The thyroid is comprised of two halves (or ‘lobes’) connected by a thin strip of thyroid tissue called the isthmus.
Both thyroid lobes and the isthmus are removed (essentially all the thyroid tissue).
Because of the presence of cancer in a thyroid nodule(s), high risk for cancer in a thyroid nodule(s) based on biopsy or molecular analysis results, Graves’ disease or multiple toxic (‘hot’) thyroid nodules causing hyperthyroidism, or bilateral (both sided) large thyroid nodules / goiter / substernal goiter causing compressive symptoms or cosmetic concerns.
Attempting to carve out the cancer or thyroid nodule from the thyroid increases the risk of leaving part of the cancer or nodule behind which would require a repeat or revision surgery in the future.
Attempting to preserve thyroid tissue can increase the risk for injuring important nearby structures such as the recurrent laryngeal nerve (controls voice and swallowing) and parathyroid glands (controls calcium levels in the body).
Attempting to preserve thyroid tissue can increase the risk for bleeding following surgery which can potentially be life threatening.
When accounting for the nodule that needs to be removed, often there is not a substantial amount of normal functioning tissue remaining in the thyroid lobe worth trying to preserve (especially when considering the above increased risks associated with attempting this).
Lowers the risk of cancer recurrence in certain scenarios.
Read more about this here: Well Differentiated Thyroid Cancer – Surgery.
The surgery is performed under general anesthesia in the operating room.
An incision is made low in the midline neck, in a natural horizontal crease of the skin.
The incision needs to be long enough to remove the largest thyroid lobe (based on measurements made on a previous thyroid ultrasound).
Surgery usually takes 1.5 – 2.0 hours.
So long as there are no pain or nausea issues in the recovery area, most surgeries can be done as an ‘outpatient’ where you go home the same day.
It is not safe for you to drive home following general anesthesia.
Therefore, you should arrange for a ride to and from the hospital.
Typically the entire day lasts ~ 6 hours.
1 hour after surgery, you are transferred to your hospital room where your family and/or friends can see you.
The nursing staff takes care of you overnight.
Dr. Kay and his team see you the following morning and you are usually ready to be discharged home by 10:00 am provided your recovery is going as expected.
If for any unexpected reason you need to spend the night, your insurance company will pay for a 23-hour observation period at no extra cost to you.
A drain is a small rubber tube placed in the neck connected to a suction bulb.
Most surgeries do not need a drain placement.
Exceptions to this include:
If you receive a drain, you can go home with it and Dr. Kay’s office will arrange for an appointment to have this removed in the office 1-2 days following surgery.
If you spend the night in the hospital, on most occasions the drain can be removed the following day before you are discharged home.
Dr. Kay calls you with the pathology report 2-3 business days following the surgery.
When you schedule surgery, a post-operative appointment will also be scheduled for you ~ 6 weeks following your surgery.
Yes, when the entire thyroid gland is removed 100% of the time you will need to take a once daily thyroid hormone medication for the rest of your life.
You need a physical performed by your primary care provider to clear you prior to surgery.
If you see a sub-specialist for a significant medical issue like a cardiologist or pulmonologist, Dr. Kay will ask you to be cleared by this specialist as well.
If you are on a blood thinner, Dr. Kay will ask you to get permission to stop this blood thinner for the appropriate amount of time before surgery (varies by medication type) and for 5 days following surgery as well.
You can expect to experience pain and swelling around the incision lasting up to 1 week.
You can also expect to experience a sore throat and hoarse voice lasting up to 1 week.
Everyone experiences pain in different ways and has different pain thresholds, therefore your experience may differ to some extent.
For 24 hours: Limit your activity for the first 24 hours following surgery and get plenty of rest as you recover from general anesthesia.
For 1 week: No heavy lifting or pushing (> 10lbs), active sports (e.g., running or jumping), strenuous exercise, heavy household work, or any activities that elevate your heart rate or blood pressure in order to reduce the risk of bleeding in your neck. Objects that cannot be lifted with one hand are considered too heavy.
There are no activity restrictions after 1 week.
In general, you may plan to return to work in 1 week, 2 weeks if your job requires manual labor, or as otherwise instructed.
Due to the sore throat caused by the breathing tube and surgical dissection, we recommend starting with liquids and soft foods.
You may progress to solid foods (your normal diet) as tolerated; this may take 1 – 3 days.
There are no restrictions in the positioning of your head and neck following surgery. You may relax and sleep in whatever position that is comfortable for you.
It is not uncommon for your sleep cycle to be affected by general anesthesia. Do your best to resume normal sleep patterns and avoid excessive daytime napping following the initial 24-hour rest period.
You can drive once you are off the strong (prescription) pain medication and when you can turn your head / neck to check your blind spots without hesitating. This may take 1-3 days.
Your incision was closed in two layers:
You may bathe or shower as soon as you like after surgery.
If the glue and bandage is still present 2 weeks after surgery, you may peel off the bandage (Steri-Strip) and the rest of the glue.
After the bandage comes off, you may notice several small bumps under the skin along your incision line and the incision line may appear raised.
As your incision heals, it is not uncommon to experience sensations of tingling, burning, itching, or pinching / shooting pains.
Once the bandage is off, please purchase over the counter Vitamin E oil from a pharmacy or supermarket (Vitamin E oil capsule which can be broken open are an acceptable alternative).
Once the bandage is off, please keep your incision out of direct sunshine for the first 3 months after surgery (using shade, a scarf, and/or sunscreen with SUV 30 or higher with both UVA and UVB protection) in order to prevent discoloration of the scar.
Ice compresses can help to treat swelling and pain around the incision. Apply for 10 min at a time. You can repeat every 30 minutes as needed.
Sore throat lozenges (particularly those with the active ingredient ‘Benzocaine’ such as found in Cepacol lozenges) will help to treat the discomfort deep in your throat.
Drinking fluids frequently will help the small scratches inside the throat caused by the breathing tube to heal more quickly and also relieve your pain faster.
Over the counter Tylenol (acetaminophen) can be taken every 6 hours as needed for pain relief, up to 1,000 mg each dose, do not exceed 4,000 mg total in 24 hours. Do not take 3,000 mg total per day for > 3 consecutive days.
Over the counter NSAID’s (Non-Steroidal Anti-Inflammatory Drugs)
OR
In situations when the above pain control regimen does not control your pain symptoms adequately, you were prescribed 5 tablets of a low dose narcotic medication (either Tramadol or Hydrocodone / Acetaminophen).
Even if all four of the parathyroid glands (which control calcium levels in the body) were successfully preserved during surgery, they can be temporarily stunned and this can result in temporary low calcium levels.
To prevent against this, please take ~ 1,000 mg of an over-the-counter calcium supplement three times per day for 1 week, then twice per day for 1 week, then once per day for 1 week, then discontinue.
Please watch out for symptoms of low calcium which include numbness and tingling in the lips / fingertips or cramping in the hands / feet (if this occurs, it will usually happen ~ 36-48 hours following surgery).
If you were instructed to take an over the counter or prescription Vitamin D supplement before surgery, please continue taking this until your follow-up appointment with Dr. Kay.
If you are discharged home on the same day of surgery, you will be given an antinausea prescription called Zofran (ondansetron). This comes in a tablet form that dissolves underneath your tongue.
You can use this as needed if you are experiencing nausea. Please have a low threshold to use this in order to prevent vomiting (which can increase the risk of bleeding in your neck).
You will receive narcotics as part of your general anesthesia on the day of surgery and you may also take a prescription narcotic pain medication following surgery. These narcotic medications can cause constipation.
In order to prevent this, you may consider purchasing an over-the-counter stool softener (such as docusate or senna) and take for 24-48 hours following surgery as directed on the package (especially if you are prone to constipation).
You should resume taking all other medications the day after surgery, unless instructed otherwise by your primary care provider.
If you were on any blood thinners (Plavix, Coumadin, Eliquis, Xarelto, Aspirin, etc.) prior to surgery, please do no restart the medication until 5 days after your surgery to limit the risk of bleeding, unless instructed otherwise.
experience thick mucus in your throat for 24-48 hours. It is ok to gently clear your throat and cough to clear this mucous.
If the sensation of mucous in your throat persists for > 48 hours, it is usually not because there is still mucous there. At this point, persistent inflammation and sensitivity of the vocal cords caused by the breathing tube can mimic the sensation of mucous and is best treated by drinking plenty of liquids, using over the counter throat lozenges with the active ingredient ‘Benzocaine’ such as found in Cepacol lozenges, and avoiding further throat clearing / coughing.
Swelling beneath or near your incision site, particularly if it is visibly noticeable and/or causing pressure in the neck.
If you notice rapid and progressive swelling in your neck, or bleeding from your incision, please call 911 as this could represent a hematoma, or active bleeding in the neck, and this is a medical emergency.
If you notice redness and itching around the bandage, especially if starting 24-48 hours after surgery, you may be experiencing an allergic reaction to the skin glue or the white steri-strip bandages.
Please record your drain output twice daily.
OK to get the drain wet in the shower.
Dr. Kay’s office will call to arrange drain removal 1-2 days following your surgery.
When surgery is scheduled, an appointment should have been made for you to follow-up ~ 6 weeks after surgery.
During surgery, particularly when thyroid cancer is known to be present or highly suspicious to be present, unexpected findings (not seen on preoperative ultrasound or CT scan) may be encountered such as spread of cancer to lymph nodes and/or direct invasion of the cancer into nearby structures.
Image Source: Mary Ann Liebert, Inc.
This nerve travels just behind the thyroid gland and enters the larynx (voice box) very close to where the thyroid gland attaches to the trachea (windpipe).
This nerve controls the movement of the vocal cord on that side, helping to produce your voice and assist in swallowing.
This nerve travels near the superior pole of the thyroid (upper portion of the thyroid lobe).
This nerve controls the movement of specific voice box muscles that are needed for singing in high pitches and projecting the voice (yelling).
The parathyroid glands are small rice grain sized glands that control calcium levels in the body.
They sit on the surface of the thyroid and should be identified and preserved during thyroid surgery.
Pain following surgery typically lasts up to 5-7 days and is usually tolerated with little to no narcotic use (see more information in the ‘What to Expect Following Surgery’ section).
There is very low risk (~1 %) for infection following hemithyroidectomy.
Antibiotics are given to you during surgery, but none are routinely used following surgery.
There is a 1% chance of significant bleeding following surgery.
Signs of bleeding include significant swelling in the front of the neck, similar to the appearance of a bullfrog.
Sometimes this bleeding stops on its own, other times it does not and it can be life threatening requiring urgent surgery to stop the bleeding.
Risks for bleeding are higher when a patient cannot be taken off their blood thinners completely.
You are required to be cleared by your primary care provider prior to surgery and any other sub-specialty providers who provide care for important medical conditions.
The incision is made as small as possible (based on thyroid lobe size and the patient’s anatomy) and attempted to be hidden in a natural skin crease (if present) or hollow of the neck.
Ultimately it is up to how your body heals (based on previous incisions or scar).
Typically, incisions in the neck heal very nicely.
If there is a history of keloid formation, a steroid called Kenalog may be injected into the skin at the time of surgery to lower the risk of keloid formation as best as possible.
Surgery to remove very large goiters (enlarged thyroid glands) and goiters that extend below the level of the collar bones and/or behind the sternum (substernal goiters) presents unique challenges and risks that differ from a standard total thyroidectomy:
Due to the increased manipulation required to remove very large goiters and substernal goiters (out from the chest), there is a higher risk of temporary and permanent injury to the nerve causing a weak and hoarse voice.
Due to the increased size of very large goiters and substernal goiters, the risk of accidentally removing or permanently injuring a parathyroid gland is higher than a typical total thyroidectomy.
Due to the larger blood vessels associated with very large goiters and substernal goiters, there is an increased risk for life-threatening bleeding following surgery requiring urgent return to the operating room to control the bleeding.
Due to the increased size of the void (empty space) left behind by removing a very large goiter or substernal goiter, and the higher risk of developing a seroma (fluid produced by the body to fill this void) associated with this, a drain (rubber tube exiting the skin attached to a bulb) will be necessary to help seal down the empty space and prevent the formation of a seroma.
Due to the sum of increased risks associated with surgery to remove very large goiters and substernal goiters as discussed above, it is safest for the patient to be observed overnight in the hospital, as opposed to going home the same day (outpatient surgery).
