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68
J. L. McMullin and A. Gillis
References
1. Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Burman KD, etal. American Thyroid
Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid.
2012;22(11):1104–39.
2. Smallridge RC, Copland JA.Anaplastic thyroid carcinoma: pathogenesis and emerging therapies. Clin Oncol (R Coll Radiol). 2010;22(6):486–97.
3. Kebebew E, Greenspan FS, Clark OH, Woeber KA, McMillan A.Anaplastic thyroid carcinoma. Treatment outcome and prognostic factors. Cancer. 2005;103(7):1330–5.
4. Alobuia W, Gillis A, Kebebew E.Contemporary management of anaplastic thyroid cancer.
Curr Treat Options Oncol. 2020;21(10):78.
5. Rao SN, Zafereo M, Dadu R, Busaidy NL, Hess K, Cote GJ, etal. Patterns of treatment failure
in anaplastic thyroid carcinoma. Thyroid. 2017;27(5):672–81.
6. Cancer AJCo. AJCC Cancer staging manual. 8th ed. Chicago, IL: Springer; 2017.
7. Jungels C, Pita JM, Costante G.Anaplastic thyroid carcinoma: advances in molecular proling
and targeted therapy. Curr Opin Oncol. 2023;35(1):1–9.
8. Chen H, Nicol TL, Udelsman R.Clinically signicant, isolated metastatic disease to the thyroid gland. World J Surg. 1999;23(2):177–80. discussion 81.
9. Chung AY, Tran TB, Brumund KT, Weisman RA, Bouvet M. Metastases to the thyroid: a
review of the literature from the last decade. Thyroid. 2012;22(3):258–68.
10. Shimaoka K, Sokal JE, Pickren JW.Metastatic neoplasms in the thyroid gland. Pathological
and clinical ndings. Cancer. 1962;15:557–65.
11. Wood K, Vini L, Harmer C.Metastases to the thyroid gland: the Royal Marsden experience.
Eur J Surg Oncol. 2004;30(6):583–8.
12. Papi G, Fadda G, Corsello SM, Corrado S, Rossi ED, Radighieri E, etal. Metastases to the
thyroid gland: prevalence, clinicopathological aspects and prognosis: a 10-year experience.
Clin Endocrinol (Oxf). 2007;66(4):565–71.
13. Ansell SM, Grant CS, Habermann TM. Primary thyroid lymphoma. Semin Oncol.
1999;26(3):316–23.
14. Ruggiero FP, Frauenhoffer E, Stack BC Jr. Thyroid lymphoma: a single institution’s experience. Otolaryngol Head Neck Surg. 2005;133(6):888–96.
15. Cha C, Chen H, Westra WH, Udelsman R.Primary thyroid lymphoma: can the diagnosis be
made solely by ne-needle aspiration? Ann Surg Oncol. 2002;9(3):298–302.
Chapter 9
Thyroidectomy: Techniques, Adjuncts,
andPotential Complications
Q.LinaHu-Bianco andCatherineMcManus
Overview
• Thyroidectomy involves removal of the entire thyroid parenchyma of either one
or both lobes with or without the isthmus, while preserving the parathyroid
glands, recurrent laryngeal nerves, and superior laryngeal nerves. “Nodulectomy”
is almost never performed.
• Thyroid surgery can be performed using open or remote access techniques with
or without intraoperative nerve monitoring.
• Potential complications include nerve injury (recurrent and/or superior laryn-
geal), hypocalcemia, bleeding, and infection.
Techniques
Open
• Thyroid lobectomy
– Patient is supine with arms tucked. The neck is mildly extended with a shoul-
der roll or inated IV pressure bag.
– The neck is prepped and draped from chin to upper chest and to beyond both
anterior borders of the sternocleidomastoid muscles.
– The transverse incision is made in a natural skin crease near the isthmus and
cricoid cartilage and deepened through the subcutaneous tissue (Fig.9.1).
Q. L. Hu-Bianco · C. McManus (*)
Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
e-mail: cm3304@cumc.columbia.edu
Switzerland AG 2024
R. M. Gartland, J. A. Lee (eds.), Endocrine Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-62091-1_9
69© The Author(s), under exclusive license to Springer Nature
70
Fig. 9.1 Cervical incision
in a natural skin crease
Fig. 9.2 Excision of
prelaryngeal tissue in the
midline, superior to the
thyroid isthmus
Q. L. Hu-Bianco and C. McManus
– The platysma is divided and subplatysmal aps are raised to the thyroid carti-
lage superiorly and sternal notch inferiorly. A self-retaining retractor is placed.
– The strap muscles are separated in the midline to expose the thyroid gland.
– The prelaryngeal tissue, including the Delphian lymph node as well as any
pyramidal lobe if present, is dissected (Fig.9.2).
– The thyroid isthmus is divided ush with the contralateral thyroid lobe.
– The strap muscles are separated off the thyroid lobe with blunt dissection to
expose the superior pole.
– The avascular space of Reeves is dissected close to the thyroid gland to avoid
injury to the external branch of the superior laryngeal nerve.
– The superior pole vessels are identied and ligated.
– The middle thyroid vein is divided and the thyroid is rotated anteromedially.
– The recurrent laryngeal nerve is identied in the tracheoesophageal groove
perpendicular to the inferior thyroid artery and is traced to its insertion into
the larynx, which serves to separate the nerve from the thyroid (Fig.9.3).
– The landmarks for identifying the recurrent laryngeal nerve are:
Runs in the tracheoesophageal groove anterior to the esophagus.
Runs perpendicular to the inferior thyroid artery and may be medial, lateral, or interdigitate between branches of the artery.
9 Thyroidectomy: Techniques, Adjuncts, andPotential Complications
Fig. 9.3 Dissection of the recurrent laryngeal nerve, which is most consistently identied perpendicular to the inferior thyroid artery in the tracheoesophageal groove
Fig. 9.4 Division of the
ligament of Berry
71
Runs posterior to the inferior parathyroid gland and anterior to the superior
parathyroid gland.
Often lies near the junction of the tubercle and inferior thyroid lobe.
– The inferior thyroid artery is divided close to the thyroid to preserve blood
supply to the parathyroids.
– Remaining attachments of the ligament of Berry are divided (Fig.9.4).
– Hemostasis in the thyroid resection beds is attained; a hemostatic agent may
be used as an adjunct.
– The strap muscles and platysma are re-approximated with a simple inter-
rupted suture. The skin is closed with a subcuticular running suture.
• Total thyroidectomy
72
– The bilateral thyroid lobes are removed in an identical fashion as described
for a hemi-thyroidectomy.
– Usually, the thyroid lobe containing the pathology or the larger lobe is
removed rst.
– The recurrent laryngeal nerve should be visualized and its function conrmed
if nerve monitoring is utilized prior to resecting the contralateral lobe to pre-
vent bilateral recurrent laryngeal nerve injuries.
Q. L. Hu-Bianco and C. McManus
Remote Access
• Many remote access thyroidectomy techniques have been described to remove
the thyroid gland without an incision in the neck. These techniques have gained
popularity in parts of Asia and are offered at certain centers in the United States.
• The transaxillary approach places the incisions within the axilla and tunnels to
the cervical working space with or without the use of CO2 insufation and may
be performed laparoscopically or robotic-assisted [1].
• The bilateral axillo-breast approach uses incisions in bilateral circumareolar
areas and axillae and improves access to the bilateral central neck compared to
the transaxillary approach [1].
• The retroauricular or facelift approach places the incision posterior to the earlobe
and creates a subplatysmal ap along the anterior border of the sternocleidomastoid muscle [1].
• The transoral endoscopic approach uses an incision in the inside of the lower lip
and tunnels over the mandible into the anterior neck in the subplatysmal plane [1].
Adjuncts
• Intraoperative laryngeal nerve monitoring
– Nerve monitoring may be used during thyroid surgery to aid in intraoperative
identication of the recurrent laryngeal nerve.
– The system includes electrodes on the endotracheal tube to detect vocal cord
movement, a stimulation probe on the eld to stimulate the nerve as well as
grounding electrodes (Fig.9.5). A positive signal is evoked when the probe
stimulates the nerve, resulting in laryngeal muscle contraction and vocal cord
movement.
– Nerve monitoring has not been shown to reduce the incidence of transient or
permanent RLN injury in meta-analyses but may be a helpful adjunct in reoperative cases or to help identify aberrant anatomy [2].
• Intraoperative parathyroid gland identication
9 Thyroidectomy: Techniques, Adjuncts, andPotential Complications
Fig. 9.5 Example of a nerve monitoring system, including electrodes on the endotracheal tube
(red and blue wires), grounding wires (green and white wires), and a probe (blue probe attached to
red wires)
73
– Many adjuncts have been described to aid in the identication and preserva-
tion of parathyroid glands during thyroidectomy, including the use of exogenously administered contrast agents such as methylene blue dye and
indocyanine green, and other parathyroid-localizing labels [3].
– A newer adjunct, near infra-red autouorescence (NIRAF), is based on the
discovery that parathyroid tissue autouoresces more strongly than the surrounding tissue when excited by light in the infra-red wavelengths and may be
detected using a probe or imaging system [3].
– Although more robust and long-term data is still needed to demonstrate the
utility of these parathyroid identication techniques, they may be helpful
adjuncts to prevent postoperative hypoparathyroidism after thyroidectomy.
Potential Complications
• Laryngeal nerve injury
– Unilateral recurrent laryngeal nerve injury results in vocal cord paresis/paral-
ysis, which presents as hoarseness or dysphonia and upper airway dyspnea
and dysphagia, particularly for liquids. Reported incidence ranges from 1.5%
to 38.4% for temporary paresis and 0% to 18.6% for permanent paralysis [4].
– Bilateral recurrent laryngeal nerve injury is extremely rare, with an incidence
of 0.4%, that results in acute life-threatening dyspnea when the vocal cords
are paralyzed in adduction [5].
– Injury to the external branch of the superior laryngeal nerve results in a
decreased vocal power and range due to inability to tense the vocal cords.
Incidence is reported around 0.4–3% [6].
– Factors that increase the risk of laryngeal nerve injury include:
74
Q. L. Hu-Bianco and C. McManus
Underlying pathology (malignancy, chronic thyroiditis, and Graves’
disease).
Re-operative neck surgery.
Patient anatomy (larger goiters and smaller nerves).
Low volume surgeons [6, 7].
– Diagnosis is made by visualizing the vocal cords via techniques like berop-
tic laryngoscopy.
– Treatment is symptom-focused.
For unilateral RLN palsy, treatment is aimed at improving quality of life,
respiratory function, and phonation [6].
Spontaneous recovery of vocal function by either nerve regeneration or
compensation of the contralateral vocal cord can occur up to 12months
after the injury.
Urgent intervention should be reserved for patients with signicant risk
of aspiration or poor tolerance of their dysphonia.
Early injection of the paralyzed or paretic cord with temporary llers to
increase bulk may improve quality of life until normal function is
restored.
Bilateral vocal cord paralysis in adduction requires urgent re-intubation
and persistent cord immobility may require tracheostomy.
High-dose corticosteroids may be administered for 48 h to reduce
laryngeal edema [8].
Surgical management of vocal cord paralysis includes medialization of the
vocal cord with intracordal injection, thyroplasty with implantation of
various materials into the vocal cord, or adduction of the arytenoid muscle [6, 7].
• Hypocalcemia
– Hypocalcemia is usually secondary to hypoparathyroidism due to spasm or
compromise of the blood supply to the parathyroid glands and impaired secretion of PTH [7].
– The incidence of post-thyroidectomy hypocalcemia varies widely (2–83%)
depending on the denition (symptomatic hypocalcemia, asymptomatic
hypocalcemia with or without transient hypoparathyroidism). Estimates for
transient hypoparathyroidism range from 6.9 to 46% and permanent hypoparathyroidism from 0.4% to 33% [9].
– Diagnosis is made with postoperative measurement of calcium and PTH lev-
els [10].
– Management of postoperative hypocalcemia is based on patient symptoms [7].
No treatment is necessary for mild hypocalcemia (calcium level 8–8.8mg/
dL) in asymptomatic patients.
9 Thyroidectomy: Techniques, Adjuncts, andPotential Complications
Patients with symptoms of paresthesia or neuromuscular excitability
should be given calcium and vitamin D with weekly measurement of calcium and phosphate levels until biological equilibrium is reached.
Patients with acute severe hypocalcemia (calcium level <7mg/dL) or with
severe symptoms (tetany, muscular fasciculations, carpo-pedal spasm,
and/or positive Chvostek sign) are at risk for cardiac decompensation or
laryngospasm and should be treated urgently with intravenous calcium
gluconate, oral calcium, and vitamin D supplementation until the calcium
level is corrected.
• Hematoma
– Bleeding complications have a reported incidence of 05 to 6.5% [11].
– Factors that may cause increased risk of bleeding include older age, male sex,
malignancy, extent of resection, large goiter, Graves’ disease, and re- operation
[11, 12].
– Mild or stable hematoma may be observed, but expanding or compressive
hematoma in the neck compartment is a surgical emergency and requires
urgent evacuation at the bedside.
• Other
– Dysphagia may occur due to postoperative inammation and usually improves
over time [7].
– Lymphorrhea or seroma formation can result from ligation of small lymphat-
ics during resection of large goiters, extensive nodal dissections or injury to
the thoracic duct. These generally resolve with time or needle aspiration [7].
– Surgical site infection is rare with estimated incidence of 0.4% and is treated
with antibiotics +/− incision and drainage [13].
75
References
1. Graves CE, Suh I.The current status of remote access thyroidectomy in the United States.
Surgery. 2020;168(5):845–50.
2. Higgins TS, Gupta R, Ketcham AS, Sataloff RT, Wadsworth JT, Sinacori JT.Recurrent laryngeal nerve monitoring versus identication alone on post-thyroidectomy true vocal fold palsy:
a meta-analysis. Laryngoscope. 2011;121(5):1009–17.
3. Wong A, Wong JCY, Pandey PU, Wiseman SM.Novel techniques for intraoperative parathyroid gland identication: a comprehensive review. Expert Rev Endocrinol Metab.
2020;15(6):439–57.
4. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R.Diagnosis of recurrent laryngeal
nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract. 2009;63(4):624–9.
5. Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, etal. Complications of
thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5
years. World J Surg. 2004;28(3):271–6.
76
6. Hartl DM, Travagli JP, Leboulleux S, Baudin E, Brasnu DF, Schlumberger M.Clinical review:
current concepts in the management of unilateral recurrent laryngeal nerve paralysis after thyroid surgery. J Clin Endocrinol Metab. 2005;90(5):3084–8.
7. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg.
2013;150(4):249–56.
8. Dispenza F, Dispenza C, Marchese D, Kulamarva G, Saraniti C.Treatment of bilateral vocal
cord paralysis following permanent recurrent laryngeal nerve injury. Am J Otolaryngol.
2012;33(3):285–8.
9. Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H.The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate
analysis of 5846 consecutive patients. Surgery. 2003;133(2):180–5.
10. Wang TS, Cayo AK, Wilson SD, Yen TW.The value of postoperative parathyroid hormone levels in predicting the need for long-term vitamin D supplementation after total thyroidectomy.
Ann Surg Oncol. 2011;18(3):777–81.
11. Promberger R, Ott J, Kober F, Koppitsch C, Seemann R, Freissmuth M, etal. Risk factors for
postoperative bleeding after thyroid surgery. Br J Surg. 2012;99(3):373–9.
12. Godballe C, Madsen AR, Pedersen HB, Sørensen CH, Pedersen U, Frisch T, etal. Postthyroidectomy hemorrhage: a national study of patients treated at the Danish departments of
ENT head and neck surgery. Eur Arch Otorhinolaryngol. 2009;266(12):1945–52.
13. Myssiorek D, Ahmed Y, Parsikia A, Castaldi M, McNelis J.Factors predictive of the development of surgical site infection in thyroidectomy—an analysis of NSQIP database. Int J Surg.
2018;60:273–8.
Q. L. Hu-Bianco and C. McManus
Chapter 10
Central andLateral Neck Dissection:
Techniques andPotential Complications
JamesX.Wu andRajamRaghunathan
Overview
• All subtypes of thyroid cancer1 can metastasize to the cervical lymph nodes.
• Careful examination of the cervical nodes with physical exam and neck ultra-
sound is required in the workup of all thyroid cancer patients.
• Cross-sectional imaging, CT and MRI, can be helpful in patients with extensive
nodal disease or whose physical habitus limits ultrasound assessment [1–4].
• When nodal involvement is identied, the rst line treatment is surgical removal
of the nodes, called cervical lymphadenectomy or neck dissection.
• Given that microscopic deposits of cancer cells may exist in the lymph nodes
next to the clearly abnormal nodes, neck dissection involves removal of an entire
anatomical compartment.
• “Berry-picking” only the involved nodes for excision should not be performed
due to a uniformly higher recurrence rate (~100%) with this practice in comparison with anatomic compartment-oriented neck dissection (9%) [5].
1
The majority of thyroid cancer develops from the follicular epithelial cells of the thyroid gland
and is classied as well-differentiated thyroid cancer (WDTC), including papillary (PTC) and
follicular (FTC) subtypes. Medullary thyroid cancer (MTC), which arises from the neuroendocrine C-cells of the thyroid gland, is rare and can occur sporadically or as part of an inherited
syndrome (MEN 2). Exceedingly uncommon anaplastic or poorly differentiated thyroid cancer
(ATC) is characterized by highly invasive, aggressive, bulky disease and is associated with a poor
prognosis.
J. X. Wu (*) · R. Raghunathan
Section of Endocrine Surgery, Department of Surgery, University of California, Los Angeles,
David Geffen School of Medicine, Los Angeles, CA, USA
e-mail: jameswu@mednet.ucla.edu
Switzerland AG 2024
R. M. Gartland, J. A. Lee (eds.), Endocrine Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-62091-1_10
77© The Author(s), under exclusive license to Springer Nature