THYROIDECTOMY & MINIMALLY INVASIVE VIDEO-ASSISTED (ENDOSCOPIC) THYROID SURGERY
Frequently Asked Questions (FAQ)
What is thyroidectomy?
Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed. The most common indications for thyroidectomy include a large mass in the thyroid gland, difficulties with breathing related to a thyroid mass, difficulties with swallowing, goiter, suspected or proven cancer of the thyroid gland and hyperthyroidism (overproduction of the thyroid hormone, Graves' disease). The need for thyroidectomy is based on your history, the results of a physical examination and tests. The most common tests to determine whether a thyroidectomy is necessary include a fine needle aspiration biopsy, thyroid scan, ultrasound, x-rays and/or CT scan, and assessment of thyroid hormone levels. The procedure is usually done under general anesthesia. The extent of surgery (removal of one or both lobes) may sometimes be determined in the course of surgery after microscopic examination of tissue removed during the surgery.
What is minimally-invasive video-assisted (endoscopic) thyroidectomy (MIVAT)? What is endoscopic thyroidectomy?
MIVAT or Minimally-invasive video-assisted thyroidectomy (also called endoscopic thyroidectomy) is a new surgical technique which allows the surgeon to perform thyroid surgery through a very small incision in the neck. This technique which has been used in Europe since 1998 has recently gained popularity in the USA. The combined use of fiberoptic endoscopic telescopes and harmonic scalpels has made it possible to remove parathyroid tumors as well as small and medium sized thyroid glands from incisions as small as one inch. Obviously, the smaller incisions are less invasive, less painful and result in smaller finer scars. This operation is safe, achieves esthetically pleasing scars and requires shorter recovery periods.
What happens before surgery?
We will schedule a pre-operative visit during which the doctor will fill-out hospital forms, go over your medical history, current medications, allergies etc. and perform a complete physical examination. You will also be given the opportunity to ask questions about the procedure, hospitalization, complications, etc. You will sign the pre-operative surgical consent form and receive your post-operative instructions, and prescriptions for antibiotics, pain killers and other medications you may need after surgery.
What is pre-operative assessment?
After you finish with the doctor, you will then go to the hospital for pre-operative registration and assessment. This is where pre-operative blood tests, EKG, chest x-rays, etc. are carried out. You will also have the opportunity to talk to the anesthesiologist and ask questions or express concerns about anesthesia. Here also, you will be informed of the time of the operation and given instructions about when to take your medications and what to wear. You may also be asked to sign consent forms for surgery, anesthesia and blood transfusions. Sometimes, this assessment may not be necessary and may be carried out on the telephone.
What time do I show up on the day of surgery?
The assessment nurse will tell you the exact time of your operation and when to come to the hospital. In general, you are expected to be in the hospital, an hour and a half prior to your scheduled procedure.
What happens on the day of surgery?
If you have been assigned a room and have been admitted to a hospital bed, then you will be transported to the pre-operative holding area about 30 minutes prior to your operation. Your family may remain in your room or wait in the Surgery waiting area on the second floor. It would be helpful if family members or friends notify the nurses’ desk or the waiting room receptionist of their whereabouts, so that we can find them to let them know that your surgery is over.
If you have not been assigned a room, you would be asked to go to the second floor registration and from there, you would be directed to Day Surgery pre-op holding.
In pre-op holding, the nurses will start an IV line and review your history and medications. They will ask you questions to make sure you understand what is going to be done and that you have consented. They may make you sign the consent forms if you have not signed them during assessment. They will also mark the operative site with ink and if applicable, write on your neck LEFT or RIGHT so that there will be no confusion as to which side is being operated on. You may request a tranquilizer if you are very anxious.
What is recurrent laryngeal nerve monitoring?
Recurrent laryngeal nerve monitoring and mapping using EMG (electromyography) is the latest in technological innovation in thyroid and parathyroid surgery. A special endotracheal tube with right and left electrodes is placed near the muscles of the vocal cords which are innervated by the recurrent laryngeal nerve. These electrodes are connected to a computer that analyzes the electric activity and displays the electro-myographic (EMG) activity of the vocal cords ( muscle electrical potentials) on a screen. During the operation, the electrical activity (EMG response) of the nerve is continuously monitored. If the recurrent laryngeal nerve is stimulated or disturbed, an electrical impulse is detected by the monitoring technician who alerts the surgeon.
What happens during surgery?
When the thyroid is removed, it is sent for frozen section. This means that they freeze a piece of the gland, slice it very thin and color it for the pathologist to examine it under the microscope. Most often, the pathologist is able to determine if it is a cancer or a benign lesion. If there is cancer, the remaining thyroid tissue is removed and sometimes, the lymph nodes of the neck are removed as well (neck dissection). In rare instances, the pathologist may be unable to make a diagnosis on frozen section and the diagnosis is postponed until the tissue has been permanently processed in the laboratory. This may take a few days. It is therefore possible for a patient to go home and be called back for more surgery if a cancer is discovered in the permanent preparation.
What happens after surgery?
When you wake up from surgery, you will be transported to the recovery room (PACU), where would spend about 30 minutes to an hour, until you are fully awake and stable for transportation to your room.
You will be asked to speak to find out if your voice is hoarse. Many patients, especially smokers, have a raspy or hoarse voice when they wake up from anesthesia. Smokers have a tendency to cough.
You will notice that the wound is not covered with a dressing; it is just sealed with acrylic glue (Dermabond). Occasionally, however, dressings or drains are needed and you may notice a dressing wrapped around your neck and drain tubes attached to your clothes or a necklace. These are usually removed the next day. Please do not pull on them or try to empty the attached plastic bulbs.
For 2 – 3 days after the surgery, it is not unusual to have pain or difficulty on swallowing.
The nurses have standing orders to give you antibiotics, pain killers, thyroid replacement hormone and medications for nausea and vomiting. If there are no contraindications, you will also receive your usual home medications.
Most patients develop a transient hypocalcemia (low calcium) in the immediate post-operative period. That is why your calcium, phosphorus and magnesium levels will be monitored every six hours and sometimes more frequently. If you develop hypocalcemia, you will be given calcium by mouth and / or intravenously. Tingling around the mouth and face, muscle spasms of the hands and feet, involuntary grimacing and sometimes difficulty in breathing and gasping for air (stridor) are signs of hypocalcemia.
If you feel up to it, you are allowed to stand up, walk and go to the bathroom, with assistance and always, with someone present in the room. Do not attempt at walking or going to the bathroom if you are alone in the room. You may be too groggy from the pain killers or you may pass-out and fall down.
In general, the wound is sealed with a thin clear acrylic layer (Dermabond) and the sutures are buried under the skin. There is no need to apply antibiotic ointment on the wound. You are allowed to take a shower without covering the wound. This acrylic film will peal off in a couple of weeks. When you go home, please keep the wound exposed and do not hide it with a dressing or scarf. A little antibiotic ointment may be used at the site of the drains for a day or two. In general the drain wound heals and stops oozing in 24 hours.
When do I go home?
Most patients are discharged the day after the operation. By then, they should be able to eat, walk and go to the bathroom. Occasionally, however, some patients may run a temperature or continue to have hypocalcemia, nausea or excessive drainage. It is not uncommon for older men, especially those with large prostates, to develop urinary retention after general anesthesia. In all these instances, discharge is delayed a day or two, until the problem is resolved.
Bleeding or infection are possible short term complications. Although rare in thyroid surgery, some patients may develop a thick scar or keloid.
Two complications specific to thyroid surgery are hypocalcemia and vocal cord weakness or paralysis.
Hypocalcemia, or low blood levels of calcium, may occur after complete removal of both thyroid lobes. This condition is caused by interference with four tiny glands called parathyroid glands, which are located within or very close to the thyroid gland. Hypocalcemia is usually temporary, but sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcemia is fortunately rare. Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the thyroid gland. Temporary hoarseness may result. Again, this is an uncommon, usually temporary complication. Permanent vocal cord paralysis is rare. Finally, in very infrequent situations, airway obstruction may occur and a tracheotomy may become necessary to gain access to the airway. This is an extremely rare life saving measure and every effort would be made to avoid it.