15 Revision Thyroidectomy

Ashok R. Shaha

In February 1974, Otolaryngology Clinics of North America devoted the entire volume to the symposium on revision surgery in otorhinolaryngology.1 Dr. Jerome C. Goldstein was the guest editor for this volume. Dr. Goldstein describes in his foreword,

We all know that not every operation is successful, and failure can assume different forms. Perhaps the primary disease was not eradicated or complication ensued. In those procedures done for traumatic or cosmetic reasons, the patient or the surgeon may not be satisfied with the result. Anyone faced with the further management of a patient in this difficult situation soon becomes aware of the paucity of information in the literature. Human nature being what it is, people are naturally more eager to publicize their successes than to discuss the management of failures.

The subject of revision thyroidectomy is very interesting, with a variety of indications and several controversial issues related to completion thyroidectomy. For a head and neck surgeon, this is a challenging surgical procedure in relation to certain adverse complications related to recurrent laryngeal nerve injury or permanent hypoparathyroidism. Although there are no definite data suggestive of increased complication in revision thyroidectomy, it is the general consensus that there is definitely a higher risk of complications, both wound-related problems and injury to the surrounding vital structures due to scarring and fibrosis. Obviously, the incidence of complications is related to the indications for which revision thyroidectomy is performed. In this chapter, we will describe the indications, the complications, and the special technical issues related to revision thyroidectomy.

Indications for revision thyroidectomy are enumerated in Table 15.1. The most common is completion thyroidectomy performed after ipsilateral thyroid lobectomy where the final pathology report reveals thyroid cancer. The other most common indication is recurrent thyroid cancer in the thyroid bed or metastatic disease in the cervical lymph nodes. The surgical procedures and the concerns regarding the complications are minimal if the surgical procedure is performed for metastatic nodes as compared with recurrent disease in the thyroid bed or in the tracheoesophageal groove area. Recurrent hyperthyroidism is a rare indication nowadays, as most patients with Graves disease are treated with radioactive iodine; a few who undergo surgical intervention mostly undergo total thyroidectomy, or very small residual thyroid tissue is left that is unlikely to result in recurrent hyperthyroidism. The surgical procedure in recurrent hyperthyroidism is very complex, and the residual thyroid tissue may be entangled in severe scar tissue, leading to a surgical procedure being most difficult with high incidence of injury to the recurrent laryngeal nerve and parathyroids. In such patients, due consideration may be given to treating them with radioiodine rather than reoperative surgery.

Postoperative Hematoma and Bleeding

Thyroid surgery is generally considered to be a safe procedure; however, postoperative wound hematoma and bleeding can be serious complications, generally seen within the first 24 hours following surgery. The overall incidence of postoperative hematoma ranges between 1 and 2%, generally requiring surgical exploration. The most common cause for wound hematoma is slipping of a ligature. This is more common in patients who have recovered from anesthesia bucking and coughing. The small venous tributaries in the thyroid bed may start bleeding due to increased intrathoracic pressure. After thyroidectomy, patients should be observed closely in the postoperative period as expanding hematoma may cause airway compression and severe difficulty in breathing, requiring opening of the wound at the bedside to avoid airway distress. Generally, the patient should be brought back to the operating room for surgical exploration and ligation of the bleeding vessel. Quite often no bleeding vessel is noted, and the hematoma is evacuated. The wound is irrigated, and fresh drains are placed in the thyroid bed.

Table 15.1 Indications for Revision Thyroidectomy

Completion Thyroidectomy

One of the major indications for completion thyroidectomy is the patient presenting with a solitary thyroid nodule and having undergone thyroid lobectomy reported to be benign at the time of frozen section. The permanent section is reported as either follicular carcinoma or follicular variant of papillary carcinoma of the thyroid (Table 15.2). There continues to be considerable controversy regarding completion thyroidectomy. Obviously, the decisions related to completion thyroidectomy should be based on the risk group of the initial thyroid tumor. If the patient belongs to the low risk group—with the tumor being < 4 cm, the patient’s age < 45 years, and a low-grade thyroid cancer—there is very little justification to proceed with completion thyroidectomy. However, there appears to be a consensus among many endocrinologists to consider completion thyroidectomy for a cancer > 1.5 cm in size. The surgeon will be asked to proceed with completion thyroidectomy to facilitate radioactive iodine dosimetry and possible ablation and routine serial thyroglobulin follow-up. In a low-risk thyroid cancer patient, the overall long-term outcome is so good that the role of completion thyroidectomy remains controversial and questionable. However, the general indications for completion thyroidectomy are a tumor > 4 cm in size or aggressive histology (e.g., poorly differentiated carcinoma; tall cell, insular, trabecular, or undifferentiated carcinoma of the thyroid; older patients or patients with major capsular or vascular invasion who are at high risk for development of distant metastasis). Some of the major indications for completion thyroidectomy are the fear of development of distant metastases and the need for consideration of radioactive iodine dosimetry and ablation. This is because radioactive iodine cannot be used in the presence of normal thyroid tissue. Although a medical thyroidectomy can be performed with low-dose radioactive iodine, it takes a long time and is generally not satisfactory. Most of the time, the radioactive iodine will be absorbed by the normal thyroid rather than used to detect distant metastases.

Table 15.2 Recurrent Thyroid Cancer

Stay updated, free articles. Join our Telegram channel

Join