Thyroidectomy

Thyroidectomy is the removal of part or all of the thyroid, a butterfly-shaped gland in the neck. Learn why it’s performed and what to expect after surgery.

A thyroidectomy is the removal of part or all of the thyroid, a butterfly-shaped gland in the neck. The thyroid gland produces a hormone that helps regulate vital body functions like heart rate and metabolism.

A surgeon will usually perform a thyroidectomy when a patient either has thyroid cancer, a suspicious thyroid nodule, or other thyroid conditions such as an enlarged goiter or hyperthyroidism.

The amount of thyroid gland removed depends on the reason for surgery. If only half of the patient’s thyroid gland is removed, the remaining gland may continue to function normally and produce sufficient thyroid hormone such that the patient does not have to take thyroid medication. However, if a patient’s entire thyroid gland is removed, they will need to take thyroid hormone medication to replace the function of the gland.

Types of Thyroidectomy

Thyroidectomy - Thyroid

Total Thyroidectomy

A total thyroidectomy is the removal of the entire gland, and is most commonly recommended for patients who have been diagnosed with thyroid cancer. However it may also be recommended in benign conditions such as Graves’ disease or symptomatic multinodular goiter. The thyroid is removed through a small, horizontal incision in the low central neck. These incisions generally heal extremely well and, over time, the scar fades until it is almost undetectable. After surgery, patients will require daily thyroid hormone medication to replace their thyroid’s natural function.  

Hemithyroidectomy

Removal of one half of the thyroid gland is called hemithyroidectomy, thyroid lobectomy, or sometimes partial thyroidectomy. A hemithyroidectomy may be recommended for some small, low risk thyroid cancers or for some nodules with suspicious or indeterminate biopsy results.  When only half of the thyroid is removed, the remaining half of the thyroid may produce enough thyroid hormone, and the patient might not require thyroid hormone replacement after surgery. Roughly 3 in 4 patients who have one thyroid lobe will produce sufficient thyroid hormone so that no replacement therapy is needed. Patients are also at lower risk for postoperative calcium issues after a hemithyroidectomy, as compared to a total thyroidectomy.

Isthmusectomy

Isthmusectomy involves the removal of only the isthmus of the thyroid (the small central part of the thyroid that connects the two lobes). This procedure is performed in patients with small nodule(s) confined to the isthmus. Isthmusectomy will only be chosen if doctors are sure that the nodule(s) can be completely and confidently removed by resecting only the isthmus. In these cases, Isthmusectomy helps to protect important nearby structures and preserve as much of the healthy, functioning thyroid tissue as possible.

Completion Thyroidectomy

Completion thyroidectomy is the removal of the remaining half of the thyroid after a patient has already undergone a hemithyroidectomy.  This is sometimes required when the final pathology from the initial hemithyroidectomy showed an unexpected cancer, more aggressive pathologic features, or lymph node involvement.  These findings are difficult to determine at the time of the original surgery, and therefore a completion thyroidectomy must be performed during a second operation. Completion thyroidectomy is most commonly performed so that a patient can undergo radioactive iodine treatment postoperatively.  It may also be performed when multifocal disease (more than one thyroid cancer in different parts of the gland) is suspected. The timing for the completion thyroidectomy is usually delayed for 6–8 weeks after the initial surgery. Patients will require daily thyroid hormone replacement following a completion thyroidectomy.

What You Can Expect

Before Surgery

To appropriately prepare for the procedure, you should not eat or drink anything, aside from essential medications, after midnight the night before surgery. On the day of surgery, you should arrive at the hospital a few hours before the scheduled procedure. The nurses, anesthesiologist, and surgical team will check in with you to review the plan and answer last minute questions you may have. You should alert their physician if you feel sick before surgery.

The endotracheal tube will not only monitor the nerves during the surgery but will also indicate how well these nerves are working after the thyroidectomy. The surgeon may also choose to insert a surgical drain in the neck, which will be removed a day or two after surgery.

The Surgery

General anesthesia will be used to put you to sleep during the surgery. The surgeon will create a small, horizontal incision in the low central neck to perform your thyroidectomy.  This incision should heal well over time and scarring is usually minimal. The healthcare team will provide information about minimizing scarring during your postoperative visit. The surgeon may monitor the nerves that control movement of the vocal cords (recurrent laryngeal nerves) during the operation using a specialized tube. The surgeon may also place a temporary surgical drain in the neck to help remove excess fluid. The drain is very small and can normally be painlessly removed within 1-2 days. 

Additionally, the surgeon may remove lymph nodes in the central neck compartment that are adjacent to the thyroid gland. This is done to ensure that as much disease or problematic tissue as possible is removed. In cases where cancer has spread to areas on the side of the neck (lateral compartments of the neck), lateral compartment lymph nodes will likely be removed as well.

After Surgery

Recovery will depend on the extent of the surgery. Typically, total thyroidectomy patients will remain in the hospital overnight and be discharged the following morning. Hemithyroidectomy patients will usually be able to go home the same day of the procedure. Eating and drinking is permitted immediately after the surgery. A dedicated discharge planning team will work with your family to ensure you are properly cared for once you leave the hospital. 

The neck scars from a thyroidectomy will appear red initially and fade over time. To ensure that your thyroidectomy scar heals well, you should avoid direct exposure to the sun for six months post-operation. Over the counter skincare products, like sunscreen, can be used to minimize the appearance of the scar. After a total thyroidectomy, you will need to visit your endocrinologist intermittently and so that they can monitor thyroid hormone levels and adjust your medication if needed.

Post Surgical Scarring

All scars proceed through a course of maturation, including neck scars from a thyroidectomy. They begin as red and fade over time. However, there are certain things a patient can do to minimize the appearance of their scar. Patients should avoid direct sun exposure for 6 months following their operation. They may also purchase over the counter skincare products to minimize the appearance of their scar.

Central Compartment Lymph Node Dissection

In addition to the thyroidectomy procedure, a surgeon may plan to remove lymph nodes from the central compartment of the neck, which is located next to the thyroid gland. The central compartment nodes will be assessed to determine if there are suspicious features such as size, color, or texture of the lymph nodes. Any nodes that the surgeon decides to remove will then be submitted for frozen section analysis by a pathologist. If positive, the surgeon will likely remove additional central compartment nodes. If there is already a definitive thyroid cancer diagnosis, the patient should have an ultrasound of the entire neck to find out if the cancer has spread to the lymph nodes. In circumstances where cancerous or suspicious lymph nodes are detected in the lateral compartments, on the side of the neck, a lateral compartment lymph node removal will likely be performed as well. Ultrasound is not as reliable in detecting suspicious nodes in the area adjacent to the thyroid, so these nodes are usually left for the surgeon to assess, as noted above.

Risks of Thyroidectomy

  • Bleeding (including Hematoma)
    If there is severe bleeding after the procedure, the surgeon might need to quickly take the patient back to the operating room to stop the bleeding.  However, some mild bleeding or small blood collections under the skin (hematomas) can be observed. 
  • Seroma
    This is a collection of normal body fluid in the neck that occurs after a surgical drain is removed. This can be treated with observation, as the body will usually resorb it, or repeated needle aspiration to drain the fluid. 
  • Infection
    With any surgical procedure, there is a risk of an infection. This might require antibiotics and/or drainage of the infection.
  • Hypoparathyroidism or Hypocalcemia
    Low calcium and/or parathyroid levels can occur postoperatively if there is damage to the parathyroid glands during surgery. This can happen if all four parathyroid glands are either removed and not re-implanted during surgery (permanent hypocalcemia) or if they are left in a state of shock by a decrease to their blood supply (temporary hypocalcemia). Calcium is important for the health and function of the bones, blood, muscles, heart, and nervous system, among others. This is why calcium levels need to be closely monitored after a total thyroidectomy and calcium replacement will be given as needed.
  • Hypothyroidism
    This is expected if both lobes of the thyroid gland are removed, but can also happen if only one lobe is removed but the other lobe cannot make enough thyroid hormone. In any case, thyroid function can be measured with blood tests, and a once-daily pill can replace the function of the naturally produced thyroid hormone.
  • Hoarseness or Change in Voice (Dysphonia)
    The most common cause of hoarseness after thyroid surgery is temporary swelling of the vocal cords from the endotracheal tube. This will usually subside after a few days.  However, the persistence of hoarseness following the operation may occur if there is irritation or damage to the nerves that control the vocal cords. Injury to the recurrent laryngeal nerve will result in a quiet, breathy voice. Injury to the superior laryngeal nerve will result in problems controlling the pitch and volume of the voice. These changes are usually temporary and will return to normal over a period of weeks.  They will only be permanent if either of the nerves are completely cut and not repaired at the time of surgery. The risk of permanent nerve injury is very low. In the extremely rare circumstance that both recurrent laryngeal nerves are cut, a patient may require a temporary tracheostomy tube to allow them to breathe comfortably.