Total thyroidectomy for non malignant goiter

Role of total thyroidectomy in benign thyroid swellings. A talk given i

1. Total Thyroidectomy for Total Thyroidectomy for
Non-Malignant goiter Non-Malignant goiter
Javed Iqbal, FCPS,FRCSJaved Iqbal, FCPS,FRCS
Professor of surgeryProfessor of surgery
Quaid-e-Azam Medical College, Quaid-e-Azam Medical College,
BahawalpurBahawalpur

2. Total thyroidectomy is the Total thyroidectomy is the
procedure of choice for procedure of choice for
thyroid malignancythyroid malignancy

3. Commonly performed procedures Commonly performed procedures
for non-malignant thyroid:for non-malignant thyroid:
LobectomyLobectomy
Lobectomy with isthamectomyLobectomy with isthamectomy
Sub-total thyroidectomySub-total thyroidectomy
Total ThyroiectomyTotal Thyroiectomy

4. Sub-total thyroidectomy is Sub-total thyroidectomy is
commonly performed because:commonly performed because:
It is thought that it is associated with low It is thought that it is associated with low
incidence of RNL damageincidence 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 will Of the fear that total thyroidectomy will
need permanent replacement therapyneed permanent replacement therapy
It is easier to perform then total It is easier to perform then total
thyroidectomythyroidectomy

5. Problems with lesser resectionProblems with lesser resection
Significant chances of recurrence (up to Significant chances of recurrence (up to
23% in MNG)23% in MNG)
Small but Significant number of MNG have Small but Significant number of MNG have
been found to have tiny foci of Malignancybeen found to have tiny foci of Malignancy
Thyrotoxicosis can also reoccur and Thyrotoxicosis can also reoccur and
specially the ophthalmopathy may stay or specially the ophthalmopathy may stay or
even progress after lesser resectioneven progress after lesser resection

6. The mid-term freedom rate The mid-term freedom rate
from thyroid nodule from thyroid nodule
recurrence or parenchymal recurrence or parenchymal
irregularity after lobectomy irregularity after lobectomy
for solitary nodule of the for solitary nodule of the
thyroid is unsatisfactory. thyroid is unsatisfactory.

11. Theodore Kocher performed the Theodore Kocher performed the
first total thyroidectomy for MNG first total thyroidectomy for MNG
with very good results and with very good results and
thought it to be the procedure of thought it to be the procedure of
choice in 1909choice in 1909
mortality less than 0.18%mortality less than 0.18%
minimal risk to RNL and minimal risk to RNL and
ParathyroidsParathyroids

12. He, however abandoned He, however abandoned
this procedure due to post-this procedure due to post-
operative hypothyroidismoperative hypothyroidism
As the thyroid extract was made As the thyroid extract was made
much latermuch later
Thyroxine was available in 1913Thyroxine was available in 1913

13. Capsular dissection Capsular dissection
techniquetechnique
1992….Professor Reeve and 1992….Professor Reeve and
Professor DelbridgeProfessor Delbridge

14. Total thyroidectomy is now the preferred option for the surgical Total thyroidectomy is now the preferred option for the surgical
management of Graves disease," management of Graves disease," ANZ Journal of SurgeryANZ Journal of Surgery, Volume , Volume
72 Issue 5 Page 321 - 200272 Issue 5 Page 321 - 2002
Total thyroidectomy will remove the target organ for the Total thyroidectomy will remove the target organ for the
immune response in patients with hyperthyroidism and immune response in patients with hyperthyroidism and
the risk of toxic ophthalmopathy is minimised. Lastly, the the risk of toxic ophthalmopathy is minimised. Lastly, the
risk of recurrent disease is eliminated. Six per cent had risk of recurrent disease is eliminated. Six per cent had
minor and probably transient local complaints at control minor and probably transient local complaints at control
three months after the operationthree months after the operation.00000[Benign diseases of .00000[Benign diseases of
the thyroid: indications for surgical treatment and the current role of the thyroid: indications for surgical treatment and the current role of
totaltotal thyroidectomythyroidectomy]]Chir Ital 2003 Mar-Apr;55(2):179-87Chir Ital 2003 Mar-Apr;55(2):179-87        

15. 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 Am Surg
2002 Aug;68(8):678-82; discussion 2002 Aug;68(8):678-82; discussion
682-3682-3     Farkas EA; King TA; Bolton JS;      Farkas EA; King TA; Bolton JS;
Fuhrman GM Fuhrman GM

16. Assessment of the morbidity and complications Assessment of the morbidity and complications
of of totaltotal thyroidectomythyroidectomy..Arch Otolaryngol Arch Otolaryngol
Head Neck Surg 2002 Apr;128(4):389-Head Neck Surg 2002 Apr;128(4):389-
9292    (ISSN: 0886-4470     (ISSN: 0886-4470
[[TotalTotal thyroidectomythyroidectomy in the surgical treatment in the surgical treatment
of thyroid disease a retrospective clinical study]of thyroid disease a retrospective clinical study]
[La tiroidectomia totale nel trattamento della [La tiroidectomia totale nel trattamento della
patologia tiroidea.]patologia tiroidea.]Minerva Endocrinol 2001 Minerva Endocrinol 2001
Jun;26(2):41-51Jun;26(2):41-51    (ISSN: 0391-1977)    (ISSN: 0391-1977)

17. TotalTotal thyroidectomythyroidectomy for the treatment of for the treatment of
hyperthyroidism in patients with hyperthyroidism in patients with
ophthalmopathy. ophthalmopathy. Thyroid 2002 Thyroid 2002
Mar;12(3):265-7Mar;12(3):265-7    (ISSN: 1050-    (ISSN: 1050-
7256) Kurihara H 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 Rundsch Med Prax 2002 Feb
6;91(6):206-156;91(6):206-15    (ISSN: 1013-    (ISSN: 1013-
2058) Gemsenjager E; Valko P; Schweizer I 2058) Gemsenjager E; Valko P; Schweizer I
Chirurgische Klinik, Spital Zollikerberg, Chirurgische Klinik, Spital Zollikerberg,
Zollikerberg.Zollikerberg.

18. Indications, risks, and acceptance of Indications, risks, and acceptance of totaltotal
thyroidectomythyroidectomy for multinodular benign for multinodular benign
goiter.goiter.Surg Today 2001;31(11):958-Surg Today 2001;31(11):958-
6262        
Surgery for Graves' disease: Surgery for Graves' disease: totaltotal versus versus
subtotal subtotal thyroidectomythyroidectomy-results of a -results of a
prospective randomized trial.prospective randomized trial.World J World J
Surg 2000 Nov;24(11):1303-11Surg 2000 Nov;24(11):1303-11         

19. [Benign thyroid disease: 20-year experience in [Benign thyroid disease: 20-year experience in
surgical therapy][Malattia tiroidea benigna: surgical therapy][Malattia tiroidea benigna:
esperienza ventennale di terapia esperienza ventennale di terapia
chirurgica.]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 trattamento.]incidenza, prevenzione e trattamento.]Chir Ital Chir Ital
2002 Sep-Oct;54(5):635-422002 Sep-Oct;54(5):635-42    (ISSN: 0009-    (ISSN: 0009-
4773)4773)

20. Complication rates after operations for Complication rates after operations for
benign thyroid disease. benign thyroid disease. Acta Acta
Otolaryngol 2002 Sep;122(6):679-Otolaryngol 2002 Sep;122(6):679-
8383    (ISSN: 0001-6489) Dener C     (ISSN: 0001-6489) Dener C
Department ol Surgery, Fatih University Department ol Surgery, Fatih University
School of Medicine, Ankara, Turkey. School 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; 4151) Marchesi M; Biffoni M; Faloci C;
Biancari F; Campana FP Biancari F; Campana FP
3rd Department of Surgery, University La 3rd Department of Surgery, University La
Sapienza, Rome, Italy. Sapienza, Rome, Italy.

21. TotalTotal thyroidectomythyroidectomy: the procedure of : the procedure of
choice for multinodular goitre.choice for multinodular 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 cases: Total Thyroidectomy: A study of 58 cases:
Javed Iqbal, Babar Ali and Haroon K. Javed Iqbal, Babar Ali and Haroon K.
Pasha: 1997 JCPSP Vol. 7 (1) 20-21 Pasha: 1997 JCPSP Vol. 7 (1) 20-21

22. 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 Hypocalcaemia1.4%1.4%
These results are not different from These results are not different from
patients who underwent lesser patients who underwent lesser
resection studiesresection studies

23. 1995-20031995-2003
n-more than 300n-more than 300

24. 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

25. ConclusionsConclusions
No chances of recurrenceNo chances of recurrence
Lesser resection has no influence on post-Lesser resection has no influence on post-
operative thyroxine therapyoperative thyroxine therapy
Chances of missing a focus of malignancy Chances of missing a focus of malignancy
is eliminated.is eliminated.
The total resection has better effect of The total resection has better effect of
progression of Ophthalmopathy in Toxic progression of Ophthalmopathy in Toxic
goitergoiter

26. ConclusionsConclusions
With capsular dissection technique the With capsular dissection technique the
incidence of damage to RLN and incidence of damage to RLN and
Parathyroids is comparable with that of Parathyroids is comparable with that of
sub-total resectionsub-total resection