Thyroid Surgery


Minimally invasive thyroid surgery

Minimally invasive thyroid surgery is the removal of one half or whole thyroid gland through a small mid neck incision. The incision is placed in the natural skin crease. Minimally invasive thyroid surgery includes video-assisted or endoscopic thyroidectomy, when surgeon uses camera to magnify the view. This technique makes the healing process faster and with minimum scar formation.

YOUR SURGERY:

Anesthesia

The procedure is done under general. For some patients patients, who can not tolerate or not allowed to have general anesthesia (for example during pregnancy), the procedure can be performed under local/regional anesthesia with general sedation. The later one helps surgeon to use voice monitoring and avoid injury to important nerves which go to your vocal cords

Recurrent Laryngeal Nerve and External Branch of the Superior Laryngeal Nerve Monitoring during Thyroid Surgery

Recurrent Laryngeal Nerve Monitoring and External Branch of the Superior Laryngeal Nerve Monitoring is useful to identify the recurrent laryngeal nerve or/and External Branch of the Superior Laryngeal Nerve during Thyroid Surgery under general anesthesia. Monitoring is performed all thyroid cases and some parathyroid cases if anatomic location of those nerves is complex and altered by previous neck surgery as result of significant scarring, or by cancer, or large thyroid goiter. Special endotracheal tube (ET) (breathing tube) with an electrode is used (picture below), surgeon stimulates nerve or, if nerve is difficult to find, the area where the nerve is supposed to be. The signal is received on ET tube and transformed to computer station in the back of operating room. Visual and audio signal will be analyzed by technician (picture below). Nerve monitoring helps to identify and localize the nerve, to prevent complications such as injury to the nerve, it is also helps to identify the nerve and determine its function during cancer surgery, when cancer is growing over the nerve.

Endotracheal (ET) tube with the sensor for the nerve monitoring during thyroid surgery.

Nerve monitoring during thyroid surgery, computer station.

Length of hospital stay

Surgery is performed as an outpatient procedure. The average stay after the surgery is about 6 hours. Most patients do not require overnight stay. If patient has significant comorbidities, or very large goiter that extends into the chest cavity, or if patient prefer to stay for social reasons, than patient can stay over night

Pain

Most patients have little or no pain. Some patients may feel discomfort or pressure after the surgery. Some patients may feel discomfort or pain with swallowing after the surgery. It normally resolves within couple of days. If procedure is performed under the local anesthesia with a nerve block, then some patients might feel shoulder/arm weakness after the neck block, which also resolves within 4-8 hours after the surgery

Postoperatively most of the patients have no pain at all. If you do develop mild pain at home, you can take either Tylenol or Motrin.

Drain:

There will be NO drain placement.

Stitch and Scar:

The stitches will be removed the day of the surgery, right before you go home. You will have just a strip of skin glue on the skin. It will peel off on its own in about 6 - 10 days. Because the incision will be small and the stitch will be removed the same day of the procedure the size of the scar will be much less than that with traditional thyroid surgeries performed in the past. The incision will be placed in the natural skin crease of your neck, which will help to make it less noticeable or not visible at all.

However the scaring tendency is dependent on the individual skin healing proprieties. The surgeon will make all efforts to have best cosmetic result possible.

Complications:

Voice changes:

Only 1% (1 in 100 patients) experience complications related to the damage of the nerve goes to the vocal cords. When this occurs the patient will have hoarse voice or inability to make high-pitched sounds. More commonly hoarseness lasts for a couple of days. In about 1 in 50 operations patient might experience temporally voice changes which resolve in 8 to 12 weeks.

Low calcium level:

In about 0.5% (1 in 200 operations) for total removal of thyroid gland the patient may experience low calcium levels. It happens secondary to malfunction of parathyroid glands, which are located on the or near the thyroid gland and have the same blood supply as the thyroid gland. If it happens, patients need to stay on calcium and vitamin D supplementation permanently. Because there are four parathyroid glands, this is a rare occurrence. Because of the nature of the surgery, all patients with total thyroid removal will go home on calcium pills for 2-3 weeks. If patient develops cramps in the hands or legs, or tingling of the face muscles it will indicates that the calcium level is low. In this case you should immediately take 2 Calcium pills (1000 mg) and call your doctor.

Bleeding:

With current technique the incidence of bleeding is less than 0.5%.

Wound infection:

With current technique the incidence of wound infection is is less than 0.5%. You do not need any antibiotics for the surgery, unless you have condition which requires you to take antibiotics with every procedure.

POSTOPERATIVE CARE:

Incision site:

The skin glue will peel off on its own in 6-10 days. After that you can apply you can use Mederma or lotion with Vitamin E 3-6 times a day to the wound. Try not to have sun exposure to the wound for about 1-2 months (especially during summer months), such as it will cause skin discoloration in the wound area and it will look different from the other skin areas.

Physical restrictions:

It is better not to drive for several days if you feel uncomfortable moving your neck. Do not drive if you are taking narcotics such as Percocet or Vicodin. There are no significant physical restrictions, but it is not advisable to do any stretch exercises to your neck for 2-3 weeks. Most of the patients resume their normal physical activities within day after the surgery.

Shower:

You can take shower in 2 days after the surgery. Do not scratch or peel off the skin glue, just wipe it with the towel.

Pathology report:

Usually available within 5-7 days after the surgery

Problem calls:

Please immediately call doctor if you develop significant neck swelling or shortness of breath shortly after surgery, or you develop cramps in your hands or legs after the surgery.

Postoperative visit:

2-3 weeks after the surgery: for wound check and pathology report.

Nurse Navigator:

For complex thyroid cancer related postoperative care we will assign the nurse navigator, Joan Hallman, RN. She has tremendous expertise in taking care of thyroid cancer patients. She helps them to coordinate their care before and after the surgery, and between different physicians. She is also coordinate Endocrine Cancer Tumor Board.

POST-OPERATIVE SCAR GALLERY:

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Scar, 2 weeks after minimally invasive thyroid lobectomy surgery (1/2 of the thyroid removed)


Scar, 2 weeks after minimally invasive total thyroidectomy


Scar, 2 weeks after minimally invasive total thyroidectomy



Scar, 2 weeks after minimally invasive total thyroidectomy


Scar, 2 weeks after minimally invasive thyroid lobectomy (1/2 of the thyroid removed)


Patient with Graves' Disease. Scar 2 weeks after minimally invasive total thyroidectomy.



Scar 3 weeks after minimally invasive total thyroidectomy.


Scar 6 weeks after minimally invasive total thyroidectomy.


Scar 6 months after minimally invasive thyroid lobectomy (1/2 of the thyroid removed).



Scar, 2 years after minimally invasive thyroid lobectomy (1/2 of the thyroid removed)


Scar, 9 months after minimally invasive total thyroidectomy


Scar, 9 months after minimally invasive total thyroidectomy


Scar. Patient with papillary thyroid carcinoma who has had the first surgery 5 weeks prior (1/2 of the thyroid was removed). Patient came back for completion of total thyroidectomy that included removal of the remaining ½ of the thyroid and lymph nodes in the central neck compartment (level 6 and 7), Second incision was placed in the old scar. This picture represents second scar 2 weeks after the second surgery.



Scar, 1 year after thyroid lobectomy.

Scar, 1.5 years after a total thyroidectomy for cancer.


Scar, 5 years after a total thyroidectomy for follicular thyroid carcinoma.


Scar, 3 years after a total thyroidectomy with modified radical neck dissection (removal of entire right neck lymph nodes) on the right side for advanced thyroid cancer with metastatic disease to the right side neck lymph nodes



Image on operating table, right after the completion of minimally invasive total thyroidectomy: you can see total thyroid with multiple nodules, above the thyroid is incision which is closed with temporally placed stitch. The size of the incision is much smaller than size of the thyroid with nodules.jpg


Total thyroid with cancer (papillary thyroid carcinoma) in the right thyroid lobe


Gigantic total thyroid gland extended into the chest cavity on the left side and resulted in airway compression.


This picture represents a new scar within the old scar: patient is 2 weeks after completion of total thyroidectomy - removal of the remaining 1/2 (left side) of the thyroid after her prior surgery - removal of 1/2 of the thyroid (right side) that was done with a big scar 30 years ago (the new scar is much smaller,was placed into the old scar and it is invisible within the old scar)



Scar, 2 weeks after a total thyroidectomy with central neck lymph nodes dissection (lymph nodes removal from the central neck) for Papillary Thyroid Carcinoma


Scar, 2 weeks after the left thyroid lobectomy (left 1/2 of the thyroid removed)


Scar, 3 months after total thyroidectomy


Scar, 2 weeks after the left thyroid lobectomy (left 1/2 of the thyroid removed) as a completion of total thyroidectomy for papillary thyroid carcinoma. First surgery was 4 weeks prior, only final pathological report has revealed cancer in the right side nodule and patient had to go back for a completion of total thyroidectomy (new incision was placed in the old scar)



Left Thyroid lobe with a large, 4 cm, nodule (Follicular Neoplasm by preoperative FNA Biopsy)



Scar, 2 weeks after the right thyroid lobectomy (removal of the right 1/2 of the thyroid) for 6 cm (2 and 1/4 inches) hyperfunctioning nodule.


Scar, 2 weeks after a total thyroidectomy with central neck (level 6 and 7) lymph nodes dissection for metastatic to the lymph nodes Papillary Thyroid Carcinoma.


Scar, 2 weeks after total thyroidectomy for small Papillary Thyroid Carcinoma.



Scar, 2 weeks after the right thyroid lobectomy (removal of the right 1/2 of the thyroid) for 2.6 cm (about 1 inch) thyroid nodule.


Scar, 2 weeks after the left thyroid lobectomy (removal of the left 1/2 of the thyroid) for 3.1 cm (about 1 inch and 1/2) Follicular Adenoma.



A large thyroid goiter with multiple nodules that has extended inside of the chest cavity on the left side (multinodular goiter measured 3 and 1/2 inches width with intrathorasic extension on the left).


Scar, 2 weeks after the a total thyroidectomy in patient with goiter on the picture above: there was no chest split performed and an entire procedure has been performed through the neck; this scar is less then 2 inches, while the thyroid goiter itself is measured 3 and 1/2 inches).



A large multinodular thyroid gland with extension of the entire right side into the right chest cavity. Surgery was performed through the neck incision without chest opening.



Scar, 2 weeks after a total thyroidectomy for small Papillary Thyroid Carcinoma.


Scar, 1 year and 3 months after a total thyroidectomy with central neck (level 6 and 7) lymph nodes dissection for a Papillary Thyroid Carcinoma.


Scar, 2 weeks after the right thyroid lobectomy (removal of the right side of the thyroid gland) for follicular adenoma that was measuring 4.5 x 2.1 x 3.1 cm (almost 2 inches in size), the scar is less than 2 inches



Scar, 2 weeks after a total thyroidectomy for small Papillary Thyroid Carcinoma (multifocal micropapillary thyroid carcinoma) in one lobe and follicular adenoma in another lobe.


Scar, 2 weeks after a total thyroidectomy.


Scar, 2 weeks after a total thyroidectomy for multinodular goiter.



Scar, 2 weeks after a total thyroidectomy with central neck lymph nodes (level 6 and 7) dissection for papillary thyroid carcinoma.


Scar, 2 weeks after a total thyroidectomy for 2.1 cm (about an inch) Papillary Thyroid Carcinoma on the right side.



Gigantic thyroid gland that was removed in 42-year-old female (picture below). The gland was extending inside of her left chest cavity for about 4 -5 inches. It was almost completely inside of her left chest cavity, and was not noticeable on the direct neck examination but only had being seen on CT scan. It was completely removed through the neck incision without splitting her chest bone (sternum)



Scar, 2 weeks after a total thyroidectomy in the patient mentioned above. The patient had only a neck incision for the removal of this gigantic thyroid gland that has extended inside of the her chest cavity for about 4 -5 inches on the left. It was completely removed through the neck incision without splitting her chest bone (sternum)


Scar, 3 months after a total thyroidectomy for Follicular Thyroid Carcinoma in 73-year-old male patient. The patient also had radioactive iodine treatment after the surgery


Scar, 2 weeks after a total thyroidectomy with central neck lymph nodes (level 6 and 7) dissection for papillary thyroid carcinoma in 22-year-old female.



Scar, 7 years after total thyroidectomy for Graves' disease.


Scar, 2 weeks after the total thyroidectomy for papillary thyroid carcinomas 3 cm and 3.2 cm in the right thyroid lobe.


Scar, 2 weeks after a total thyroidectomy with central neck lymph nodes (level 6 and 7) dissection for 2.5 cm (1 inch) papillary thyroid carcinoma in 22-year-old female.



Scar, 3 years after a left thyroid lobectomy in 25-year-old female for 2 cm x 2 cm (less than an inch) follicular adenoma.