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Indications for Surgery

Patients for whom surgery may be considered as a treatment option include:

• Individuals with very large goiters which may compress the airway
• Pregnant women in the second or third trimester who have failed to reach euthyroidism with antithyroid drugs
• Individuals who have severe reactions to antithyroid drugs
• Patients who refuse radioactive iodine therapy
• Patients who exhibit problems of compliance with taking medication
• Children or adolescents with severe Graves' disease
• Patients in whom there is concern about RAI treatment causing an exacerbation of Graves' ophthalmopathy
• Patients who fail to achieve euthyroidism or who suffer pain or dysphagia (difficulty swallowing) after undergoing RAI

Types of Surgery

Surgical thyroidectomy is a procedure to remove most or all of the thyroid tissue. There are several types of thyroidectomy that may be considered:

• Total thyroidectomy - the whole gland is removed

• Subtotal thyroidectomy - the bulk of the thyroid gland is removed

• Bilateral subtotal thyroidectomy - approximately 95-97% of each lobe of the thyroid gland is removed

• Hartley - Dunhill operation - one complete lobe and the isthmus are removed and a partial lobectomy is done on the second lobe. Some surgeons find that advantages to this type of procedure include:

  • a lower risk of injury to the recurrent laryngeal nerve
  • a larger segment of the second lobe can be left in place
  • if surgery is required a second time, the incision is smaller

Studies find little difference between these surgical procedures regarding rates of recurrence or postsurgical complications. The expertise of the surgeon can help determine which option is chosen. It is important for a highly competent surgeon to perform any type of thyroidectomy. Studies indicate that medical centers with extensive experience with thyroidectomy have the lowest rates of complications.

A combination of antithyroid and beta-blocker drugs is usually administered before thyroidectomy in order to reach euthyroidism and to reduce the risk of exacerbation of thyrotoxicosis or thyroid storm. In order to reduce the blood supply around the thyroid gland and reduce bleeding during surgery, some doctors additionally prescribe potassium iodide or sodium ipodate approximately two weeks before surgery.

Subtotal thyroidectomy is recommended for most patients. Total thyroidectomy is recommended if:

• There is severe Graves ophthalmopathy
• There is coexistent thyroid malignancy
• The patient will refuse to undergo a second surgery in the event of recurrence of hyperthyroidism

Estimates for the occurrence of hypothyroidism following subtotal thyroidectomy range from 3-48% and may be determined by factors including:

• Size of thyroid gland that remains - if less than 4 grams remain, the incidence of hypothyroidism is approximately 50% or higher
• Autoimmune activity and evidence of lymphocytic activity or infiltration may result in gradual destruction of the remaining thyroid gland leading to hypothyroidism

When subtotal thyroidectomy is performed on children, the remnant left in the patient is usually smaller than that of an adult patient because the risk of recurrence of hyperthyroidism is higher than for an adult. With the minimal thyroid tissue left in children, the risk of recurrence is reduced to approximately 10% and the risk of developing hypothyroidism is approximately 40%.