ENDOSCOPIC THYROID SURGERY/ SCARLESS THYROID SURGERY

BASIC FACTS ABOUT THE THYROID

The Thyroid gland is an essential organ of your body that produces hormones (Thyroid Hormone) that serve to regulate functions such as our blood pressure, heart rate, weight and body temperature.

The gland is located at the base of our neck and when there is disease, can be enlarged in size.

There are 4 types of diseases that can happen to our thyroid gland:

1. Hyperthyroid (too much hormone production)
2. Hypothyroid (too little hormone production)
3. Cancer of the thyroid
4. Thyroid nodules

What are some of the possible signs and symptoms of thyroid disease?

1. Hyperthyroid: weight loss, rapid heartbeat, sweating, tremors, anxiety, difficulty sleeping
2. Hypothyroid: weight gain, feeling tired, hair loss or thinning, depressed mood, muscle weakness
3. Thyroid cancer: lump on the neck, difficulty swallowing, swollen lymph node, change in the voice
4. Thyroid nodule: often, nodules do not have symptoms. Some can grow large enough to be felt. Most are benign, but some can become cancerous.

When the thyroid gland is enlarged, it is called a goitre. The usual presentation would be of a neck swelling, either on one side( unilateral) or both sides (bilateral). The gland can enlarge over a period of months to years. Thyroid disorders and goitres are actually quite common in the Malaysian population, in particular among females.

There are many factors causing thyroid disorders , for eg: environmental and dietary factors. Immune causes, genetics and family history also play a role; but most commonly no actual cause can be found.

Whom should you see if you suspect you have thyroid disease?

Most of the time, thyroid diseases are first evaluated by an internal medicine physician who will ask a detailed history, do an examination of the neck and order blood tests to check your thyroid function. Often, radiological imaging like an ultrasound or a CT scan is required.

Sometimes, a tissue sample is needed. This would be performed by a surgeon or an interventional radiologist.  

When do you need thyroid surgery?

Surgical treatment is recommended for those patients with thyroid nodules that are considered cancerous. 

• Patients with an overactive thyroid enlargement may require surgical treatment especially if you do not respond to antithyroid drugs.
• Patients who have experienced radiation of the head and neck area, may develop a nodularity of the thyroid gland which may require surgical treatment. Particularly if there is 30 to 60% chance of cancer in such glands.
• Patients on occasion may develop an enlargement of the thyroid gland to the extent of pressure on the windpipe. This pressure may cause the patient to have the feeling it is hard to swallow or have difficulty breathing. This can be verified on x-ray examination of the chest where the windpipe can be seen to be deviated by the enlarged thyroid gland. In this situation surgery is effective and may be preferred.

What is thyroid surgery (throidectomy)?

Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed. 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 anaesthesia. 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.

Traditionally, this procedure is done as an open surgery, requiring at least 8 to 10cm of incision at the lower neck. The scar is quite aesthetically displeasing.

 

MINIMALLY INVASIVE (ENDOSCOPIC) THYROID SURGERY

Using new surgical techniques, specialized surgeons can now perform scarless (otherwise known as minimally invasive) surgery.  Special cameras (endoscopes) are inserted into small holes or very small incisions through which the surgeon can see the thyroid gland. Another specialized instrument can then be inserted to remove the thryoid gland.

There is no neck scar. There will only be a small scar in the armpit area (axilla) and small 5mm scar at the chest area. This operation is safe, achieves aesthetically pleasing scars and requires shorter recovery periods.

Usually, patients will require general anesthesia for thyroid surgery.  However, using endoscopic techniques, patients may only need local anesthesia and moderate sedation for comfort,

Minimally invasive surgery is typically an outpatient procedure, with most patients going home within in a few hours of the operation.  Traditional surgery almost always means at least a one-night stay in the hospital.

Any patients undergoing thyroid surgery will experience a few days of hoarseness and soreness in the throat, but patients who undergo the minimally invasive procedure will have less discomfort around the external wound.   This helps to speed recovery and hasten return to normal daily activities.  

Patients can usually go home in one to two hours after minimally invasive thyroid surgery.  They can resume most normal activities the next day, although return to driving or other activities that require turning the head comfortably may take slightly longer.

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, ECG, chest x-rays, etc.  are carried out.  You will also have the opportunity to talk to the anaesthesiologist and ask questions or express concerns about anaesthesia.  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, anaesthesia and blood transfusions.

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.  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.

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 tranquiliser if you are very anxious.

What happens after surgery?

When you wake up from surgery, you will be transported to the recovery room , 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 anaesthesia.  Smokers have a tendency to cough.

You might notice that there will be a small drain or tube coming out from your wound, and the tube is normal kept for at least 48 hours to prevent collection under the skin.

For 2 – 3 days after the surgery, it is not unusual to have pain or difficulty on swallowing.

Complications

• 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 hypocalcaemia and vocal cord weakness or paralysis.
  • Hypocalcaemia, 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.
  • Hypocalcaemia is usually temporary, but sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcaemia 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.

To know more about Endoscopic Thyroidectomy, speak to our Consultant General Surgeons.