Thyroid surgery is typically categorized as subtotal or total (also called near-total) and further divided into right and left lobectomy. Subtotal surgery is characterized by leaving a small but appreciable amount of thyroid tissue in the thyroid bed that may allow the patient not to be hormone dependent and potentially decrease the risk of recurrent laryngeal nerve injury. The advantage of doing a total thyroidectomy is the decreased risk of recurrent disease (either goiter in patients with multinodular goiters or hyperthyroidism in hyperthyroid patients) and improved efficacy of radioactive iodine therapy for patients with differentiated thyroid cancer. The surgical technique for a total thyroidectomy is very similar to that for a subtotal (shown here) except for the amount of thyroid tissue left, which is none or 1–2 mm of tissue along the nerve.
The indications for thyroid surgery are evolving. There is a lower incidence of endemic goiters, both colloid and nodular. In addition, the increasing effectiveness of medical therapy in patients who present with thyrotoxicosis, whether due to Graves’ disease or nodular toxic goiter, often makes surgery unnecessary. However, the incidence of thyroid cancer has risen markedly over the past 20 years but with an improved understanding of the indolent nature of small, differentiated cancers. Modern treatment guidelines for small, differentiated thyroid cancers now call for a more measured approach because many of these cancers can be fully treated with a thyroid lobectomy or potentially close observation.
A definite indication for thyroid surgery is the removal of a solitary nodule suspected of being malignant, as determined by a fine-needle aspiration. Total lobectomy or total thyroidectomy ensures a better margin and allows pathologic examination of the excised thyroid lobe for multicentric foci should a malignant tumor be found.
The controversy as to whether surgical or medical treatment for thyrotoxicosis is desirable in patients younger than 35–40 years of age and in pregnant patients has yet to be resolved, but it is generally agreed that the use of radioactive iodine is contraindicated. Surgical removal should be considered if antithyroid drugs are tolerated poorly or required in large, prolonged doses and if thyrotoxicosis recurs after an apparently successful medication regimen. In high-risk patients or those who have recurrence of toxicity following previous thyroid surgery, medical therapy is usually the treatment of choice. Also, some pregnant patients may be best treated with antithyroid drugs in order to defer surgery until after the patient has delivered. However, thyroid replacement is given daily once the patient is euthyroid to prevent the development of goiter in the fetus.
Subtotal thyroidectomy or total thyroidectomy is performed for an enlarged thyroid gland that produced pressure symptoms or an undesirable cosmetic effect (endemic goiter), for toxic goiters, and occasionally for inflammatory conditions such as Riedel’s struma and Hashimoto’s disease.
The only indication for emergency thyroidectomy is in ...