There are several reasons to refer an individual for thyroid surgery. These include thyroid nodules that may be cancerous, known thyroid cancer, a compressive thyroid goiter causing pressure symptoms, and hyperthyroidism that has become difficult to control medically. Whether the reason is thyroid cancer, goiter, or a thyroid nodule, many people referred for thyroidectomy have questions about the technique of thyroidectomy and risks involved with the procedure. Also, given the highly visible location of the thyroid gland, many are interested in minimally invasive thyroidectomy techniques. This page is intended to help to provide some general information about thyroid surgery, with specific attention to minimally invasive thyroidectomy techniques.

Anatomy: The thyroid gland is located in the central neck just below the larynx (or voice box). While it is often divided into right and left when discussing tumors and surgery, it is only one gland and each side is more accurately described as a “lobe”. The gland is firmly attached to the trachea (wind pipe) and moves up and down with the trachea whenever you swallow. That’s why thyroid goiters can sometimes cause difficulty when people eat or drink.

Goal of Surgery: Whatever the diagnosis, the goal of thyroid surgery is to remove a portion or all of the thyroid gland in the safest, least traumatic manner possible. Because the central neck contains many important structures, thyroid surgery is especially challenging. The recurrent laryngeal nerve (RLN) and the parathyroid glands, which lie behind the thyroid gland, must be preserved to avoid problems with voice and blood calcium levels postoperatively. In cases of cancer, the lymph nodes of the central neck must be removed to ensure that no cancer is left behind. The following are issues commonly brought up by patients when choosing a thyroid surgeon:

The Incision: Because the central neck is usually exposed and extremely visible, many people ask about minimally invasive thyroid surgery. Naturally, incision length is the first thing that comes to mind when considering minimally invasive surgery. Generally, a 1 to 1.5 inch incision is adequate to remove a normal sized thyroid gland. Keep in mind, however, that the gland has to ultimately fit through the incision to come out. Longer incisions will be needed for large goiters or if excessive neck dissection is needed in cases where cancer has spread to nearby lymph nodes. Fortunately, this is not the case for the majority of thyroid operations and the 1.5 inch incision rule will apply to most. If incision length is important to you, don’t hesitate to ask you surgeon about this specifically. If available, seeing some examples of postoperative scars in the surgeon’s picture gallery is a good way to get an idea of what to expect.

A note about postoperative pictures:  If you end up comparing picture galleries, make sure that multiple skin types and age groups are represented. That’s important because younger, smoother skin makes hiding an incision more difficult. As we mature, skin laxity and natural tension lines (wrinkles) develop which make hiding even relatively large incision quite easy. When evaluating pictures, you want to make sure to see at least a few examples of incisions in younger individuals because these are more difficult to hide and will give you a better sense of the technique and results. Feel free to visit our picture gallery to see some examples of minimally invasive thyroid surgery performed through incisions around 1.5 inches.   We have taken care to include pictures of people in all age groups.

The Recurrent Laryngeal Nerve (RLN): While a common goal of minimally invasive surgery is to keep incisions small and local trauma to a minimum, the most important goal is to remove all diseased tissue while keeping vital structures intact. The RLN, which is responsible for movement of the vocal cords, lies very close to the thyroid gland. All surgeons agree that keeping the nerve intact during thyroidectomy is one of the most important goals of the operation. Two techniques are utilized when it comes to preserving the nerve:

Nerve identification technique: Many surgeons start the major part of the dissection by first identifying the nerve and tracing its course into the voice box where it innervates the vocal cord muscle. This way, the nerve can be kept in view and out of harms way as the gland is removed and surrounding tissues are cauterized and cut.

Nerve avoidance technique: Some surgeons prefer to remove the gland without first identifying the nerve.  The hope is that if the general area of the nerve is avoided, it won’t be damaged. Many would consider this approach too risky, since abnormal growths and enlarged lymph nodes can push the nerve into areas where you don’t normally expect it. 

Currently, most academic centers and the majority of surgeons advocate the first approach. The thinking is that if you have identified the nerve, the chances of accidentally damaging it are minimized. However, because both techniques are utilized you will have to decide which of these approaches you feel more comfortable with. Once you make that decision, you can ask your surgeon which technique they employ.  Dr. Amini's preference is to always identify the nerve along its entire course in the neck first.

Recurrent laryngeal nerve monitoring is a new technology that allows the surgeon to monitor for stimulation of the RLN. This may make identifying the nerve easier and can help reduce the risk of accidental injury. While beneficial as a tool, especially in revision cases and in cases of advanced cancer, its not considered an alternative to finding the nerve visually which most surgeons still advocate. Dr. Amini routinely uses RLN monitoring during difficult thyroidectomy cases.

Neck Dissection: When thyroid surgery is being performed for thyroid cancer, neck dissection is always considered. A central neck dissection, which involves removing the nodes surrounding the thyroid gland, has become common practice in treating thyroid cancer, particularly in cases of advanced disease or if an aggressive tumor is suspected. The need for neck dissection will be discussed with you during your preoperative interview. You should be prepared to ask about the factors that would make neck dissection necessary in your particular case. In cases where neck dissection is considered, it again becomes important to identifying and save the recurrent laryngeal nerve and the parathyroid glands because the majority of lymph nodes that are removed surround these structures.