Thyroid operation

Every node in the thyroid gland is to be assessed as pathological and must be examined more closely. 20-30% of adults in our latitudes have nodes of >1 cm in the thyroid gland. In iodine deficiency areas, the percentage is up to almost 50%. The incidence of thyroid cancer is increasing across Europe and is increasingly affecting the younger population.

In Eastern Europe the incidence is ten times and in some areas even higher than the Central European figures. A distinction is made between "hot knots" with independent hormone production and "cold knots" without hormone production. Since cold nodules have a higher risk of malignant degeneration, these nodules require precise clarification, regular checks and, in many cases, an operation

First there is information about the therapy options, the surgical techniques, the planned extent of the resection and possible complications. In principle, the smallest possible resection and the maximum preservation of the thyroid gland are sought depending on the type of disease, the size and location of the pathology. The focus is on the patient and their safety. With the most modern instruments and techniques, with magnifying glasses for the safe implementation of the microsurgical procedure and with the help of neuromonitoring, in which the vocal cord nerve is shown and thus safely spared, and ICG-NIR, a new technique with which the blood flow can be monitored and thus the maintenance of the If the parathyroid body succeeds even better, the procedure can be carried out in the best possible way and the complication rate can be reduced to a minimum, namely below 1%. The operation is carried out over the smallest possible skin incision, which, however, is selected according to the situation in terms of length. The result is an excellent cosmetic result with a scar that is almost invisible after a few weeks.

Cold nodules with a diameter of >1cm, which are hypoechoic or have microcalcifications in the thyroid ultrasound, should be operated on, as well as in the case of a large, solitary nodule in an otherwise healthy thyroid is a significantly enlarged lump in a thyroid gland with otherwise many small nodes (= multinodular goiter). Furthermore, (autonomous) growth or a suspicious fine needle puncture / fine needle aspiration represent a clear indication for surgery. The (decompensated) hot lump or autonomy (which cannot be controlled by medication) means that the thyroid gland produces too much thyroid hormone in an uncontrolled manner. These circumstances also require surgical rehabilitation in order to avoid physical damage. In contrast to adults, the hot lump in children shows a significantly increased tendency to degenerate and is almost always an indication for surgery. Suspicion or confirmed carcinoma, Graves disease, goiter (enlarged thyroid gland) with compromise or compression of other surrounding organs are further important surgical indications

Table of indications:

  • Cold lump: >1cm, hypoechoic or microcalcifications in the thyroid ultrasound
  • (Autonomous) growth
  • Suspicious fine needle aspiration / fine needle aspiration
  • Large solitary nodule in an otherwise healthy thyroid
  • Significantly enlarged nodule in a multinodular goiter
  • (decompensated) hot lump or (medically uncontrollable) autonomy
  • hot knot in children
  • Suspected or confirmed carcinoma
  • Basedow's disease
  • Goiter (enlarged thyroid) with compromising or compression of other surrounding organs

Preliminary examinations

A precise anamnesis and creation of a risk profile as well as regular tactile findings, controls of thyroid values. Any tumor markers are just as important as an ultrasound of the thyroid gland and a scintigraphy. With the last-mentioned examinations, based on the sound pattern and storage behavior, it is already possible to assess fairly precisely how high the individual risk and the associated need for therapy is. If the situation is unclear, further information can be obtained through a fine needle aspiration.

  • Thyroid values ​​(TSH, fT3, fT4) including tumor markers such as calcitonin, thyroglobulin, (CEA only for medullary thyroid carcinoma)
  • Calcium level, vitamin D3 level, parathyroid hormone in the blood
  • Sonography
  • Scintigraphy
  • possibly Fine needle aspiration (FNA)
  • ENT for assessing the vocal cord function

Maximum safety thanks to the most modern instruments and techniques, magnifying glasses for safe microsurgical intervention.

Neuromonitoring

For reliable identification or reliable representation of the recurrent laryngeal nerve and the superior laryngeal nerve (vocal cord nerves). Neuromonitoring takes place either continuously (especially in technically difficult recurrence interventions) or intermittently (the most frequently used method). In the latter case, the measurement is taken before removal or for identification and after removal of the thyroid gland.

ICG-NIR

A new, revolutionary procedure consisting of a special dye and an infrared optics / infrared camera to check and document the blood flow in the epithelial cells (= parathyroid bodies) in the course of the operation or after the operation (e.g. after removal of the thyroid gland). The blood circulation is essential for the function of the parathyroid gland. If the blood flow is no longer guaranteed, the parathyroid body in question must be histologically confirmed as such by the pathologist and then transplanted into a well-perfused area - usually in the sternocleidomastoid muscle—so that the epithelial body can grow again there and resume its function .

Cosmetics

The operation is carried out using the smallest possible skin incision, which, however, is selected to be appropriate to the situation in terms of length. The result is an excellent cosmetic result with a scar that is almost invisible after a few weeks.

Operationsschritte

Nach Markierung vor der Operation zusammen mit der Patientin/dem Patienten Zugang durch einen kleinen Hautschnitt in einer Hautfalte, Durchtrennen des subcutanen Fettgewebes, stumpfe Präparation und Mobilisation unter Schonung der präplatysmalen Venen. Inzision der geraden Halsmuskulatur entlang der Raphe. Darstellen der Schilddrüse. Präparation des oberen Schilddrüsenpols und fakultative Darstellung des oberen Stimmbandnervs (nervus laryngeus superior). Dokumentation der Funktion durch das Neuromonitoring. Schilddrüsennahes Präparieren und Unterbindung der Blutgefäße des oberen Schilddrüsenpols. Darstellung und Schonung des oberen Nebenschilddrüsenköperchens. Die Durchblutung desselben wird mit einem speziellen Farbstoff ICG und mit Hilfe einer Infrarotkamera dokumentiert (siehe oben). Falls die Durchblutung des Nebenschilddrüsenkörperchens als nicht ausreichend eingestuft wird, wird nach histologischem Verifizieren das Nebenschilddrüsenkörperchen zum Erhalt der Funktion in den benachbarten Muskel Sternocleidomastoideus „autotransplantiert“. Nun Unterbinden der unteren Schilddrüsenarterie und analoges Vorgehen im Bereich des unteren Schilddrüsenpols. Nun wird der eigentliche Stimmbandnerv (nervus laryngeus recurrens) dargestellt und die Funktion vor und nach der Entfernung des Schilddrüsenlappens mit Hilfe des Neuromonitorings dokumentiert. Das Lymphfettgewebe im Bereich des Stimmbandnerven wird fakultativ mitreseziert und als eigenes Präparat an den Pathologen gesandt. Je nach Ausmaß der Resektion wird nun weiter der Schilddrüsenlappen von der Luftröhre unter striktem Erhalt des unteren Stimmbandnerven – dokumentiert durch das Neuromonitoring – abgelöst, der Isthmus der Schilddrüse (die Verbindung zwischen rechtem und linkem Schilddrüsenlappen) und der Lobus pyramidalis, der sich als embryonales Relikt nach oben in Richtung Zunge erstreckt, präpariert und entfernt. Bei diesem Arbeitsschritt werden fakultativ das Lymphfettgewebe vor dem Kehlkopf und vor der Luftröhre entfernt und als getrenntes Präparat an den Pathologen gesandt. Das entfernte Stück der Schilddrüse wird nun zum Schnellschnitt geschickt, um ein Schilddrüsenkarzinom auszuschließen. Je nach Befund ist die Operation hiermit beendet oder, im Falle eines Karzinoms, muss zusätzlich auch der kontralaterale Schilddrüsenlappen entfernt werden und je nach Art und Größe des Tumors Lymphknoten aus der zentral jugulären Gruppe oder im Extremfall sogar Lymphknoten anderer, entfernterer Stationen mitreseziert werden. Der Wundverschluss verläuft fast immer ohne Drainage und die Haut wird geklebt, um ein ideales kosmetisches Ergebnis zu erzielen.

After the operation

12h monitoring gives the patient maximum security. Determination of calcium (Ca) and parathyroid hormone takes place after the operation and 24 hours later. The controls are continued depending on the extent of the resection and the values. In the event of low calcium values ​​and/or calcium-dependent symptoms such as tingling or cramps, calcium and calcitriol substitution is initiated immediately. On the 1st postoperative day, an ENT assessment is carried out to check the function of the vocal cords. Soft food and sips of cool drinks on the 1st and 2nd day after the operation have proven to be effective. After that there are no restrictions on nutrition. The discharge takes place on the 2nd to 3rd postoperative day.

Complications:

In very rare cases; in 90% the symptoms regenerate within 6 months.

  1. Injury to the vocal cord nerve: temporary 2-4% or permanent recurrent palsy 0.2%; The main symptom is hoarseness
  2. Very rare bleeding—less than 1%
  3. Underfunction of the parathyroid gland bodies (hypoparathyroidism): in the vast majority of cases temporary around 20%, very rarely permanent underfunction < 1%