Evidence - Total thyroidectomy for benign multinodular goiter on both sides.

Thyroid Surgery: Paradigm Shift in Surgical Strategy and Change in Resection Procedure Over the Last 30 Years

In the last 30 years, the surgical strategy in thyroid surgery has changed significantly. The reasons are a new endocrine understanding of the various forms of thyroid disease, advances in morphological, functional, and immunological diagnostics, and also the development of surgical techniques that have led to a reduction in procedure-specific complications (28).

For benign goiter, subtotal resection was long considered the standard procedure, where a "thumb-sized" remnant of thyroid tissue was left in situ. A subtle depiction of the vocal cord nerve and the parathyroid glands did not seem necessary, and the resection line was at a safe distance from these structures. Complications such as recurrent laryngeal nerve palsy and postoperative hypoparathyroidism were largely believed to be avoidable.

However, subtotal resections have high recurrence rates of up to 40%, making the need for more radical resections apparent, which inevitably led to the development of modern surgical techniques with visualization of the vocal cord nerve and parathyroid glands to avoid a high rate of serious complications (1, 3).

In addition to perfecting nerve preparation techniques, improved diagnostics of thyroid diseases have taught that (almost) total thyroid removal is often required for definitive cure. In multinodular goiter, the thyroid is often entirely nodular, so no healthy tissue can be left in situ. In Graves' disease, the entire thyroid tissue is subject to increased stimulation, so remaining tissue often leads to renewed hyperfunction.

In thyroid carcinoma, total removal soon became the standard procedure, inherently requiring subtle preparation of the vocal cord nerve and parathyroid glands, often performed using microsurgical techniques.

The trend towards more radical resection forms is shown by Dralle, University Clinic Halle an der Saale, where the proportion of total lobe resections for benign goiter increased from 20 to 70% within 13 years from the mid-1990s (20).

The immediate consequence of increasingly radical primary interventions is the declining number of reoperation cases, which can be seen as confirmation of the paradigm shift.

Intraoperative Neuromonitoring (IONM)

Intraoperative neuromonitoring in thyroid surgery is a reliable tool for locating the recurrent laryngeal nerve (RLN). When performed correctly, the intraoperative functional testing of the nerve shows good agreement with the vocal cord function controlled postoperatively by laryngoscopy. The negative predictive value (unremarkable nerve stimulation = no recurrent laryngeal nerve palsy) is between 92 and 100%, and the positive predictive value (prediction of recurrent laryngeal nerve palsy) is between 35 and 92%. Neuromonitoring increases the identification rate and preservation of the nerve, thus enabling the required radicality (total instead of subtotal resection), improves preparatory safety in challenging situations (carcinoma, recurrence), and allows guideline-compliant surgery.

Since the introduction of intraoperative neuromonitoring, the frequency of recurrent laryngeal nerve palsy in thyroid surgery has declined. An evidence-based improvement was only noted in reoperation cases, where the rate of permanent recurrent laryngeal nerve palsy has decreased from 6.6 to 2.2% over the past 15 years. In primary interventions, the complication rate regarding recurrent laryngeal nerve injury is now very low due to the consistent visualization of the RLN per se.

Literature: 3, 4, 12, 21, 29, 30, 47

Outpatient Thyroid Surgery

In the era of shortened postoperative hospital stays, there are also approaches in thyroid surgery to perform procedures on an outpatient basis. Regarding the procedure-specific complication "bleeding," the data does not support "one-day surgery."

Most bleedings occur within the first 6 hours after the procedure. Burkey (5) reports that 19% of patients showed the first signs of bleeding only after 24 hours, Sonner (44) describes in a prospective study that 54% of all patients in thyroid and parathyroid surgery experience nausea and vomiting more than 24 hours postoperatively and are at increased risk of bleeding during this phase. Marohn (39) and McHenry (40) also emphasize the need for surgical revisions due to bleeding beyond the 24-hour mark. Clark (13) notes that after thyroidectomies, about 25% of bleedings occur up to 24 hours and later after the procedure. Data from Dralle (22) show that in 20% of cases, bleedings occur later than 24 hours postoperatively.

Based on the data, "one-day surgery" in thyroid surgery is unsafe and not recommended.

A Multicenter, Randomized, Controlled Clinical Study on the Feasibility and Safety of Gasless Transaxillary Posterior Endoscopic and Open Thyroidectomy for Papillary Thyroid Cancer.

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The Use of Autofluorescence and Indocyanine Green to Avoid Hypocalcemia After Total Thyroidectomy: A Randomized Clinical Trial

Intraoperative Monitoring (Parathormone Values and Continuous Neuromonitoring) to Predict Postoperative Complications After Total Thyroidectomy

Effectiveness of Intraoperative Neuromonitoring to Identify and Preserve External Branch of Superior Laryngeal Nerve During Thyroid Surgery

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