Total thyroidectomy for clinically benign disease of the thyroid gland

BACKGROUND: The role of total thyroidectomy in the treatment of patients with benign thyroid disease remains controversial. However, this procedure may be appropriate when both thyroid lobes are involved and when the risk of recurrence is significant. This study is a review of a 15-year experience of total thyroidectomy for benign disease. METHODS: Between 1988 and 2002, 834 patients underwent total thyroidectomy for clinically benign disease at the Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital. There were 128 men and 706 women with a mean age of 52 (range 16-91) years. Indications for surgery were euthyroid multinodular goitre (MNG), toxic MNG and Graves' disease in 730 (87.5 per cent), 57 (6.8 per cent) and 47 (5.6 per cent) respectively. A total of 74 patients had previously undergone partial thyroidectomy. RESULTS: The incidence of temporary recurrent laryngeal nerve palsy was 2.3 per cent and that of temporary hypoparathyroidism 14.4 per cent. Permanent recurrent laryngeal nerve palsy occurred in 1.1 per cent, and 2.4 per cent of patients had permanent hypoparathyroidism. Neither the initial clinical diagnosis nor a history of previous treatment significantly influenced the rate of complications. The incidence of malignancy, other than incidental microscopic papillary carcinoma, was 4.6 per cent. CONCLUSION: Total thyroidectomy has an important role in the management of patients with benign disease when both lobes of the thyroid gland are involved. This approach avoids disease recurrence and the increased risk of morbidity associated with secondary operation.     

Recurrent nerve palsy and hypocalcemia after surgery of benign thyroid diseases

Summary Background A critical analysis of early and late postoperative complications is necessary to assure the quality of surgery for benign thyroid diseases. The 2 major complications are palsy of the recurrent laryngeal nerve and hypoparathyroidism. Yet, long-term and follow up studies. as well as pre and post operative investigations are rather scarce. Methods 3246 patients operated on for benign thyroid diseases between 4/86 and 12/93 were retrospectively screened and analyzed for early postoperative recurrent laryngeal nerve palsy and hypoparathyroidism. Permanent laryngeal nerve paralysis and hypocalcemia was investigated by sending questionnaires to these patients and their physicians. Results 88 patients (2.7%) had aerly postoperative laryngeal nerve palsy. 58 (1.78%) of them recovered completely. reducing the cases of permanent paralysis to 30 patients (0.92%), 22 of which had proven (0.68%) permanent recurrent laryngeal nerve paralysis. The 8 questionable cases (0.24%) could not be evaluated. Hypoparathyroidism necessitating calcium and/or vitamin D-treatment for more than 2 years was present in 18 patients (0.6%), which were without symptoms under this medication. Conclusions Dissecting the recurrent laryngeal nerve and visualizing the parathyroid glands during surgery for benign thyroid diseases decrease nerve paralysis and hypoparathyroidism to a permanent prevalence of less than 1%.      

精细被膜解剖法在甲状腺手术中预防喉返神经与甲状旁腺损伤的应用

目的：探讨甲状腺手术中应用精细被膜解剖法预防喉返神经与甲状旁腺损伤的方法和效果。方法回顾性分析2007年6月-2012年6月195例应用精细被膜解剖法行甲状腺手术的临床资料。均沿甲状腺真假被膜之间疏松间隙进行超微化解剖,贴近甲状腺真被膜进行血管离断的精细被膜解剖手术方法。结果195例手术均获成功,术中明确见到喉返神经9例。暂时性喉返神经麻痹4例（2．1％）,永久性麻痹1例（0．5％）,其余均无永久性喉返神经、喉上神经损伤及永久性甲状旁腺功能减退。结论运用精细被膜解剖法不仅可以有效避免喉上神经及喉返神经损伤,还可以原位保留甲状旁腺及其滋养血管。     

A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation

A series of 1,000 consecutive thyroid operations is presented, without a case of permanent recurrent laryngeal nerve injury. Emphasis is placed on the identification of variations and complete dissection of the recurrent laryngeal nerve, including peripheral branches and technical aspects of the dissection. Sixty-five percent of the cases had multiple terminal branches of the recurrent laryngeal nerve and five cases on the right side had a nonrecurrent course. A low incidence of hypoparathyroidism is presented, due in part to the avoidance of ligating the inferior thyroid artery in continuity and the technique of extracapsular dissection of the thyroid gland. The external branch of the superior laryngeal nerve was protected by the early mobilization of the superior thyroid vessels and ligatures placed flush on the capsule of the superior pole.     

Reoperations of the thyroid gland

Reoperative thyroid surgery may be necessary in recurrent simple goiters, thyrotoxicosis and especially cancers of the thyroid gland. The present series reviewed 33 cases representing 7.3 % from our experience consisting of 440 thyroid operations. Five patients had undergone two prior operation. Details of original procedures were available only for 26 patients, the first operations being carried "extra muros" in 20 cases. There were 25 women and 8 men with mean patient age 44.5 (range 22-75) years, which had undergone one prior operations. The interval between the primary operation and the second one varies between 5 days and 44 years. Eleven cases had benign lesions: eight with uni or bilateral nodular goiters and three thyrotoxicosis (two with Basedow-Graves'disease and one with toxic adenoma) for which nodulectomy, subtotal lobectomies or thyroidectomies were performed. In twenty one cases the surgical indication was done for persistent or recurrent thyroid carcinomas (16 papillary, two follicular and one case each of medullary, anaplastic and malignant lymphoma). Among these 6 patients underwent completion total thyroidectomies associated in 9 another patients with radical or modified neck dissection and in the 6 remaining cases conservative procedures (lobectomies, tumoral excision) of the gland or nodes were done. Complications, includes two recurrent laryngeal nerve palsy, two spontaneously healed esophageal fistulas and one case each of permanent hypothyroidism and hypoparathyroidism. Reoperative thyroid surgery constitute a valuable surgical procedure for persistence or recurrence of benign and especially malignant thyroid lesions but is associated with significant increased risk of functional and anatomic complications rate than those of the initial surgery.     

甲状腺全切除术治疗良性甲状腺疾病128例临床疗效

目的：探讨甲状腺全切除术治疗甲状腺良性疾病的疗效及术后并发症的预防。方法：回顾性分析128例行甲状腺全切除术的甲状腺良性疾病病人的临床资料,其中首次手术者98例,再次手术者30例。分析总结该128例病人的术后并发症。结果：128例病人术后均未发生永久性甲状旁腺功能低下和永久性喉返神经损伤。首次甲状腺全切除组术后暂时性喉返神经损伤和暂时性甲状旁腺功能低下的发生率均为1．02％,再次手术组的发生率明显增高,分别为10．00％和13．33％,两组比较,Fisher精确概率P分别为0．040、0．011。两组暂时性喉上神经损伤发生率均很低,无明显差别。结论：对符合指征的良性甲状腺疾病,甲状腺全切除术是一合适的治疗选择。熟悉甲状腺解剖和精细手术操作,可有效预防并发症发生。     

甲状腺手术中喉返神经损伤的预防

目的 通过回顾性分析,评价甲状腺手术中解剖喉返神经的必要性.方法 将手术治疗的甲状腺疾病患者512例按术中是否解剖喉返神经分为解剖组和未解剖组,比较两组间喉返神经损伤的发生率.结果 全组解剖喉返神经组189例,术后出现声嘶3例(1.59%),未解剖神经组323例,术后出现声嘶5例(1.55%).两组差异无统计学意义(P＞0.05);但在存在有喉返神经损伤高危因素的患者中解剖与未解剖神经患者神经损伤率则有差异(1.02%vs.3.95%,P＜0.05).结论 是否解剖喉返神经应根据具体情况决定,对大多数甲状腺良性病变尽可能不暴露喉返神经,但对于巨大甲状腺肿瘤、二次或多次手术及甲状腺癌应暴露喉返神经.     

甲状腺全切除术治疗甲状腺良性疾病

目的　探讨甲状腺全切除术治疗甲状腺良性疾病的安全性和临床意义。方法　对 88例甲状腺良性疾病患者进行甲状腺全切除术 ,并对手术并发症进行分析。结果　首次甲状腺全切除术暂时性甲状旁腺功能低下和暂时性喉返神经损伤的发生率分别为 2 .5 %和 1.2 % ,再次手术的并发症明显增高 ,分别为 2 8.6 % (P<0 .0 5 )和2 8.6 % (P<0 .0 1)。术后患者均未发生永久性甲状旁腺功能低下和永久性喉返神经损伤。结论　首次甲状腺全切除术安全可行 ,能避免因组织残留所致的病变复发 ,降低再手术率     

Surgically treated Hashimoto's thyroiditis

The primary way to treat Hashimoto's thyroiditis is conservative. However, it has a relatively high occurrence in operated patients, up to 13% in the literature. Indications for surgery are suspicion of malignancy, and/or trachea/esophagus compression. 2818 thyroid operations were performed at our department between 1986 and 1995. 279 patients suffered from thyroid cancer and 2539 had benign disease. Histology revealed Hashimoto's thyroiditis in 118 cases. Coexisting malignant thyroid tumor was found in 14 cases (11.8%): 9 papillary, 2 follicular, 1 anaplastic cancer, and 2 non-Hodgkin lymphoma. Postoperative recurrent laryngeal nerve paralysis occurred in 8 cases, of which 6 remained permanent. This relatively high incidence supports the importance to identify the laryngeal nerve during every operation for Hashimoto's thyroiditis. Four patients had temporary and one had permanent hypoparathyroidism. Coexistence of Hashimoto's thyroiditis and thyroid carcinoma, the increased risk for the development of non-Hodgkin's lymphoma in chronic lymphocytic thyroiditis and the need for thyroxin supplementation in many cases justify a careful, long-term follow-up of patients with Hashimoto's disease.     

Total thyroidectomy. The preferred option for multinodular goiter.

Total thyroidectomy is an operation that has generally been reserved for the management of differentiated thyroid carcinoma. Over the last decade total thyroidectomy has become used increasingly and is now the preferred option in the authors' unit for the management of multinodular goiter affecting the entire gland. Over the period from 1975 to 1985, 853 thyroidectomies have been performed for multinodular goiter; of these, 115 have been total thyroidectomies. During that time, the incidence of total thyroidectomy for multinodular goiter has increased in percentage terms from 9% in 1975 to 50% in 1985. There have been two cases of permanent hypoparathyroidism and one case of permanent recurrent laryngeal nerve injury, and these occurred in patients who had less than total thyroidectomy. Total thyroidectomy is an appropriate operation for the management of diffuse multinodular goiter where the entire gland is involved because it precludes patients from requiring further surgery for recurrent disease, with its high associated risks. It must be emphasized, however, that protection of the recurrent laryngeal nerve and parathyroid glands must still be paramount in dealing with benign thyroid disease.     

Zuckerkandl's tuberculum: could it be useful in thyroid surgery?

A thorough knowledge of thyroid anatomy could reduce the incidence of lesions to the inferior laryngeal nerve. In view of its relationship with the recurrent laryngeal nerve and the parathyroid gland, Zuckerkandl's tuberculum should be considered an anatomical landmark for the recurrent laryngeal nerve in thyroid surgery. The aim of the study was to verify whether the identification of Zuckerkandl's tuberculum could be useful to reduce the incidence of recurrent laryngeal nerve lesions. Four hundred and thirty-two patients underwent thyroid surgery over the period from January 2001 to December 2003 for benign (377 patients) or malignant disease (55 patients). Three-hundred and forty-eight (81%) underwent total thyroidectomy. Zuckerkandl's tuberculum was found in 74.5% of patients, with a high prevalence in the right lobe: in 5% of patients it was grade I, in 50% grade II and in 45% grade III. Its presence was associated with the recurrent laryngeal nerve in almost all cases. Eight of the patients undergoing total thyroidectomy suffered recurrent nerve paralysis, only 4 of which proved definitive. Identification of Zuckerkandl's tuberculum allows safer isolation of the recurrent laryngeal nerve and superior parathyroid gland dissection.     

221例甲状腺癌的外科治疗体会

目的 探讨甲状腺癌的诊断和外科治疗方法。方法 回顾性分析我院2003年1月-2007年12月间收治的221例甲状腺癌患者的临床资料。甲状腺次全切除161例，甲状腺全切57例，姑息性手术3例。除3例行姑息性手术外其余所有患者均常规颈部中心区淋巴清扫。结果 术后病理检查证实有淋巴转移者为40．3％（89／221）。术后并发症包括5例短暂喉返神经麻痹，37例短暂低血钙抽搐，1例永久性甲状旁腺功能低下，2例术后颈部血肿。本组患者术前B超检查均发现甲状腺内实性或囊实性低回声结节，其中结节内伴微钙化灶者79例（35．7％）。获得随访187例患者，随访率为84．6％，随访6月～5年，除未分化癌患者术后7月死亡，其余患者均存活。结论 患侧甲状腺＋峡部＋对侧甲状腺大部分切除＋中心区淋巴清扫是甲状腺癌的主要手术方式，术前高频B超检查提示甲状腺结节内沙砾微钙化灶对甲状腺癌的术前诊断有重要意义。     

Complications of thyroidectomy and parathyroidectomy in the rural community hospital setting

The objective of this study was to examine the complications encountered in a series of 150 consecutive thyroid and parathyroid procedures performed by a single surgeon in a rural community hospital setting. The goal was to demonstrate that these procedures may be performed safely and with outcomes equivalent to those of academic hospitals in major metropolitan areas despite the lack of availability of specific technologies that are being increasingly used for these procedures in tertiary care settings. Specifically, these include intraoperative parathyroid hormone measurements, intraoperative recurrent laryngeal nerve monitoring, and the use of the gamma probe for detection of parathyroid adenoma. A retrospective chart review was conducted on a series of 150 patients undergoing any thyroid or parathyroid operation by a single surgeon in a rural setting over a 4-year period. Data was reported regarding success at achieving the goal of the operation and any perioperative complications such as recurrent laryngeal nerve injury, permanent hypoparathyroidism, wound hematoma, infection, or pneumonia. One hundred thirty-one thyroid procedures were performed (71 lobectomies, 60 total or near total procedures) for a diverse range of patholological conditions: multinodular goiter, 76 (50.7%) patients, follicular adenoma, 9 (6.0%) patients, Hashimoto's thyroiditis, 13 (8.7%) patients, papillary carcinoma, 14 (9.3%) patients, follicular carcinoma, 5 (3.3%) patients, follicular variant of papillary carcinoma, 13 (8.7%) patients, and medullary carcinoma, 1 (0.7%) patient. Nineteen successful parathyroid explorations were performed for primary hyperparathyroidism. The overall incidence of recurrent nerve injury was 1.33 per cent overall (0.99% for each nerve encountered). The incidence of transient postoperative hypocalcemia was 13 per cent, with one patient suffering permanent hypoparathyroidism (0.8%). Two patients developed wound hematomas requiring evacuation. The overall complication rate with respect to recurrent laryngeal nerve injury and permanent hypoparathyroidism was consistent with or below that that in recent large series, despite the absence of specialized equipment for nerve monitoring. The success of identifying parathyroid adenoma was 100 per cent, despite the absence of intraoperative parathormone assays, and the decision not to perform radio-guided parathyroidectomy. We conclude that outcomes and complications in thyroid and parathyroid surgical procedures are largely dependent on surgeon skill and experience, and can be performed safely in the community setting by an experienced general surgeon despite the absence of advanced technology in this setting. We encourage all surgeons to continually examine their operative results with all technically demanding procedures when deciding the composition of their individual practices.     

TOTAL THYROIDECTOMY: THE TECHNIQUE OF CAPSULAR DISSECTION

Book reviews in this article: This paper describes the technique of total thyroidectomy using capsular dissection. Total thyroidectomy is a safe straightforward anatomical procedure in which meticulous dissection can provide protection to the parathyroid glands and to the recurrent laryngeal nerve. This protection is achieved by using capsular dissection, hugging the gland and dividing the tertiary branches (i.e. the third order of division) of the vessels while dissecting the parathyroid glands with their vascular pedicles free from the thyroid surface, with minimal exposure of the recurrent laryngeal nerve and disturbance of its blood supply. Total thyroidectomy removes all visible thyroid tissue although it is permissible to leave a very small remnant of tissue (less than a fraction of a gram) in the region of the ligament of Berry in order to protect the recurrent laryngeal nerve and the blood supply to the parathyroid glands. This technique ensures that the incidence of complications, including permanent hypoparathyroidism and recurrent laryngeal nerve palsy, is reduced to a minimum.     

甲状腺全切除术治疗良性甲状腺疾病临床价值的研究

目的:探讨甲状腺全切除术治疗甲状腺良性疾病的价值及临床意义。方法:回顾分析我院2005年3月～2007年3月收治的169例行甲状腺全切除术的甲状腺良性疾病患者临床病理资料,并对其术后并发症进行分析总结。结果:首次甲状腺全切除术后暂时性甲状旁腺功能低下和暂时性喉返神经损伤的发生率分别为0.76%和1.52%,再次手术的并发症明显增高,分别为40.54%和32.43%,P<0.01。术后患者均未发生永久性甲状旁腺功能低下和永久性喉返神经损伤。结论:甲状腺全切除术治疗良性甲状腺疾病能避免组织残留所致的病变复发和癌变,降低再手术率,且首次手术较再次手术的并发症率低,但需在术中精细操作。     

甲状腺手术喉返神经与甲状旁腺的识别与保护183例分析

目的:探讨甲状腺手术中识别与保护喉返神经与甲状旁腺的技术改进方法及其临床效果.方法:回顾性总结分析183例甲状腺手术病例,以暴露喉返神经方法分组:对照组81例,于甲状腺下动脉下方解剖暴露喉返神经;治疗组102例,以寻找Zuckerkandl结节为主要途径暴露喉返神经.比较两组病人术后喉返神经的损伤、甲状旁腺功能及并发症等方面情况.结果:治疗组102例均临床治愈,术后并发暂时声嘶1(0.9%)例.2例(1.9%)甲状腺次全切除术加颈廓清扫术后出现暂时性甲状旁腺功能低下,32例(31.3%)术后2 d内血钙水平较术前一过性降低.对照组81例有6例(7.4%)损伤喉返神经,4例(4.9%)出现甲状旁腺功能低下.两组差异有统计学意义.结论:甲状腺手术技巧的一系列改进,尤其是对喉返神经和甲状旁腺的识别和保护,可控制术中出血量,减少术后并发症,促进术后康复.     

Damage to the recurrent nerve during an operation for benign goiter

Damage of the recurrent nerve was found in 40 (2.5%) of 1555 patients operated upon for benign goiter. The probability of complications was higher in wider volumes of operations. The main task of prophylactics of damages of the recurrent nerves is to identify them during operation and to observe the principle of subfascial dissection and resection of the thyroid gland.     

Total thyroidectomy: the technique of capsular dissection.

This paper describes the technique of total thyroidectomy using capsular dissection. Total thyroidectomy is a safe straightforward anatomical procedure in which meticulous dissection can provide protection to the parathyroid glands and to the recurrent laryngeal nerve. This protection is achieved by using capsular dissection, hugging the gland and dividing the tertiary branches (i.e. the third order of division) of the vessels while dissecting the parathyroid glands with their vascular pedicles free from the thyroid surface, with minimal exposure of the recurrent laryngeal nerve and disturbance of its blood supply. Total thyroidectomy removes all visible thyroid tissue although it is permissible to leave a very small remnant of tissue (less than a fraction of a gram) in the region of the ligament of Berry in order to protect the recurrent laryngeal nerve and the blood supply to the parathyroid glands. This technique ensures that the incidence of complications, including permanent hypoparathyroidism and recurrent laryngeal nerve palsy, is reduced to a minimum.     

Total thyroidectomy: its role in the management of thyroid disease.

Of 7812 patients treated for thyroid disease in the Endocrine Surgical Unit at the Royal North Shore Hospital, 825 underwent total thyroidectomy as an initial procedure. One third of these patients (269) were operated on for malignancy and the remaining 556 were treated for benign conditions such as multinodular goitre (405), Graves' Disease (79) and thyroiditis (45). The rate of recurrent laryngeal nerve palsy was 0.5% while permanent hypoparathyroidism occurred in 0.6% of cases, the low complication rate being due to the technique of capsular dissection employed in the Unit. The number of total thyroidectomies performed as a percentage of all thyroid operations has risen from 4% in 1970 to more than 40% in 1990. The majority of this increase has been due to surgery for multinodular goitre where the proportion of patients treated by total thyroidectomy now exceeds 80%. A similar but smaller increase has been seen in an analysis of the New South Wales figures for all other public and private hospitals. It is concluded that the complication rate from total thyroidectomy can no longer be used to argue against its use as the definitive operation for malignant disease of the thyroid. Furthermore, in view of the risks of re-operative surgery, total thyroidectomy should be considered the operation of choice for most benign disease affecting the whole thyroid gland such as multinodular goitre, thyroiditis, and in a significant number of goitres affected by thyrotoxicosis.     

甲状腺全切术中精细化被膜解剖结合环甲间隙显露喉返神经应用于甲状腺癌治疗的价值

目的 探讨甲状腺全切术中精细化被膜解剖结合环甲间隙显露喉返神经在甲状腺癌患者治疗中的应用价值.方法 选取2018年1月至2020年9月东莞康华医院接诊的90例甲状腺癌患者,按照随机数字表对照法分为对照组和观察组,每组45例.对照组行常规甲状腺全切术+甲状腺下动脉显露喉返神经治疗,观察组采取精细化被膜解剖结合环甲间隙显露...