2 instrument arms without
the ProGrasp. The docking method is similar
to the trans-axillary approach where the
Maryland dissector and harmonic scalpel are
controlled by the surgeon’s left and right
hands, respectively.
3. Console Stage
The steps of hemi-thyroidectomy via the
retroauricular approach begin with the identication and dissection of the superior pole.
The superior pole is gently retracted superiorly, and the superior pole vessels are carefully ligated one vessel at a time. During these
steps, the surgeon must identify and preserve
the superior PTG.
Once the superior pole is mobilized and
the cricothyroid muscle is exposed, isthmusectomy is then performed. This will facilitate
identication and dissection of the RLN.The
nerve is identied in the tracheo-esophageal
groove near the cricothyroid joint where the
nerve enters the larynx. The IONM probe can
be used to conrm the RLN.The rest of the
thyroid gland is then dissected off of its surrounding soft tissue while keeping the RLN
intact along its course. With dissection of the
inferior pole, the procedure is completed.
Advantages oftheRetroauricular
Approach
This approach signicantly reduced the eld of
dissection, provided a faster recovery and less
postoperative discomfort when compared to the
trans-axillary approach [191]. Terres also
described this technique to be easier than the
trans-axillary in obese patients [191]. Other
advantages are reduced risk of injury to the great
vessels, esophagus or anterior chest sensory
nerves, since these are not encountered during
the working space formation.
Disadvantages oftheRetroauricular
Approach
The main disadvantages include injury to GAN
and MMN [181, 191, 193]. These are usually
temporary and resolve completely within a few
months following surgery.
14.8.4.3 Transoral Approach
Steps oftheProcedure
1. Working Space Formation
Once the patient is placed under general
anesthesia, the neck is placed in slight extension. Three incisions are made in the
gingival- buccal sulcus: one in the midline,
approximately 2 cm above the frenulum
labii inferioris, and 2 laterally near the angle
of mouth. The central incision is addressed
rst. A submental subplatysmal pocket is
formed to create a tunnel toward the edge of
the mandible. Blunt dissection is performed
to elevate the platysma off the strap muscles
all the way down toward the suprasternal
notch.
Once an adequate ap is created, the endo-
scope (30 degrees, down facing) cannula is
inserted. CO2 insufation (8–10 L/min) is
introduced and maintained via the central
port. A similar blunt dissection is also performed from the two lateral incision sites
allowing insertion of the instrument cannulae
into the subplatysmal working space. A few
Vicryl stitches are used to help retract the subplatysmal ap superiorly in order to create a
larger working space.
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2. Docking Stage
Once the working space formation is com-
plete, the robotic system is deployed. The cannulae are inserted into the robotic arms,
starting with the central cannula to secure the
position of the endoscope. A Maryland dissector and the harmonic scalpel are inserted
into the left and right ports, respectively.
3. Console Stage
Dissection in the midline raphe is per-
formed to separate the strap muscles, which
are dissected off the thyroid gland, exposing
the lobe(s) of interest. The pyramidal lobe is
dissected off the thyroid cartilage, and isthmusectomy is performed. Once the thyroid
lobe is freed off the trachea medially, the
superior pole is addressed. Careful dissection
of the superior lobe is performed ligating one
vessel at a time. The superior PTG is identied and preserved. The thyroid lobe is
retracted inferiorly to facilitate the identication of the RLN at its entry point into the larynx. Once the RLN is identied and carefully
preserved, the Berry’s ligament is addressed.
Dissection is then carried out inferiorly preserving the inferior PTG. Once the inferior
lobe is free off of its surrounding soft tissue,
hemi-thyroidectomy is complete.
Advantages oftheTransoral Approach
This approach to thyroid was rst described by
Witzel et al. in 2008 [159] and has been performed with an endoscope for the majority of
cases performed internationally. The rst robotic
series was published by Lee et al. [194]. The
main advantages of this approach are (1) completely invisible intraoral scars, (2) excellent
access and exposure to both thyroid lobes for TT,
and (3) a lower complication prole compared to
other remote-access approaches.
Disadvantages oftheTransoral Approach
The main disadvantages of this technique are (1)
the need for postoperative antibiotics, (2) longer
length of stay, and (3) inability to perform lateral
neck dissections. There are no reports of postoperative infections; however, postoperative antibiotics are given for all patients given the possible
risk of infection as the transoral thyroidectomy is
not considered to be a clean procedure. Another
possible downside of this approach is the inability to control massive hemorrhage in case of
inadvertent great vessel injury. If such hemorrhage were to occur, then an anterior neck incision would have to be made to control the
bleeding. The biggest weakness of the transoral
approach is the inability to perform lateral neck
dissections. According to the ATA statements, the
presence of lateral neck disease is currently a
contraindication to remote-access thyroid [175].
14.9 Completion Thyroidectomy
14.9.1 Preoperative Assessment [9]
14.9.1.1 History ofInitial
Thyroidectomy/Physical
Examination
If possible, the operative notes and pathology
reports from the initial thyroidectomy should be
obtained. Initial conservative surgery (isthmusectomy, hemi-thyroidectomy) makes re-exploration
easier than initial extensive surgery, which may
involve both sides of the neck. One or more PTGs
may have been resected with the thyroid, and this
information may change the surgical strategy to
prevent permanent hypoparathyroidism.
Physical examination of patients with recurrent goiters may reveal a hard cervical mass,
barely movable on swallowing, sometimes
resembling a carcinoma.
14.9.1.2 Laboratory Tests
As in other thyroid diseases, thyroid function
should be determined before surgery. Patients
presenting with hyperthyroidism should be
treated with antithyroid drugs (ATDs). Because
most, if not all, thyroid tissue will be removed,
the patient must be aware that Levo-thyroxine
(L-T4) replacement therapy will be necessary for
life.
Serum calcium (Ca) measurements are recommended. Patients with recurrent goiters are usually normo-calcemic, but the true status of each
PTG cannot be ascertained from preoperative Ca
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or parathyroid hormone (PTH) studies.
Consequently, the surgeon must be extremely
careful to identify and to preserve all viable parathyroid tissue. Preoperative or intraoperative
PTH assays on blood drawn from the lowermost
part of both internal jugular veins could be used
to determine whether PTGs are missing on one
side. This might help the surgeon in planning a
more conservative surgery or in proceeding to
parathyroid auto-transplantation if viability of
identied PTGs seems doubtful.
14.9.1.3 Fine-Needle Aspiration (FNA)
Fine-needle aspiration (FNA) conrms the diagnosis of “benign” goiter in virtually all cases,
although occasionally “carcinoma” may be suspected. On the other hand, a recurrent thyroid
nodule after partial thyroidectomy for cancer
may represent a benign nodule arising in the contralateral lobe.
14.9.1.4 Laryngoscopy
Laryngoscopy should be performed routinely to
ascertain whether prior surgery or recurrent goiter may have caused vocal cord paralysis. Normal
voice should not prevent the surgeon from ordering a laryngoscopy because contralateral vocal
cord compensation may minimize the clinical
sequelae of previous nerve injury.
14.9.2 Aim ofSurgical Treatment
The aim of surgical treatment of recurrent goiter
is to relieve compression symptoms and to prevent any further recurrence. Total thyroidectomy
(TT) is thus the treatment of choice. This aim
should be balanced against the risk of nerve
injury and hypoparathyroidism.
14.9.3 Surgical Approach [9]
The surgical approach to recurrent goiters
depends mainly on three factors: (1) the type of
initial procedure and the (2) size and (3) location
of the recurrence.
If the initial procedure was a “conservative”
operation (e.g., isthmusectomy), re-operation
should not be too difcult because the dorsal
aspects of both thyroid lobes were probably left
undisturbed. A midline or lateral approach for
total or subtotal resection is usually possible, and
surgery is similar to a standard procedure for
multinodular goiter (MNG). The ease of nding
the RLN and PTG is inuenced by the size and
anatomy of the underlying goiter. If the initial
procedure was a hemi-thyroidectomy (lobectomy), chances are the contralateral lobe was not
mobilized, and TT may be carried out with little
difculty with few, if any, postoperative complications. In these cases, a lateral approach facilitates the exposure of the upper pole and dorsal
aspect of the remaining lobe.
The prior collar incision should be used. The
skin aps are elevated, and the lateral space of the
neck is entered. The supercial neck fascia is
divided sharply between the anterior border of
the SCM muscle and the sterno-thyroid muscle.
Dissection is deepened and the intermediate tendon of the omohyoid muscle transected. The
medial cervical fascia is then incised along the
vascular sheaths, and the middle thyroid vein is
identied and ligated. At this stage, if the goiter is
large or if the patient’s neck is short or difcult to
hyperextend, exposure of the upper thyroid vessels may require dividing the strap muscles lateral to the thyroid cartilage. The upper pole
vessels are ligated on the surface of the thyroid to
avoid injury to the SLN, and the thyroid is mobilized medially. Locating and encircling the main
trunk of the superior thyroid artery (STA) at this
stage helps to dene better the anatomy of the
goiter and to identify the RLN.The upper PTG
and the RLN are found, and dissection is continued downward. If the thyroid has an intrathoracic
extension, the hilum may lie very posteriorly, and
it may be preferable at this stage to pull the thyroid out of the thorax before identifying the
RLN.Care is taken to identify the thyro-thymic
ligament and ligate it on the surface of the thyroid
to avoid damaging an intra-thymic inferior parathyroid. The lower pole of the thyroid is inspected
to uncover any subcapsular inferior parathyroid
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PTG that may require dissection or resection and
auto-transplantation if preservation of its blood
supply is not feasible. Medial rotation is completed, and the remaining isthmus is peeled off
the trachea and the strap muscles that are usually
adherent to it.
The most difcult procedure for recurrent goiter is completion thyroidectomy after “subtotal”
unilateral or bilateral resection and reoperation to
excise a remnant that has developed into a large
thyroid nodule. In these cases, the surgeon should
proceed laterally. The most difcult step of this
procedure is dissecting the relapsing thyroid nodule off its dorsal and lateral (vascular) adhesions
and dissecting the hilum of the inferior thyroid
artery (ITA) where the RLN and the upper PTG
may be encased in brous tissue. Identifying the
nerve in the lowermost part of the neck and tracing it to the vascular hilum, where it intertwines
with the terminal branches of the ITA may be a
helpful maneuver. Alternatively, if dissection is
deemed too dangerous, the surgeon may perform
subtotal or near-total intra-capsular resection,
leaving 0.5–2g of thyroid tissue. In contrast to
thyroidectomy for cancer, there is no absolute
need for total resection in benign recurrent goiter,
particularly if this increases the risk of postoperative complications. When operating on patients
with prior vocal cord paralysis, one should
always attempt to identify and preserve the RLN.
14.9.4 Risk ofPostoperative
Complications
At the beginning of this century, Theodor Kocher
warned against the risks of reoperative thyroid
surgery. Beahrs and Sakulsky [195] reported a
high incidence of nerve palsies when recurrent
diffuse toxic goiter was treated by repeated thyroidectomy. Although re-operation for Graves’
disease is no longer performed because of the
alternative of radioactive iodine (RAI) ablation,
reoperation for compressive or hyperfunctioning
recurrent goiter still accounts for about 5% of
Table 14.1 Prevalence of permanent unilateral vocal
cord paralysis after repeated thyroidectomy for recurrent
benign goiter
Reoperation
Authors Year
Roeher and
Goretzki [198]
Levin etal. [199] 1992 36 3%
Kraimps etal. [200] 1993 30 6%
Jatzko etal. [197] 1994 40 7.5%
Al-Suliman
etal. [201]
Menegaux etal. [202] 1999 203 2%
number
1987 125 18%
1997 82 3.6%
RLN
Injury
thyroidectomies in specialized units. This is currently the type of thyroid operation with the highest rate of permanent RLN palsy and
hypoparathyroidism.
The risk of permanent vocal cord paralysis
was evaluated by Weitensfelder etal. [196] in a
series of 525 thyroidectomies. The probability of
RLN injury increased in the following sequence:
uncomplicated nodule < goiter < thyroid cancer <
recurrent goiter. Early palsies (3.2%) were more
frequent than permanent ones (0.8%); only one in
four early palsies became permanent. This 75%
recovery rate was similar to the 86% rate reported
by Jatzko and colleagues [197]. The prevalence
of permanent vocal cord paralysis after repeated
thyroidectomy for recurrent benign goiter in
reports from specialized thyroid units is shown in
Table14.1. Permanent nerve injury is observed in
very experienced hands, even when subtotal
resections were performed at reoperation.
Permanent hypoparathyroidism seems to be a
problem of less importance than RLN injury. In
the series of Jatzko etal. [197] and Levin etal.
[199], no patient experienced permanent hypoparathyroidism after repeated thyroidectomy for
recurrent benign goiter. A 3% permanent hypocalcemia rate was reported by Kraimps and colleagues [200], and a 1.2% rate by Al-Suliman
etal. [201]. It is not possible to know with certainty how much viable parathyroid tissue
remains, and where it remains, in a patient with
recurrent goiter.
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14 Thyroidectomy Procedures
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14.10 Complications
ofThyroidectomy
The morbidity associated with thyroid surgery is
very low, but remains a matter of concern since
thyroid disease often occurs in younger patients
who have long life expectancy. Most complications can be avoided by an experienced endocrine
surgeon.
General complications associated with thyroidectomy include cardiac and pulmonary problems, gastrointestinal dysfunction such as nausea,
vomiting and ileus, and renal and urinary tract
problems. Local complications common to all
operations include postoperative bleeding, infection and keloid formation, while those specic to
thyroidectomy include injury to the RLN,
EB-SLN, hypoparathyroidism, and airway
obstruction. Other local complications such as
injury to the esophagus, trachea, thoracic duct,
IJV, carotid artery, and spinal accessory nerve
(SAN) are extremely rare [203–208].
14.10.1 Bleeding
hematoma. If respiratory distress is not relieved,
a tracheostomy should be performed. An
alternative approach is to insert an endotracheal
tube to secure the airway and then return the
patient to the operating theatre to gain hemostasis. Seromas also occur after thyroidectomy, and
most of them are small and do not pose any respiratory problem. They resolve spontaneously;
though some must be aspirated [214–216].
14.10.2 Respiratory Distress
Respiratory distress does not only occur due to
respiratory compression and/or laryngeal edema
by bleeding and hematoma formation. It can also
occur with tracheal collapse from chondromalacia or kinking of a soft tortuous trachea. These
problems are quite rare and usually occur with
long-standing large MNGs. Tracheostomy is the
standard treatment in such cases, although prolonged endotracheal intubation and external
splinting of the trachea by custom made rings or
Marlex mesh has been tried [217].
The thyroid gland is extremely vascular and
bleeding can occur anywhere in the operative
eld. Special care must be taken with the superior
thyroid vessels as these can retract and become
difcult to control. Postoperative bleeding can be
life-threatening by compromising the airway.
Any postoperative respiratory distress can be
thought of as attributable to a neck hematoma
until proved otherwise. Most bleeding occurs
within 4 h of operation and virtually all occur
within 24 h. Several studies have reported the
successful use of bipolar vessel sealing systems
[209–211] or the harmonic scalpel [212, 213] in
shortening the length of thyroid surgery and
reducing blood loss, while retaining a good
hemostasis.
Drains do not prevent hemorrhage and are
unlikely to prevent airway compromise since
they are usually blocked by clot formation. If
respiratory distress occurs, the wound should be
opened immediately to release and drain the
14.10.3 Recurrent Laryngeal Nerve
(RLN) Injury
Patients with a “single” RLN injury may remain
asymptomatic, but are more likely to have temporary or permanent hoarseness. Injury of the RLN
associated with thyroidectomy has progressively
decreased but still occurs in 0.1–5% of patients.
If the nerve is inadvertently transected, it should
be re-anastomosed immediately, if recognized
intraoperatively, to avoid permanent hoarseness
(>1 year). In such cases, a number of measures
can help lessen hoarseness. These include speech
therapy, Teon injection into the vocal cord and
nerve anastomoses. “Bilateral” RLN injury will
cause respiratory distress and stridor since both
vocal cords will assume a midline position.
Patients will require reintubation or tracheostomy to secure an airway. A vocal cord lateralization procedure can be performed if the injury has
been present for over a year [218].
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14.10.4 External Branch
oftheSuperior Laryngeal
Nerve (EB-SLN) Injury
Damage to the EB-SLN occurs in 0.3–2% of
patients undergoing thyroidectomy. The nerve
may be injured when taking down the superior
pole of the thyroid lobe. This will lead to. The
patient will complain of voice weakness and a
subtle loss of voice pitch. In case of bilateral
injury, patients can experience swallowing disorders and be susceptible to aspiration [219].
14.10.5 Other Nerve Injuries
Rarely, the cervical sympathetic trunk may be
injured during thyroidectomy, resulting in
Horner’s syndrome. This is a rare complication,
but can occur with very large glands, invasive
tumors or with recurrent goiters due to obliteration of normal tissue planes by scar tissue. Injury
to the SAN can occur with neck dissections when
combined with thyroidectomy, but should not
occur with thyroidectomy alone [219].
14.10.6 Hypoparathyroidism
“Transient” asymptomatic hypocalcemia occurs
in most patients undergoing thyroidectomy, but
this complication has decreased dramatically
with the increased understanding of the anatomy
and physiology of the PTGs. “Permanent” hypoparathyroidism has been reported in <1–2% of
patients. It occurs if all the PTGs are removed,
injured, or rendered ischemic during thyroidectomy. Symptoms of acute postoperative hypocalcemia usually develop 1–7days postoperatively.
If untreated, carpal pedal spasm, tetany, and lifethreatening cardiac arrhythmias may occur [220].
For symptomatic patients, intravenous calcium gluconate must be administered.
Asymptomatic patients with mild hypocalcemia
should be treated with oral calcium supplements.
If the total serum calcium is <8mg/dl, vitamin D
replacement therapy should be initiated with one
alpha-hydroxy cholecalciferol. It is important to
also measure serum phosphorous in these
patients. If the serum phosphorous is low, the
cause of hypocalcemia may be the “bone hunger” syndrome, but if the serum phosphorous is
high, the cause of hypocalcemia is hypoparathyroidism. If hypocalcemia and hyperphosphatemia remain after a year, permanent
hyperparathyroidism is present, and the patient
will require long- term therapy with oral calcium
and vitamin D.
Permanent hypoparathyroidism can be prevented by giving special attention to identifying
the parathyroid glands and preserving their blood
supply during thyroidectomy by individually
ligating the branches of the inferior thyroid artery
(ITA). If a gland cannot be left in situ with an
intact vascular pedicle, it should be removed and
auto-transplanted (after being conrmed by frozen section) into the ipsilateral SCM muscle or
brachioradialis of the nondominating hand [221].
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