1.1 Introduction

Thyroidectomy has evolved from a barbaric, high-mortality procedure to an elegant operation, the epitome of the surgeon’s art. It was primarily the pioneering work of Kocher, rewarded with the 1908 Nobel Prize, that catalyzed this evolution. This chapter reviews the evolution of thyroidectomy, from the bloody goiter resection of the early centuries to the innovative, patient-centered, refined thyroidectomy of today.

1.2 The Normal and Enlarged Thyroid: Initial Misunderstandings

The initial interest in the thyroid gland was fostered by the large glands endemic in the first and second centuries. Goiters (Latin guttur = throat) were recognized in China as early as 2700 BC and then again by the Romans in the Alps in the first 3 centuries AD. The normal thyroid gland was not recognized until the Renaissance. Around 1500 Leonardo da Vinci drew the thyroid as a globular, bilobate structure, which he regarded as two glands, filling the empty spaces in the neck. In 1543 Andreas Vesalius of Padua described two “glandulae larynges” which, he thought, lubricated the larynx. Bartholomaeus Eustachius of Rome, who also described the adrenal glands, described a single “glandulam thyroideam” (Latin for “shield-shaped”) with an isthmus connecting its lobes, but his work was not published until the 18th century. In 1656 Thomas Wharton of London described and named “glandula thyroidoeis.” The onset of goiter in the young adult at that time led to speculation that goiter formation was associated with sexual maturity. In the late 18th century microscopy revealed colloid-filled vesicles within the gland. Caleb Hillier Parry of Bath, England, who also described exophthalmic goiter, speculated that the thyroid provided a reservoir to prevent engorgement of the brain. ^{1 , 2}

1.3 Setons, Bootlaces, and Prison: Early Days of Thyroid Surgery

Celsus and Galen have been credited with operating on goiters in the first and second centuries, but it was not until AD 500 in Baghdad that Abdul Kasan Kelebis Abis performed the first recorded goiter excision.

Roger Frugardi, in the Italian School of Salerno, provided the first credible description of operation for goiter in approximately 1170. At this time, if a large goiter failed to respond to medication (including iodine-containing marine products), two setons were inserted at right angles, with the help of a hot iron, and manipulated toward the surface twice daily until they had cut through the flesh. Another technique for goiters that projected anteriorly consisted of making a skin incision, grasping the tumor with a hook, then dissecting the skin from the goiter. The exposed pedunculated portion of the goiter would be ligated en masse with a bootlace and removed. During such procedures the patients were tied down to a table and held firmly. In 1718 German surgeons wrote an account of thyroid surgery that differed little from that of Frugardi’s.

In 1646, Wilhelm Fabricus reported the first thyroidectomy using a scalpel. This technical advance was ironically and unfortunately associated with a poor outcome. The patient died and the surgeon was imprisoned. Pierre-Joseph Desault of Paris is the first surgeon to publish an account of a successful removal of a goiter, which he performed in 1791. He used a vertical incision to isolate and ligate the superior and inferior thyroid arteries before cutting them and dissecting the thyroid from the trachea using the scalpel. He packed the wound, which suppurated and healed in a month. Guillaume Dupuytren followed in Desault’s footsteps and in 1808 performed the first “total thyroidectomy.”

Attempts to suppress the gland by ligation of the superior thyroid artery were first used by William Blizzard in 1811. Although relatively simple due to the lateral approach, this operation fell into disuse because of its minimal long-term benefit.

In the mid-19th century, William Halsted of Baltimore, in his monumental Operative Story of Goitre, could trace accounts of only 8 thyroid operations in which a scalpel had been used between 1596 and 1800, and only 69 further cases until 1848. In the 1850s, a variety of incisions were performed for thyroidectomy: longitudinal, oblique, Y-shaped. After the skin incision, most surgeons performed blunt dissection, and their control of bleeding was inadequate. Despite significant perioperative blood loss, bloodletting was performed for postoperative complications. Typically the wound was left open, and the dead spaces were packed or left to fill with blood. At this time the mortality after thyroid surgery was as high as 40%. Not surprisingly, the French National Academy of Medicine condemned any operative procedures on the thyroid gland, and Samuel David Gross, a prominent American surgeon, wrote in 1866, “No honest and sensible surgeon would ever engage in it!”

Throughout most of the 19th century the results of thyroid operations were so poor that most surgeons restricted their practice to very simple procedures, which could be grouped in three categories:

1. 
   

   Noncutting operations: setons and bristles were inserted, and cysts were punctured and injected with iodine or other irritants. Deaths from hemorrhage, inflammation, or air embolus were not uncommon.

   
   
2. 
   

   Enucleation and bootlace ligation of goiters.

   
   
3. 
   

   Cutting operations with removal of thyroid tissue: these typically included ligation of thyroid arteries and division of superficial muscles and fascia.

1.4 The 19th Century Revolution: Kocher’s Thyroidectomy

The 19th century marked a revolution in all fields of surgery, triggered by the introduction of general anesthesia and aseptic technique. In 1846, William Morton’s demonstration of ether’s efficacy at Massachusetts General Hospital marked the beginning of surgical anesthetics. The first recorded thyroid operation with anesthesia was performed in 1847 ³ , when Nikolai Pirogoff, of Saint Petersburg, Russia, employed ether for a thyroid operation on a 17-year-old girl, whose central goiter compressed the trachea (Fig. 1.1). Despite such progress, many surgeons at this time continued to manage patients without anesthesia.

One of the most distinguished surgeons of the 19th century, Albert Theodor Billroth, was involved in the new era of thyroid surgery (Fig. 1.2). In the early 1860s, while holding the chair of surgery in Zurich, he performed 20 thyroidectomies. Billroth, described by William Halstead as a rapid thyroid operator, courageously reported his initial results, documenting a 40% mortality rate due to intraoperative hemorrhage and postoperative sepsis. After abandoning thyroid surgery for more than a decade, he was again attracted to this field while working in Vienna. By then antisepsis had become more established, and he achieved an impressive mortality rate of only 8% for thyroidectomy. Billroth’s technique at that time involved division of the sternocleidomastoid muscle, incision and drainage of any thyroid cysts, arterial ligation, and the use of aneurysmal needles for controlling hemorrhage.

Despite Billroth’s pioneering work, Theodor Kocher’s name dominates the history of thyroid surgery (Fig. 1.3). Kocher’s 1872 appointment as chair of surgery in Bern, Switzerland, marks the beginning of an illustrious career, during which he performed more than 5,000 thyroidectomies. Kocher represented a new style of thyroid surgeon. With meticulous attention to the details of surgical technique, hemostasis, and antisepsis, he reported a reduction in mortality from more than 12% in the 1870s to 0.2% in 1898.

Kocher’s important contributions to thyroid surgery include the concept of total thyroidectomy, capsular dissection, and the demonstrated benefit of being a high-volume surgeon. All of these concepts remain important in the modern era. Subtotal thyroidectomy was the mainstay operation prior to Kocher’s realization that this subtotal operation led to goiter recurrence. His capsular dissection, with its emphasis on precise dissection and meticulous hemostasis, was a grand change from the earlier bloody, barbaric surgery. With experience and attention to detail, he was able to spare the recurrent laryngeal nerve and parathyroid glands, despite the unknown function of these structures at the time. ^{4 , 5}

Kocher’s technique involved a collar incision, which bears his name today. He also contributed to the understanding of thyroid physiology. His observations of “cachexia strumipriva,” the consequences of total removal of the thyroid gland, contributed to the recognition that the thyroid is essential for normal growth, development, and metabolism. In 1908, Dr. Kocher was awarded the Nobel Prize for medicine for his work on the physiology, pathology, and surgery of the thyroid gland.

1.5 The 20th Century: Maturity of Thyroid Surgery

In the late 1890s, European advances in thyroid surgery were adopted in the United States by William Halsted of Baltimore, the Mayo brothers of Rochester, George Crile of Cleveland, and Frank Lahey of Boston. The well-known medical clinics that bear their names were initially financially fueled by high-volume thyroid surgery, made safe and practical through the techniques of Kocher.

At the turn of the 20th century, Thomas Peel Dunhill of Melbourne began work on the treatment of thyrotoxicosis. He introduced the technique of total lobectomy with contralateral subtotal thyroidectomy, subsequently referred to as the Dunhill procedure. He advocated pericapsular dissection performed in a staged manner under local anesthesia, and later under light general anesthesia. He achieved a mortality of only 3% while operating on severely thyrotoxic patients. In London, the same operation at this time was associated with 30% mortality. Interestingly, at the time of Dunhill’s initial presentation of results in these patients to the Royal Society of Medicine in London, the society’s chairman was James Berry, who described the eponymous ligament that overlies the recurrent laryngeal nerve close to its entry point into the larynx. After the First World War, Dunhill moved to London. In 1919, the British Journal of Surgery published his seminal article providing a detailed surgical technique for thyroidectomy, which remains true to form today. ⁶ In that same year, Sistrunk described his radical operation for thyroglossal tract lesions, including the resection of the middle third of the hyoid bone.