Thyroidectomy

The thyroidectomy is the surgical removal of the entire thyroid gland. It is used for treatment of thyroid cancer or of benign goiter ( goiter ). If the procedure is performed only on one side, one speaks of a hemithyroidectomy. At a Strumaresektion ( removal of a benign thyroid enlargement ), the thyroid gland is only partially removed, in order to obtain a functional group. The first thyroidectomy was performed in 1880 by the Frankfurt surgeon Ludwig Rehn.

Indication

The main indication is the malignant goiter. After determination of a thyroid or is strongly suspected, the operation should be done as soon as possible. Is simultaneously an overactive thyroid ago (hyperthyroidism), this concentration of thyroid hormones in the blood, however, must first be pre-treated with medication until normalization, otherwise in the operation, a thyrotoxic crisis occur.

In addition, the thyroidectomy is used in the treatment of benign nodular goiter diffuse or apply when pathologically altered thyroid tissue should be left with a partial removal of the thyroid. Therefore are often surgically removed one side, the other resected subtotally ( Dunhill operation). → For more information on indications in benign goiter see Strumaresektion.

Preliminary

The investigations that have led to the indication for surgery, are described in the main articles diagnosis of thyroid and thyroid cancer.

The general presurgical investigations include clinical physical examination with measurement of blood pressure and pulse, the X-ray examination of the lungs and organs of the chest (thorax ) and the production of an ECG. A blood sample is taken for the determination of blood count, electrolytes, blood clotting, renal function and CRP (for the avoidance of inflammation ).

The special investigations before a Strumaresektion include the repeated determination of thyroid hormones as well as an investigation by the ear, nose and throat specialist to assess the mobility of the vocal cords.

Principle of operation

After exposure of the front of the thyroid isthmus runs beneath it on the front wall of the trachea, clamped, cut, and supplied with hemostatic Umstechungen. Both thyroid lobes are then largely removed from the environment and the associated blood vessels ( superior thyroid artery, inferior thyroid artery and the accompanying veins; Refer thyroid ) severed. Under careful preservation of the vocal cord nerves ( recurrent laryngeal nerve ) - to their accurate identification of most nerve monitoring is used - and the parathyroid glands, the procedure to the trachea, cut through the connective tissue layer between the thyroid gland and trachea and removed the cloth.

Elimination of pain

The anesthesia is now the standard for thyroidectomy. Until the early 1970s, the operation was performed under local anesthesia as an air embolism was feared by inadvertently opening a large vein. This could counteract by actively pressing the awake patient. The danger is not in a modern positive pressure ventilation with PEEP ( positive end expiratory pressure).

Storage

The patient is placed at about 30 ° erect the upper body. The head rests tilted back in a bowl, so that the neck hyperextended and the thyroid is easily accessible.

Access

The default is the Kocher collar incision, a 5 to 7 cm long, curved cross-section about two fingers above the jugular notch. The incision is marked before surgery on awake patients and placed for cosmetic reasons, if possible, in the course of a fold of skin. Skin and subcutaneous adipose tissue are severed and deported to the top and bottom of the musculature. The straight neck muscles are divided in the midline and deported to both sides of the thyroid gland, which is freely accessible now. For very large thyroid, the transverse separation of the short straight neck muscles is occasionally required. In very exceptional cases, the triggering of a strong after retrosternal thyroid extended only by partial median sternotomy ( longitudinal transection of the upper part of the sternum ) succeeds.

Extension of the procedure

If ( in the Struma maligna ) preoperatively known lymph node metastases or these are found during surgery, a radical thyroidectomy is performed with neck dissection for regional lymphadenectomy. For this purpose, the Kocher collar incision is the " door cut" extended, in one longitudinal cut one invests in the midline, the short ends under the chin and there is extended across both sides.

Wound closure

Before wound closure Redon drains are inserted to drain blood or ichor. The wound is closed in three layers: muscle and subcutaneous tissue are each closed with absorbable sutures and the skin with monofilament plastic suture. The skin closure is often done in the cosmetically favorable intracutaneous suture technique. Alternatively, adaptation plaster or fabric glue can be used.

Risks

Non-specific surgical risks

Bleeding during ( intraoperative ) or after surgery ( postoperative), may assume a dangerous level because of the good blood supply to the thyroid; in foreseeable difficulties ( Rezidivstruma ) blood products are provided therefore in advance.

Wound infection and suppuration of the wound occurred because of the good blood circulation is very rare, are easy to detect and treat, but usually leave very poor cosmetic results. Postoperative thrombosis and pulmonary embolism are also often due to the rapid mobilization of the patient.

Specific surgical risks

A complete transection of the vocal cord nerves ( recurrent laryngeal nerve ) leads to permanent paralysis of the vocal muscles ( vocal cord paralysis ) with persistent hoarseness. Damage by crushing or stretching of the nerves and the like also leads to the preliminary breakdown, but is usually reversible, so heal without special treatment from. Bilateral vocal cord paralysis can - through the closure of the glottis due to the lack of tension of the vocal muscles - lead to the complete installation of the trachea with acute suffocation. This may require application of the system of a permanent tracheostomy necessary. The exact representation of the recurrent laryngeal nerve is therefore called now mandatory according to guideline. To avoid Rekurrensverletzung comes regular way neuromonitoring apply. Very rare, as the surgical technique simpler preventable, is the violation of the superior laryngeal nerve.

The inadvertent removal or damage to the parathyroid glands ( parathyroid, parotid parathyroidea ), which are very difficult to identify in many cases, leading to derailment of calcium metabolism ( hypocalcaemia ) with the consequence of tetany, which, however, usually by supplying calcium in combination can be corrected with vitamin D good and not permanent ( See also hypoparathyroidism ). Remove or cut off from the circulation be re-transplanted parathyroid glands (autologous transplantation) by crushed into a muscle to be sewn (eg sternocleidomastoid muscle ). Is the need for irradiation foreseeable, for example in anaplastic thyroid cancer, and prophylactic removal of the parathyroid glands and their reimplantation away from the irradiation area is possible ( in a muscle of the forearm, for example ).

The risk of serious complications is dependent on thyroid carcinomas primarily on the location and extent of the tumor and thus can not be described with reliable numbers.

Postoperative and follow-up

→ For details on the tumor follow-up can be found in the main article Thyroid

The vocal cord mobility is either by laryngoscopy directly Narkoseausleitung or by testing the phonation ( end calls to the patient simply to speak on ) proved to detect a recurrent nerve palsy immediately. For information on what the recurrent laryngeal nerve palsy, respiration must be monitored in intensive care.

The serum calcium level is determined on the first postoperative day, he is markedly reduced, must be assumed that the damage to the parathyroid glands, and optionally calcium are fed.

A bleeding ( hematoma) can be defined in doubt by ultrasonography from a simple post-operative swelling.

With no complications, the patient can get up on the evening of surgery day and take fluids to himself. From the first postoperative day can be eaten normally, the mobility is not restricted. Usually only small amounts of analgesics are required. Only in cases in which the neck muscles had to be cut transversely due to the size of the goiter is not recommended for the first 10 to 15 days of extreme Umwendbewegungen of the head.

After thyroidectomy, including neck dissection, the disorder of the mobility and the pain level on the extent of lymphadenectomy were performed and the resulting partial removal of muscle, connective tissue and blood vessels depends. It can therefore longer support the neck muscles, for example, by Schantz require.

The removal of the drainages are on the 2nd, the hospital discharge earlier than the third, usually on the 4th or 5th day after surgery. The skin suture is removed after about a week. The remaining scar is in the first eight to twelve weeks striking still and then forms its final width and color. Ideally, as the final result only with difficulty a fine line in a fold of skin to see the extent of the scarring is, however, from patient to patient. After neck dissection on the " door cut" the scarring is of course much broader.

The follow-up consists of regular monitoring of thyroid hormones and TSH. Except for the fully remote small papillary carcinoma in situ of thyroid radioiodine therapy regularly ( RJT ) is carried out in the port. In this context, a renewed scintigraphy is prepared which provides information on the completeness of thyroidectomy and also brings yet undiscovered nodal or distant metastases for display. The RJT fought reliable small remaining residual tumor, lymph node metastases and distant metastases jodspeichernde. This does not apply to non- jodaviden (no iodine -storing ) tumors, such as anaplastic or medullary carcinomas. The success of the RJT is documented three months later by re- scintigraphy.

Sonographic checks are carried out initially closely ( every 3 months), re - check scintigraphy initially at yearly intervals.

The malfunctioning of the removed thyroid is balanced by a hormone replacement therapy ( HRT ), is administered in the tablets L- thyroxine ( free T4 ). The appropriate dosage is determined by determining the TSH value, which should be in thyroid carcinomas between 0.05 and 0.1 mU / l. After benign disease a target TSH of 0.4 to 0.9 mU / l per kg body weight is recommended at an initial dose of 1 ug L- thyroxine.

History

1791 led the French surgeon Pierre -Joseph Desault by the first Schilddrüsenresektion described.

The thyroidectomy was - at that time still under the no longer common name strumectomy - 1876 by ​​the Swiss surgeon and Nobel Prize winner (1909 ) Emil Theodor Kocher than total extirpation of goiter (ie in the sense of today's terminology rather than thyroidectomy ) performed and 1878 under the title " extirpation of goiter retrooesophagea " published. In the following 10 years, he has contributed significantly to the improvement of surgical technique and was able to significantly reduce the mortality rate due to a total extirpation. In 1883 published cooker that Totalexstirpationen could lead to cretinism -like state. This could be prevented by a residual thyroid tissue remain in the body of the patient. After Emil Theodor Kocher of Kocher collar incision and Kocher forceps are named, which are still used today.

1884 was carried out at a hyperthyroidism in Germany by Rehn, the first Schilddrüsenresektion.