What happens when you have thyroid surgery?
Prior to surgery, you will have the opportunity to go through the reasons for carrying out the operation, and the alternatives with myself or a member of my team. As part of this, we will explain the potential risks associated with the operation and what aftercare will be needed. Around a week before your operation, you will be seen by the pre-assessment team, who will take some blood tests, check your observations, and order any other necessary investigations to ensure that we can carry out your operation as smoothly as possible.
On the day of surgery, you will be admitted to the ambulatory care unit (for those having a hemithyroidectomy), or the admissions unit (for those having a total thyroidectomy or neck dissection, or for those with more significant other medical problems). Here, after the nursing team have admitted you, you will be seen again by myself and the anaesthetist, and have an opportunity to ask any other questions you may have.
The operation takes place under general anaesthetic, which the anaesthetist will administer through a cannula, usually placed in the back of your hand. Once done, the operation is performed through an incision in your lower neck, placed in one of the natural lines or creases in your neck to make it as invisible as possible. At the end of the operation, the incision is closed with sutures (usually dissolvable), with some steristrip dressing placed over it. You may have a drain inserted to help remove any fluid that collects.
Following the operation, you will be looked after in the recovery bay until you are awake enough to go back to ward. You will be given painkillers and anti-sickness medication if you need it.
Once back on the ward, you will be given something to eat and drink, it is not unusual to have some discomfort when swallowing immediately after the operation, but this passes over the next couple of days. Depending on the extent of your operation, you may then need blood tests that evening and following morning, and if you have had your whole thyroid removed then you will be started on levothyroxine the following day. If you have not had a drain placed, you will usually be able to go home the following morning, otherwise you will be able to go home once your drain is removed and your calcium results are stable (if you have had a total thyroidectomy). You will be given a sick note if you need one, and you will be given instructions for how to look after your wound and if you have any sutures that need removing. You should plan on having 2 weeks off work after the operation.
Your follow up will be in approximately 3 weeks for cases of suspected of confirmed cancer, or approximately 6 weeks for benign and thyrotoxic cases.
What are the risks of thyroid surgery?
Thyroidectomy is a commonly performed operation, however it does carry certain risks. It is always important to discuss these with your surgeon, and you should also feel free to ask what his or her specific complication rate is. It has been well established that the risk of complications from thyroid surgery decreases with the experience of your surgeon, with high volume surgeons having the lowest complication rate. Reporting of outcomes of thyroid surgery is a national requirement The British Association of Endocrine and Thyroid Surgeons maintains a database that allows surgeons to enter (anonymised) details, which is used to produce an annual report of each surgeon’s outcomes and number of patients they have treated. The specific complication, and risk, does depend on the type and extent of surgery you are having, with more extensive or urgent surgery carrying the highest risk. The BAETS also produces a national audit every few years which reports thyroid surgery outcomes.
As with any operation, there is a risk of developing a wound infection. This risk is low, and signs you may be developing an infection include increasing pain, redness and swelling. This may typically occur several days after the operation.
Some people develop problems with their neck scar, including keloid formation (overgrowth of scar tissue, more common in people with darker skin).
Many people will have some numbness over the front of their neck due to the small nerves that supply the skin being disrupted. This may recover over time.
As with any operation, there is a risk of continued bleeding under the skin after the operation, and this can cause swelling in the front of the neck. Around 1 in 100 patients will develop this, and the risk is increased for those patients taking blood thinners or who are having surgery for thyrotoxicosis. If there is significant swelling, a further operation may be needed to remove the haematoma. In rare circumstance, the haematoma can cause difficulty breathing, and this may require very urgent attention. Should you feel short of breath or that you neck is swollen after the operation, you should inform the nursing staff immediately, and you will be reviewed by a doctor immediately.
Recurrent laryngeal nerve injury
The recurrent laryngeal nerves (RLNs) run underneath the thyroid on each side, and supply some of the muscles of your voicebox, which helps you speak. These nerves have to be carefully identified and protected during the operation, but there is a risk that can become temporarily, or rarely permanently, damaged during the procedure. In certain cases for cancer, it may be necessary to resect the nerve to ensure that all the cancer is removed, but your surgeon will have discussed this with you beforehand if it is a possibility.
Should the RLN be injured, you may find that you have a weaker, more breathy voice, and occasionally some difficulty swallowing. The majority of RLN injuries will recover over the following 6 months, but for some patients it can take a lot longer and in some circumstances it may never recover its full function. If it is found that your nerve is not working properly, you will be offered voice therapy and in more long term cases, there are procedures that can be done on the affected side to help strengthen the voice.
Very rarely, both nerves can be injured and this can lead to significant problems with breathing, speech and swallowing. In extreme cases, the difficulty breathing can be so severe that a tracheostomy (breathing tube placed directly in to the trachea through the neck) may be needed.
Neil routinely uses RLN nerve monitoring during thyroid surgery, which allows him to identify when a nerve is at risk of injury, and also to determine whether a nerve is intact and functional before proceeding to the other side, and at the end of the operation.
The parathyroid glands are 4 glands that are situated just under the thyroid gland, they help control your calcium levels, by producing parathyroid hormone (PTH). During thyroid surgery, these glands may have their blood supply interrupted, or indeed be inadvertently removed when taking out the thyroid. If only one side of the thyroid is being operated on (a lobectomy), then if this were to happen the risk of developing calcium problems is very low. However, for total thyroidectomy the risk is higher, and if you require a central neck dissection, or are having revision thyroid surgery, the risk is higher still. If the glands stop working properly, then your calcium level may fall, and this can lead to pins and needles in your face and fingers, and in extreme cases muscle and heart problems. All hospitals carrying out thyroid surgery should have a system in place to check your calcium level after total thyroidectomy. At the Queen Elizabeth Hospital, your calcium and PTH level are check 4-6 hours after surgery, and again the following morning. Should your calcium or PTH levels be low, you will be started on calcium tablets and sometimes hormone tablets to help increase your levels, or prevent them falling. For most people, the glands will recover over the following 6 months and you will be able to be weaned off the calcium tablets, however for some the medication is needed lifelong. It is important to talk to your surgeon about what his or her rates of hypoparathyroidism are for the specific operation you are undergoing, so that you can have an idea of the potential risk of this happening.
If all of your thyroid is removed, you will need to take thyroid hormone replacement (usually levothyroxine) for the rest of your life. Should you only be undergoing a hemithyroidectomy, usually the other half of the gland will be sufficient to produce the amount of hormone you need. However, it is important that you have a check your thyroid function a couple of months after surgery as some patients may develop hypothyroidism even after lobectomy, and may require thyroid hormone replacement.
Multiple Endocrine Neoplasia