Total Thyroidectomy Total Thyroidectomy for Non-Malignant for Non-Malignant

goiter goiter Javed Iqbal, FCPS,FRCSJaved Iqbal, FCPS,FRCS

Professor of surgeryProfessor of surgeryQuaid-e-Azam Medical College, Quaid-e-Azam Medical College,

BahawalpurBahawalpur

Total thyroidectomy is Total thyroidectomy is the procedure of choice the procedure of choice for thyroid malignancyfor thyroid malignancy

Commonly performed Commonly performed procedures for non-malignant procedures for non-malignant

thyroid:thyroid:

LobectomyLobectomyLobectomy with Lobectomy with

isthamectomyisthamectomySub-total thyroidectomySub-total thyroidectomyTotal ThyroiectomyTotal Thyroiectomy

Sub-total thyroidectomy is Sub-total thyroidectomy is commonly performed because:commonly performed because: It is thought that it is associated with It is thought that it is associated with

low incidence of RNL damagelow incidence of RNL damage It is thought that the chances of It is thought that the chances of

parathyroid damage is lessparathyroid damage is less Of the fear that total thyroidectomy Of the fear that total thyroidectomy

will need permanent replacement will need permanent replacement therapytherapy

It is easier to perform then total It is easier to perform then total thyroidectomythyroidectomy

Problems with lesser Problems with lesser resectionresection

Significant chances of recurrence (up Significant chances of recurrence (up to 23% in MNG)to 23% in MNG)

Small but Significant number of MNG Small but Significant number of MNG have been found to have tiny foci of have been found to have tiny foci of MalignancyMalignancy

Thyrotoxicosis can also reoccur and Thyrotoxicosis can also reoccur and specially the ophthalmopathy may specially the ophthalmopathy may stay or even progress after lesser stay or even progress after lesser resectionresection

The mid-term freedom The mid-term freedom rate from thyroid nodule rate from thyroid nodule

recurrence or recurrence or parenchymal irregularity parenchymal irregularity

after lobectomy for after lobectomy for solitary nodule of the solitary nodule of the

thyroid is unsatisfactory. thyroid is unsatisfactory.

Theodore Kocher performed Theodore Kocher performed the first total thyroidectomy the first total thyroidectomy

for MNG with very good for MNG with very good results and thought it to be results and thought it to be the procedure of choice in the procedure of choice in

19091909

mortality less than 0.18%mortality less than 0.18%minimal risk to RNL and minimal risk to RNL and

ParathyroidsParathyroids

He, however abandoned He, however abandoned this procedure due to this procedure due to

post-operative post-operative hypothyroidismhypothyroidism

As the thyroid extract was As the thyroid extract was made much latermade much later

Thyroxine was available in Thyroxine was available in 19131913

Capsular dissection Capsular dissection techniquetechnique

1992….Professor Reeve and 1992….Professor Reeve and Professor DelbridgeProfessor Delbridge

Total thyroidectomy is now the preferred option for the Total thyroidectomy is now the preferred option for the surgical management of Graves disease," surgical management of Graves disease," ANZ Journal of ANZ Journal of

SurgerySurgery, Volume 72 Issue 5 Page 321 - 2002, Volume 72 Issue 5 Page 321 - 2002 Total thyroidectomy will remove the target organ for Total thyroidectomy will remove the target organ for

the immune response in patients with the immune response in patients with hyperthyroidism and the risk of toxic ophthalmopathy hyperthyroidism and the risk of toxic ophthalmopathy is minimised. Lastly, the risk of recurrent disease is is minimised. Lastly, the risk of recurrent disease is eliminated. Six per cent had minor and probably eliminated. Six per cent had minor and probably transient local complaints at control three months transient local complaints at control three months after the operationafter the operation.00000[Benign diseases of the thyroid: .00000[Benign diseases of the thyroid: indications for surgical treatment and the current role of indications for surgical treatment and the current role of totaltotal thyroidectomythyroidectomy]]Chir Ital 2003 Mar-Apr;55(2):179-Chir Ital 2003 Mar-Apr;55(2):179-8787        

TotalTotal thyroidectomythyroidectomy for management of for management of thyroid disease.thyroid disease.World J Surg 2000 World J Surg 2000 Aug;24(8):962-5Aug;24(8):962-5    (ISSN: 0364-2313)    (ISSN: 0364-2313)

A comparison of A comparison of totaltotal thyroidectomythyroidectomy and lobectomy in the treatment of and lobectomy in the treatment of dominant thyroid nodules. dominant thyroid nodules. Am Surg 2002 Am Surg 2002 Aug;68(8):678-82; discussion 682-Aug;68(8):678-82; discussion 682-33     Farkas EA; King TA; Bolton JS;      Farkas EA; King TA; Bolton JS; Fuhrman GM Fuhrman GM

Assessment of the morbidity and Assessment of the morbidity and complications of complications of totaltotal thyroidectomythyroidectomy..Arch Arch Otolaryngol Head Neck Surg 2002 Otolaryngol Head Neck Surg 2002 Apr;128(4):389-92Apr;128(4):389-92    (ISSN: 0886-4470     (ISSN: 0886-4470

[[TotalTotal thyroidectomythyroidectomy in the surgical in the surgical treatment of thyroid disease a retrospective treatment of thyroid disease a retrospective clinical study][La tiroidectomia totale nel clinical study][La tiroidectomia totale nel trattamento della patologia trattamento della patologia tiroidea.]tiroidea.]Minerva Endocrinol 2001 Minerva Endocrinol 2001 Jun;26(2):41-51Jun;26(2):41-51    (ISSN: 0391-1977)    (ISSN: 0391-1977)

TotalTotal thyroidectomythyroidectomy for the treatment of for the treatment of hyperthyroidism in patients with hyperthyroidism in patients with ophthalmopathy. ophthalmopathy. Thyroid 2002 Mar;12(3):265-Thyroid 2002 Mar;12(3):265-77    (ISSN: 1050-7256) Kurihara H     (ISSN: 1050-7256) Kurihara H Kurihara Thyroid Clinic, Morioka, Japan. Kurihara Thyroid Clinic, Morioka, Japan.

[Basedow disease. From subtotal to [Basedow disease. From subtotal to totaltotal thyroidectomythyroidectomy] [Morbus Basedow. Von ] [Morbus Basedow. Von subtotaler zu totaler Thyreoidektomie.] subtotaler zu totaler Thyreoidektomie.] Schweiz Schweiz Rundsch Med Prax 2002 Feb 6;91(6):206-Rundsch Med Prax 2002 Feb 6;91(6):206-1515    (ISSN: 1013-2058) Gemsenjager E; Valko P;     (ISSN: 1013-2058) Gemsenjager E; Valko P; Schweizer I Schweizer I Chirurgische Klinik, Spital Zollikerberg, Chirurgische Klinik, Spital Zollikerberg, Zollikerberg.Zollikerberg.

Indications, risks, and acceptance of Indications, risks, and acceptance of totaltotal thyroidectomythyroidectomy for for multinodular benign goiter.multinodular benign goiter.Surg Surg Today 2001;31(11):958-62Today 2001;31(11):958-62        

Surgery for Graves' disease: Surgery for Graves' disease: totaltotal versus subtotal versus subtotal thyroidectomythyroidectomy--results of a prospective randomized results of a prospective randomized trial.trial.World J Surg 2000 World J Surg 2000 Nov;24(11):1303-11Nov;24(11):1303-11        

[Benign thyroid disease: 20-year [Benign thyroid disease: 20-year experience in surgical therapy][Malattia experience in surgical therapy][Malattia tiroidea benigna: esperienza ventennale di tiroidea benigna: esperienza ventennale di terapia chirurgica.]terapia chirurgica.]Chir Ital 2000 Jan-Chir Ital 2000 Jan-Feb;52(1):41-7Feb;52(1):41-7    (ISSN: 0009-4773)    (ISSN: 0009-4773)

Complications of Complications of totaltotal thyroidectomythyroidectomy: : incidence, prevention and treatment]incidence, prevention and treatment][Complicanze della tiroidectomia totale: [Complicanze della tiroidectomia totale: incidenza, prevenzione e incidenza, prevenzione e trattamento.]trattamento.]Chir Ital 2002 Sep-Chir Ital 2002 Sep-Oct;54(5):635-42Oct;54(5):635-42    (ISSN: 0009-4773)    (ISSN: 0009-4773)

Complication rates after operations for benign Complication rates after operations for benign thyroid disease. thyroid disease. Acta Otolaryngol 2002 Acta Otolaryngol 2002 Sep;122(6):679-83Sep;122(6):679-83    (ISSN: 0001-    (ISSN: 0001-6489) Dener C 6489) Dener C Department ol Surgery, Fatih University School Department ol Surgery, Fatih University School of Medicine, Ankara, Turkey. of Medicine, Ankara, Turkey.

High rate of recurrence after lobectomy for High rate of recurrence after lobectomy for solitary thyroid nodule. solitary thyroid nodule. Eur J Surg Eur J Surg 2002;168(7):397-4002002;168(7):397-400    (ISSN: 1102-    (ISSN: 1102-4151) Marchesi M; Biffoni M; Faloci C; Biancari 4151) Marchesi M; Biffoni M; Faloci C; Biancari F; Campana FP F; Campana FP 3rd Department of Surgery, University La 3rd Department of Surgery, University La Sapienza, Rome, Italy. Sapienza, Rome, Italy.

TotalTotal thyroidectomythyroidectomy: the : the procedure of choice for multinodular procedure of choice for multinodular goitre.goitre.Eur J Surg Eur J Surg 2002;168(3):196;2002;168(3):196;    Kaushal M;     Kaushal M; Agarwal G; Mishra SKAgarwal G; Mishra SK

Total Thyroidectomy: A study of 58 Total Thyroidectomy: A study of 58 cases: Javed Iqbal, Babar Ali and cases: Javed Iqbal, Babar Ali and Haroon K. Pasha: 1997 JCPSP Vol. 7 Haroon K. Pasha: 1997 JCPSP Vol. 7 (1) 20-21 (1) 20-21

Acceptable resultsAcceptable results

RLN peresisRLN peresis 2.4%2.4% RNL damageRNL damage 0.8%0.8% Transient hypocalcaemiaTransient hypocalcaemia 4.2%4.2% Long standing HypocalcaemiaLong standing Hypocalcaemia 1.4%1.4%

These results are not different These results are not different from patients who underwent from patients who underwent

lesser resection studieslesser resection studies

1995-20031995-2003

n-more than 300n-more than 300

TOUCH WOODTOUCH WOOD

NO RLN damageNO RLN damage 3.7% transient Hypocalcaemia3.7% transient Hypocalcaemia 2 patient with long standing 2 patient with long standing

HypocalcaemiaHypocalcaemia

ConclusionsConclusions

No chances of recurrenceNo chances of recurrence Lesser resection has no influence on Lesser resection has no influence on

post-operative thyroxine therapypost-operative thyroxine therapy Chances of missing a focus of Chances of missing a focus of

malignancy is eliminated.malignancy is eliminated. The total resection has better effect The total resection has better effect

of progression of Ophthalmopathy in of progression of Ophthalmopathy in Toxic goiterToxic goiter

ConclusionsConclusions

With capsular dissection technique With capsular dissection technique the incidence of damage to RLN and the incidence of damage to RLN and Parathyroids is comparable with that Parathyroids is comparable with that of sub-total resectionof sub-total resection