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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. During the operation, the surgeon may send a frozen section biopsy. With a frozen section, the pathologist will look at one or two sections of the thyroid nodule in question while the patient is still in the operating room in order to see if there is a cancer present. If there is a clear-cut cancer, the surgeon will remove the other side of the thyroid as well. Unfortunately, since the pathologist is only able to look at a couple of slices of the nodule, the frozen section biopsy is most often not helpful and typically one has to wait until the final pathology is ready within 7 to 10 business days 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 6 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, 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.
Choices of Anesthesia
There are two main choices for anesthesia during thyroid surgery: general and local anesthesia. Thyroid surgery is most commonly performed with general anesthesia, but centers specializing in thyroid surgery may also offer the choice of local anesthesia. Dr. Paul Logerfo, the co-founder of the Columbia Thyroid Center, was one of the pioneers and creators of the local anesthesia approach to thyroid surgery and this technique is routinely employed at the Center. At the Columbia Thyroid Center, the surgeon works with each individual patient to decide which type of anesthesia is right for them.
With both anesthesia techniques the surgeon will perform a cervical nerve block to numb up the neck so that the patient does not feel pain during the operation. This block lasts about 6 to 8 hours which also helps reduce the amount of pain the patient has after the operation. With local anesthesia, the patient is given light sedation through the IV which is similar to the "twilight" anesthesia people have with colonoscopy. Typically patients will be napping throughout the operation and will be woken up when it is over. With the general anesthesia, the patient is given a slightly larger dose of medicine and a breathing tube is placed. The breathing tube is removed and the patient is woken up once the operation is over. Since the cervical nerve block does such a good job with pain control, the anesthesiologist gives much less medication for the general anesthesia then they normally would have to. For this reason, the amount of post-operative nausea and time to recover from anesthesia is about the same with both the general and local anesthesia.
Risks of Thyroid Surgery
In the hands of an experienced thyroid surgeon, thyroid surgery is a safe procedure with few complications. The main risks of thyroid surgery include:
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 6 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.
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 testsdone within 30 days of the operation
CBC (complete blood count)
BMP (basic metabolic profile)
B-HCG (blood pregnancy test) for women
Coagulation profile if the patient is on blood thinners or has a bleeding disorder
EKG done within 3 months of the operation for men and women older than 40
Chest X-ray done within 6 months of the operation for men older than 50 and women older than 60
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 approximately 2 to 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). Patients will be sent home with a prescription for a mild narcotic medication, but many patients do not need to use it. In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days.
The incision is covered with a protective strip of clear glue called collodion. The collodion will turn white and start curling up at the edges in about 7 to 10 days. When this happens, it can be peeled off or one can wait until it falls off on its own. If there is itching once the collodion comes off, lotion can be applied to the scar. If the patient is going out into the sun, we recommend putting sunscreen or sunblock on the incision so that it tans evenly. Patients may apply whatever they like to the incision as long as it does not irritate the skin. In general, most patients do nothing and the cosmetic results are excellent. Patients can shower the day after the operation, but do not soak or scrub the incision. After showering, use a cool hair dryer to dry the incision. There may be bruising around the incision or upper chest and slight swelling above the scar when sitting up or standing. In addition, the scar may become pink and hard. This hardening is part of the normal healing process, will peak at about 3 weeks and may result in some tightness or difficulty swallowing, which will disappear over the next 2 to 3 months.
Bleeding is a rare complication and those few patients who do have a bleeding problem almost always have it during the 6 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 two medications after the operation:
Pain medication: A mild narcotic medication will be prescribed. We recommend trying non-narcotic medications like Tylenol, Motrin, or Advil first and if the patient is still having pain, then trying the narcotic medication.
Calcium: All Columbia Thyroid Center patients will be sent home with a prescription for calcium pills. This calcium prescription is to help prevent patients from having symptoms of low blood calcium levels. Patients will be asked to take calcium as follows: Calcium 1000 mg every 6 hours for 7 days after the operation, followed by Calcium 500 mg every 12 hours until they are seen in the office 3 weeks later.
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%) have no problems with their voice immediately 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 may become stunned. This stunning causes the blood calcium levels to drop below normal (i.e. hypocalcemia). 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.
In order to avoid the symptoms of hypocalcemia, Columbia Thyroid Center surgeons prescribe calcium post-operatively for all patients having thyroid surgery. If patients are still having symptoms after taking the calcium as prescribed, they should take an extra 1000 mg of calcium. If the symptoms do not improve after 30 minutes, they should call their surgeon. At this point, the surgeon may prescribe a form of vitamin D called Calcitriol or Rocaltrol. This medication helps the body absorb more calcium.