Preparation and post operative

complications of thyroid surgery

 ‫بة َلَين صالح كَو يى‬.‫د‬
 ‫جراح أخصائي‬
 )‫بورد(دكتوراه‬
FICMS, FICS, MB Ch B
 GENERAL SURGEON
Preoperative preparation:
 Traditional preparation aims to make the patient
biochemically euthyroid at operation.
 The thyroid state is determined by clinical assessment,
i.e. by improvement in previous symptoms and by
serial estimations of the thyroid profile.
 Preparation is as an out-patient.
 Rarely admission to hospital is necessary, in case of
severe symptoms at presentation, failure to control the
hyperthyroidism or non-compliance with medication.
1. Carbimazole 30–40 mg/day is the drug of choice for
preparation.
 When the patient become biochemically euthyroid
(after 8–12 weeks), the dose may be reduced to 5 mg
X3 or 5mg x2
 The last dose of carbimazole may be given on the
evening before surgery.
2. An alternative method is by using β-blocker.
 β- blockers act on the target organs and not on the
gland itself.
 The drugs are (inderal) propranolol 40 mg t.d.s. or a
slow-release preparation (Nadolol) once daily.
 Propranolol (inderal) inhibits the peripheral
conversion of T4 to T3.
 Rarely larger doses (propranolol 80 mg t.d.s. or
nadolol 320 mg once daily) are necessary.
 β-Blockers do not interfere with synthesis of thyroid
hormones and hormone levels remain high during
surgery and for some days after thyroidectomy.
 It is therefore important to continue to give the drug
for 7 days postoperatively.
3. Iodine may be given with carbimazole or β-blocker for
the 10 days before operation.
 Iodine alone produces a transient remission and may
reduce vascularity.
 Iodine gives an additional measure of safety in case the
early morning dose of β-blocker is mistakenly omitted
on the day of operation.
4. combination of β- blockers (propranolol or nadolol)
with carbimazole may be used in the immediate
treatment of patients with very severe hyperthyroidism.
Specific Preoperative investigations to be carried out:
 Thyroid function test.
 Thyroid auto-antibodies
 Laryngoscopy (flexible).
 Serum calcium estimation
 Isotope scan. The surgeon should know which nodules, if
any, are autonomous and active
:General preoperative preparation
 CBC & BLOOD GROUP & RH TYPING
 FBS
 RENAL FUNCTION TEST
 CXR
 ECG
 1 UNIT BLOOD PREPARATION
 VIRAL SCREEN
Patients position
 Collar incision
Types of surgery
Redivac drain
Post op care
 Immediate
 Position of the patient
 Monitor vital signs
 Checking the wound for any bleeding and any ooze
Postoperative complications
1. Hemorrhage: A tension hematoma deep to the cervical
fascia is usually due to slipping of ligature from one of
the thyroid arteries; occasionally, hemorrhage from a
thyroid remnant or a thyroid vein may be responsible.
 This is a rare but (dangerous) emergency requiring
urgent decompression by opening the layers of the wound,
not simply the skin closure, to relieve tension before
urgent transfer to theatre to secure the bleeding vessel
 A subcutaneous hematoma or collection of serum may
form under the skin flaps and require evacuation in the
following 48 hours.
2. Respiratory obstruction:
 Most cases are caused by laryngeal edema.
 The most important cause of laryngeal edema is a
tension hematoma.
 However, trauma to the larynx by anesthetic intubation
& surgical manipulation are important contributory
factors, particularly if the goitre is very vascular, &
may cause laryngeal edema without a tension
hematoma.
 If releasing the tension haematoma does not immediately
relieve airway obstruction, the trachea should be intubated
 An ETI can be left in place for several days; steroids are
given to reduce edema and a tracheostomy is rarely
necessary.
 Intubation in the presence of laryngeal edema may be very
difficult and should be carried out by an experienced
anesthetist.
 Repeated unsuccessful attempts to intubate may
aggravate the problem & in a crisis, it is safer to perform a
needle tracheostomy as a temporary measure; using a
large bore 12G IV cannula (diameter 2.3 mm) is
satisfactory.
3. Recurrent laryngeal nerve paralysis and voice change

 INCIDENCE: 1-2 % IN EXPERIENCED HAND (FIRST

OP)
 3-5% IN RECURRENT GOITER
 RLN injury may be unilateral or bilateral, transient or
permanent.
 Bilateral inj. Needs immediate tracheostomy.
 Early routine postop laryngoscopy reveals a much higher
incidence of transient cord paralysis.
 Such temporary dysfunction is not clinically important, but
voice and cord function should be assessed at the first follow-
up 4 weeks postoperatively.
 Injury to the external branch of the superior laryngeal
nerve is more common because of its proximity to the
superior thyroid artery. This leads to loss of tension in
the vocal cord with diminished power and range in the
voice.
 Patients, particularly those who use their voices
professionally, must be advised that any thyroid
operation will result in change to the voice even in the
absence of nerve trauma.
4. Thyroid insufficiency:
 Following subtotal thyroidectomy. This usually occurs
within 2 years.
 The incidence is considerably higher than was
previously thought and rates of 20–45% at 10 years
have been reported.
 There is a definite relationship between the estimated
weight of the thyroid remnant and the development of
thyroid failure after subtotal thyroidectomy for
Graves’ disease.
5. Parathyroid insufficiency:
 This is due to removal of the parathyroid glands or to
infarction through damage to the parathyroid end
artery.
 The incidence of permanent hypoparathyroidism is <
1%.
 Most cases present dramatically 2–5 days postop.
however, very rarely the onset is delayed for 2–3 weeks
or a patient with marked hypocalcaemia is
asymptomatic.
CARPOPEDAL SPASM
TROUSSEA`S SIGN
:Note: Trousseau sign of latent tetany
 Place the sphygmomanometer cuff around the arm as you
would for measuring blood pressure.
 Slowly inflate the cuff up to 20 mmHg and wait for 2-3
minutes.
 This reduces arterial supply to the forearm.
 The ischemia, in the context of hypocalcemia, and mediated
by the mechanism of hypocalcemic neuronal irritability, leads
to muscular spasm of the wrist and hand (carpopedal spasm).
 A positive sign is characterized by the appearance of a
carpopedal spasm which involves flexion of the wrist, thumb,
and MCP joints along with hyperextension of the IP joints
 Highly specific for hypocalcemia
CHVOSTEK`S SIGN

Chvostek sign is contraction of

facial muscles provoked by
lightly tapping over the facial
nerve anterior to the ear as it
crosses the zygomatic arch.
6. Thyrotoxic crisis (storm):
 This is an acute exacerbation of hyperthyroidism.
 It occurs if a thyrotoxic patient has been inadequately
prepared for thyroidectomy and is now extremely rare.
 Very rarely, a thyrotoxic patient presents in a crisis and
this may follow an unrelated operation.
 Symptomatic and supportive treatment is for
dehydration, hyperpyrexia and restlessness.
7. Wound infection
8. Hypertrophic or keloid scar: This is more likely to form if the
incision overlies the sternum and in dark-skinned
individuals. Intradermal injections of corticosteroid should
be given at once and repeated monthly if necessary.
9. Stitch granuloma with or without sinus formation: This may
be seen after the use of non-absorbable, particularly silk,
suture material. Absorbable ligatures and sutures must be
used throughout thyroid surgery.
 REFERENCES
 Bailey & Love’s (SHORT PRACTICE
OF SURGERY) 25th Edition.
 BROWSE`S Introduction to the
Symptoms and Signs of Surgical
Disease.
 ACS surgery principle & practice