University of Virginia Health System

The patient who comes to thyroidectomy or neck exploration for a thyroid mass should have a preoperative evaluation and discussion with an endocrine surgeon. The patient can expect to come to the hospital on the day of surgery, undergo general anesthesia for approximately two to three hours and depending on the extent of the surgery, could be discharged the same day. At the University of Virginia our experience is that the patients with more than a lobectomy often spend the night and are discharged the next morning.

The risks of surgery should be fully discussed and understood by the patient prior to surgery. The primary risk of thyroidectomy, particularly total thyroidectomy, is recurrent laryngeal nerve damage on one or both sides. Damage to one or both recurrent laryngeal nerves can result in severe hoarseness. An experienced endocrine surgeon knows the location of the recurrent laryngeal nerve and should be able to avoid such injury. In patients having a total thyroidectomy, voice weakness can occur because of traction on the thyroid and tension on the external branch of the superior laryngeal nerve. This can result in a bothersome voice weakness, which occurs at the end of the day. It may take several weeks to resolve.

A second complication, particularly for patients having a total thyroidectomy, is hypoparathyroidism. An experienced endocrine surgeon should know where the parathyroid glands are and check for viability of these glands upon completion of the procedure. The parathyroid glands depend on a blood supply from the inferior thyroid artery and, in most circumstances, can be preserved. The glands may also be removed, sliced into small pieces, and placed in a muscle bed in the neck (parathyroid autotransplantation). If this is done appropriately, a 95% success rate should occur. If the parathyroids do not work postoperatively, a state of surgically induced hypoparathyroidism (lack of function of the parathyroid glands) occurs. If this should occur and there is no source of parathyroid hormone, the patient will experience a significantly low calcium level requiring calcium supplementation for the rest of his or her life.

A final complication is that the endocrine surgeon may not be able to determine exactly whether or not a thyroid nodule is cancerous. This is a particular problem with "follicular" lesions. Preoperative fine needle aspiration is unable to tell the difference between a benign and cancerous follicular lesion and intraoperative frozen section will not be of any greater benefit. Therefore, the patient with follicular cells diagnosed preoperatively by fine needle aspiration must understand that the endocrine surgeon must use his own best judgement as to the nature of the diagnosis and the extent of the surgery. If a lesion is removed with less than a lobe resection and a diagnosis then later confirms that this represents a follicular cancer, a second surgery requiring completion thyroidectomy may be required. Such surgeries can be difficult and require that the surgeon have experience in reoperative neck surgery.

At the University of Virginia, Dr. Hanks' experience with thyroid surgery is an average of 60-65 cases yearly.