Hemithyroidectomy

Hemithyroidectomy surgery

A unilateral lobectomy (synonymous: hemithyroidectomy) is a surgical operation where one of the two lobes of the thyroid gland is amputated as well as the isthmus. It is usually conducted on benign nodules of the thyroid, suspicious thyroid nodules and some forms of thyroid cancers.

Indications of Hemithyroidectomy

Hemithyroidectomy is indicated in cases where:

• Distant nodule of thyroid (benign or indeterminate)
• Recurring thyroid cysts post aspiration.
• Indeterminate FNAC / follicular neoplasm.
• Low-risk papillary thyroid carcinoma (<14cm no spread to lymph node)
• Unilateral goitre
• Thyroid adenoma
• Hyperfunctional rather than adenoma.
• One-sided enlargement Cosmetic deformity.

Benefits of Hemithyroidectomy

• Reduced chances of complications compared to total thyroidectomy.
• On the undisturbed side, parathyroid glands were stored.
• Reduced risk of thyroid hormone life-long replacement.
• Apposite to unilateral disease.

Hemithyroidectomy procedure steps

The following are step-by-step steps of Hemithyroidectomy procedure:

Preoperative Preparation

• Manifestation of the patient (thyroid functionality tests, ultrasound, FNAC).
• Fitness clearance of anaesthesia.
• Incision line marked in a natural crease on the neck.
• General anaesthesia is conducted.

Patient Positioning

• On the operating table in superman.
• Shoulder roll to neck extended (Rose/Lloyd-Davis position) position.
• The head was immobilized to reveal the thyroid area.

Skin Incision

• It is a horizontal collar incision (Kocher incision), 2 cm above the sternal notch.
• The skin and subcutaneous tissue to the platysma muscle are dissected.

Exposure of the Thyroid

• The platysma is divided.
• Higher and lower skin flaps are elevated.
• Between strap muscles midline (linea alba) is broken.
• Strap muscles are pulled to the sides exposing the thyroid lobe.

Mobilization of Thyroid Lobe

• The thyroid lobe affected is carefully removed and presented into the field.
• Middle thyroid vein is recognized and clamped.
• The ligature of superior pole vessels is done near the thyroid to safeguard the external branch of the superior laryngeal nerve.

Recognition and protection of Important Structures

• Recurrent laryngeal nerve (RLN) is recognized and spared.
• Operative side parathyroid glands are marked and even spared.
• There is maintenance of hemostasis.

Inferior Pole Vessels Ligation

• Branches of the inferior thyroid arteries are clamped near the gland in order to spare parathyroid blood flow.
• The inferior section of the thyroid gland is moved around.

Isthmus Division

• The fissure that unites the two lobes is split.
• The trachea is totally detached out of the affected lobe.

Removal of Thyroid Lobe

• The whole thyroid lobe + isthmus are excised.
• Sample to be sent to histopathology lab.

Hemostasis & Irrigation

• Operative field examined regarding bleeding.
• Hemostasis done by ligatures/electrocautery.

Closure

• A drain can be instituted when necessary (not routine).
• Strap muscles approximated.
• Platysma closed.
• Skin sewn using absorbable sutures or cosmetic skin sewn.

Postoperative Recovery

Patient monitored for:

• Migration of airway or swelling of neck.
• Voice changes
• Symptoms associated with calcium (infrequent in hemithyroidectomy)
• Normal expected discharge is in 24-48 hours.

Hemithyroidectomy for thyroid cancer

• Hemithyroidectomy is a resection of one of the thyroid lobes + the isthmus.
• It is utilized in thyroid cancer in the select low-risk cases that do not require total removal of the thyroid.

When is Hemithyroidectomy recommended in Thyroid Cancer?

Hemithyroidectomy is found to be sufficient and secure in the following cancers:

Papillary Thyroid Carcinoma (PTC) -Low Risk

• Tumor ≤4 cm
• Localized to a single lobe (no extrathyroidal enlargement).
• No lymph node involvement (N0)
• No distant metastasis
• None of the aggressive forms (e.g., tall-cell, diffuse sclerizing types)

Follicular Thyroid Carcinoma (FTC) -Minimally Invasive

• Tumor 1–4 cm
• Limited capsular invasion
• None of vascular invasion, metastasis.

Papillary Microcarcinoma

• Tumor <1 cm
• No multifocality

Why hemithyroidectomy is the best treatment for thyroid cancer?

Benefits:

• Reduced complication rates as compared to total thyroidectomy.

→ Reduced nerve damage and hypocalcemia risks.

• Remnant lobes tend to secrete sufficient hormones.

→ Large number of patients shun life time thyroid medication.

• Reduced length of surgery, recovery and cost.
• Sufficient cancer treatment in well-identified patients.

Cancer Control Outcomes:

• Low-risk cases Survival and recurrence rates are equal to total thyroidectomy.

Hemithyroidectomy Surgical Steps (Cancer-Specific Focus)

• General anaesthesia
• Kocher neck incision (collar incision)
• Exposure by platysma and contraction of strap muscles.
• The recurrent laryngeal nerve should be identified carefully.
• Maintaining parathyroid glands.
• Superior and inferior thyroid ligation.
• Movement of the involved lobe.
• Isthmus division
• Excision of the whole lobe to do histopathology.
• Lymph node inspection (in case of any suspicion, biopsy or removal can be performed)
• Closure

Post-Surgical (Cancer-Specific) considerations

Histopathology Review

The final cancer pathology ascertains:

• Indication of total thyroidectomy.
• Radioactive iodine (RAI) requirement.
• Prognosis

Thyroid Hormone Therapy

• Lifelong thyroid hormone is not necessary to many patients.
• Others are put on low dose levothyroxine to keep down the TSH to a certain degree.

Follow-Up

• Ultrasound at 6–12 months
• Thyroglobulin observation (Restricted application due to one lobe remaining)
• Frequent physical check-up.

Hemithyroidectomy recovery time

The following is a precise and much systematized description of Hemithyroidectomy Recovery Time:

Overall Recovery Timeline

• Hospital stay: 24–48 hours
• Go back to normal day life: 5-7 days.
• Return to work: 7–10 days
• Full internal healing: 2–3 weeks
• Scar healing: 2-3 months (decays with time)

It has been found that most patients heal rapidly compared to those who undergo complete thyroidectomy due to the fact that one only one lobe is removed.

Day-by-Day Recovery Timeline

Day 1–2:

• Slight pain and discomfort in the neck.
• Sore throat from intubation.
• Limited swelling in incision.
• Can eat and walk normally.
• Voice can be a bit weak or rough (generally but not always temporary).

Day 3–7:

• Pain significantly reduces.
• Capable of resuming normal activities.
• Light movement helps in the neck stiffness.
• Steri-strips or bandage most often removed.

Week 2:

• Stitches are dissolved or removed (non-absorbable).
• Majority of people are intimate with the normal.
• Is able to resume normal work and some exercise.

Week 3:

• Internal healing is primarily accomplished.
• Neck mobility nearly normal.

Long-Term Recovery

Voice:

• The transient hoarseness can be days to weeks.
• Change in permanent voice is not common.

Thyroid Function:

• A significant number of patients have normal levels of thyroid hormones.
• Others (about 20-30 percent) might get mild hypothyroidism and require medication.

Scar Healing:

• Redness in the beginning of the course disappears after 2-3 months.
• Scar cream or silicone gel enhances looks.

Hemithyroidectomy complications

Hemithyroidectomy (removal of one thyroid lobe + isthmus) is usually associated with few complications as opposed to total thyroidectomy, but has certain risks as well.

Mild and Temporary Complications (Usually)

Pain and Neck Discomfort

• Light to moderate pain in the incision point.
• Neck stiffness for 3–7 days.

Temporary Voice Changes

• Voice weakness, hoarkeness or fatigue.
• Typically as a result of irritation of the recurrent laryngeal nerve (RLN) or swelling.
• Recovers in days to weeks.

Sore Throat

• Due to intubation of the anesthesia.
• Improves within 48–72 hours.

Less Common Complications

Bleeding / Hematoma

• The blood gathers beneath the skin.
• Typically on the first 24 hours.
• Indicates the need of immediate assessment in case the neck swelling becomes bigger.

Seroma

• Under incision fluid build-up.
• May need aspiration should be large.

Wound Infection (Rare)

• Mild erythema, drainage or pain.
• Managed with antibiotics.

Particular Complications of the Thyroid

Laryngeal Nerve Injury (recurrent)

• Temporary paralysis: 1–3%
• Permanent paralysis: <1%

Effects:

• Hoarseness
• Breathiness
• Voice fatigue

Superior Varyngeal Nerve Injury

• Problem with striking high voices.
• More evident among singers or voice professionals.

Hormonal Complications

Hypothyroidism (Low Thyroid Hormone)

• Although there is still one lobe, 20-30 percent might acquire low functioning of the thyroid.

The manifestation of symptoms may occur in weeks-months:

• Fatigue
• Weight gain
• Cold intolerance
• May need levothyroxine.

Hyperthyroidism (Rare)

• Uncommon post operating overactivity of left hemisphere.

Uncommon yet Severe Complications

Airway Obstruction

• As a result of excessive bleeding or swelling.
• Life threatening yet very low.

Hypocalcemia (Very rare with hemithyroidectomy)

• As one side of the parathyroid glands can only be touched, there are very low risks.
• Tingling or cramps in case it happens.

Long-Term Complications

Visible Scar

• Normally, short, because of cut in natural crease.
• May require scar therapy in case of hypertrophy.

Repeat of Thyroid Disease (In case there are remnants left behind)

• May be in case of nodules or cancer surgery.
• Follow-up ultrasound was required over the long-term.

Conclusion

Hemithyroidectomy is an effective and safe surgical technique in the treatment of a unilateral thyroid disorder such as benign nodules, cysts, and select low risk thyroid cancer. It is a better option because the thyroid is removed in only one lobe thus thereby producing amazing results with minimal complications as compared to total thyroidectomy most of the time its removal will not lead to impaired thyroid functions. The recovery process is normally fast with the majority of patients back to normal activity within the week. Hemithyroidectomy offers long-term outcomes and high quality of life when done with sound surgical procedure, sparing of nerves and parathyroid glands and with follow-up.

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FAQ

1. Is hemithyroidectomy safe?

• Yes. It is regarded as a safe operation with the reduced risk of complication in comparison with complete thyroidectomy since only one of them is excised.

2. Will I require thyroid hormone medication postoperative?

• Not always. Approximately 70-80 percent of patients retain normal thyroid functioning with the spare lobe. Approximately 20-30 percent might require levothyroxine in the future.

3. Will my voice change?

• A weak voice or temporary hoarseness is usually experienced in few days or weeks. Changes in permanent voice are infrequent.

4. Is thyroid cancer satisfactorily treated by hemithyroidectomy only?

• Yes, small follicular cancers, small tumors that are confined to a single lobe and low-risk papillary thyroid cancer. Cancerous conditions of high risk might necessitate complete thyroidectomy.

5. Would I have a scar following hemithyroidectomy?

• Yes, but the cut is made in a crease of the neck, which means that the scar will be quite small and will not show on a cosmetic. It broadens tremendously with time.

6. Will the removal of one lobe affect the level of calcium?

• Unlikely. Since the sources of parathyroid glands that are left are not affected, hypocalcemia is extremely uncommon following hemithyroidectomy.