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SIDE EFFECTS OF ENDOCRINE TREATMENTS
Complications in thyroid resurgery: a single institutional
experience on 233 patients from a whole series of 4,752
homogeneously treated patients
M. R. Pelizzo •M. Variolo •C. Bernardi •M. Izuzquiza •A. Piotto •
G. Grassetto •P. M. Colletti •I. Merante Boschin •D. Rubello
Received: 26 December 2013 / Accepted: 21 February 2014 / Published online: 11 March 2014
ÓSpringer Science+Business Media New York 2014
Abstract The aim of this study was to examine a
homogeneous, consecutive recent series of patients who
underwent reoperation on the thyroid bed to assess the
incidence of the complications commonly correlated with
resurgery. We reviewed clinical charts of 233 patients who
underwent resurgery taken from a total of 4,752 patients
previously operated on for benign and malignant thyroid
diseases from 2006 to 2010 by the same surgical team. We
evaluated the incidence of postoperative hemorrhage,
hypoparathyroidism, and recurrent laryngeal nerve (RLN)
palsy. Analyses were done separately in relation to the type
of the type of resurgery adopted: (A) monolateral com-
pletion; (B) bilateral completion, after monolateral (B1) or
bilateral prior surgery (B2); and (C) lymph node dissection.
We also separately analyzed patients according to their
final histological diagnosis of benign or malignant disease.
Regarding hemorrhage, 6/233 patients (2.5 %) underwent
surgical revision of the thyroid within 12 h for postopera-
tive hemorrhage. They included 2 (1.5 %) of the 129
monolateral reoperations (A), 3 (4 %) of the 74 bilateral
reoperations (B), and 1 (3.3 %) of the 30 central dissec-
tions for nodal relapse (C). Transient and definitive post-
operative hypoparathyroidism was recorded in 78 (36.4 %)
and 7 (3.3 %) of the 214 eligible patients. Transient RLN
palsy occurred in 21 RLNs at risk (7 %) and definitive
RLN palsy in 5 (1.7 %). Elective total thyroidectomy
cannot always be supported as an effective policy for
preventing recurrences in patients with a single, benign
node: lobectomy, preferably with extemporaneous histo-
logical examination, unquestionably represents the best
minimal approach to thyroid resection.
Keywords Thyroid surgery Benign diseases Malignant
diseases Intraoperative complications Resurgery
Introduction
It is widely accepted that resurgery of thyroid diseases
carries a greater risk of complications than primary surgery
even when performed by skilled surgeons [1]. The term
‘‘resurgery’’ includes various procedures ranging from
minimal operations to bilateral, extensive, and complex
surgical operations including lymph node dissection. This
may give rise to misunderstandings and influence ‘‘sur-
geons’’ attitudes, perhaps causing them to opt for more
radical primary procedures that may not always be justifi-
able [1].
The aim of this study was to examine the incidence of
the complications identified in a recent consecutive
homogeneous series of patients who underwent resurgery
for thyroid diseases, and to determine which thyroid
M. R. Pelizzo M. Variolo C. Bernardi M. Izuzquiza
A. Piotto I. Merante Boschin
Surgical Clinic II, Department of Surgical, Oncological and
Gastroenterological Sciences, University of Padova, Padua, Italy
G. Grassetto D. Rubello
Nuclear Medicine Department, Santa Maria della Misericordia
Hospital, Rovigo, Italy
P. M. Colletti
Radiology Department, University of Southern California,
Los Angeles, CA, USA
D. Rubello (&)
Department of Imaging, Nuclear Medicine, Radiology,
NeuroRadiology, Medical Physics, Clinical Laboratory,
Biotechnology Laboratory, Microbiology, Pathology, Padova
University, Padua, Italy
e-mail: domenico.rubello@libero.it;
rubello.domenico@azisanrovigo.it
123
Endocrine (2014) 47:100–106
DOI 10.1007/s12020-014-0225-y
operations were more associated with complications.
Knowledge of these complications may encourage sur-
geons to reconsider their aversion to resurgery, perhaps
dispelling the opinion that total thyroidectomy should be
the surgical treatment of choice even for single, benign
nodes, and encouraging complete lobectomy as a more
appropriate initial procedure for many patients.
We considered the incidence of postoperative hemor-
rhage, hypoparathyroidism, and recurrent laryngeal nerve
(RLN) palsy in a series of 233 patients who underwent
resurgery out of a total of 4,752 patients treated surgically
for benign and malignant thyroid diseases from 2006 to
2010 by the same surgical team.
Materials and Methods
From 2006 to 2010, 4,752 procedures for thyroid diseases
were performed at the same surgical center, including
3,524 (74.2 %) total thyroidectomies, 995 (20.9 %)
lobectomies, and 233 (4.9 %) resurgery. All 4,752 opera-
tions were performed by the same leading surgeon
(P.M.R.) except for 276 patients.
We consider total thyroid lobectomy (as distinct from
nodulectomy or partial lobectomy) the total extracapsular
removal of one lobe and the isthmus, leaving behind viable
parathyroid glands and intact recurrent laryngeal and
superior laryngeal nerves. On the other hand, we consider
total thyroidectomy (as distinct from near total or subtotal
thyroidectomy) simply a matter of performing a total thy-
roid lobectomy on both sides during the same operation.
Each procedure should be performed with a specific
‘‘game plan’’ in mind, progressing in a series of logical
steps. Orderly, anatomically based steps are as follows:
exposure of the thyroid gland; dissection of the upper pole
and superior laryngeal nerve; dissection of the lateral
aspect of the thyroid lobe, preserving the recurrent lar-
yngeal nerve and parathyroid glands; and closure.
The patient is given general anesthesia and is placed in
the supine position, with arms to the side and a support is
placed transversely underneath the shoulders, thereby
extending the neck. The neck extension must not be too
extreme as it increases postoperative pain and discomfort.
The key to all successful surgery is adequate exposure.
This is especially true during thyroid surgery. After skin
preparation and draping, a collar incision is made in skin
crease approximately 2 cm above suprasternal notch. The
incision is carried through the platysma and subplatysmal
flap is elevated on both sides, superiorly and inferiorly.
Deep investing layer of fascia is divided in midline, and the
strap muscles are retracted in midline from thyroid notch to
the suprasternal notch so as to expose the thyroid gland
completely.
First of all it is useful to define the midline. The upper
border of the isthmus is dissected off the trachea by
dividing the superior suspensory ligament with any of its
vessels, and the midline is identified. If there is a pyramidal
lobe present, it is at this stage it is mobilized and divided
from the fibrous tissue of any remaining thyroglossal duct
tract. Similarly, the midline below the isthmus is defined
with division of any centrally placed inferior thyroid veins.
The thyroidea ima artery exists in approximately 3 % of
cases and may arise from the innominate artery or directly
from the aorta. If present, it should be controlled and
divided at this point.
The first major vein to be encountered at this stage is the
middle thyroid vein, which must be divided before the
lateral space is exposed. The gland is mobilized from
surrounding soft tissue, the lateral space between the thy-
roid and the carotid sheath is opened, and the thyroid lobe
is retracted medially.
Subsequently, upper pole of the thyroid gland is dis-
sected. To remove the superior pole of the thyroid safety
and completely, the overlying strap muscle is dissected off
the gland, taking care not to enter the subcapsular veins,
which may bleed profusely if lacerated. The superior pole
is gradually separated from overlying muscle, and the
space between the thyroid gland and cricothyroid muscle is
opened.
Identification and dissection of this space are greatly
assisted by traction of the thyroid in an inferior and lateral
direction; once the medial and lateral borders of the superior
pole have been mobilized, the superior pedicle is divided. To
avoid injury to external branch of superior laryngeal nerve as
it runs in Joll’s triangle medial to upper pole, the vessels of the
pedicle are ligated near the thyroid capsule. Boundaries of
Joll’s triangle are laterally upper pole of thyroid gland and
vessels, superiorly attachment of strap muscles, and deep
investing layer of fascia to thyroid cartilage, medially midline.
Its floor is cricothyroid, and the contents are external laryngeal
nerve running on cricothyroid muscle.
It is important to identify the superior parathyroid gland
in this area (about 2 % of cases) and to preserve its blood
supply before ligation of the posterior branch of the
superior thyroid artery.
The thyroid gland is now retracted medially and elevated
out of the wound. At this step, the recurrent laryngeal nerve
(RLN) must be identified and preserved. Opening the cervical
median strip, the RLN is looked for from the mediastinum to
the larynx. To identify the RLN, it is useful to isolate and tract
by a loop the inferior thyroid artery. The inferior parathyroid
is individuated next to the inferior thyroid artery and it is
preserved. The RLN is encountered in this region deeping the
tubercle of Zuckerkandl which may be considered an allow
pointing to the RLN, a constant anatomical landmark used to
locate the RLN. The tubercle of Zuckerkandl is present in all
Endocrine (2014) 47:100–106 101
123
thyroid glands and is represented as a thickening where the
ultimobranchial body fuses into the principal median thyroid
process.
When enlarged, it may develop into a nodular process
with the RLN passing medial to it in a fissure on the lateral
tracheal surface. It is important that the plane of dissection
continues along the surface of the tubercle elevating it
progressively. The ligament of Berry and its surrounding
terminal branches of the inferior thyroid artery can then be
divided from the tracheal surface, and the gland is
removed. After attaining complete haemostasis, drain is put
and the wound is closed in layers.
Numerous innovative studies have found it more effec-
tive to use a cut-and-sew instrument such as the ultrasound
dissector in thyroid surgery, both for the purposes of
hemostasis and to contain the operating time. Using dis-
sector causes more limited surgical trauma, probably
because it bites the thyroid capsule between its jaws, unlike
the traditional sutured ligatures or placement of clips.
Resurgery
We reviewed the clinical data for all 233 patients who
underwent resurgery by the same surgeon (M.R.P.) and her
team: for 18 patients (7.7 %) this was their third operation,
and for 2 (0.8 %) it was their fourth; 165 patients (70.8 %) had
been operated for the first time at other centers. The mean time
elapsing between the previous operation and the resurgery
was 219 months (18 years and 3 months), ranging from
1 day to 47 years. Our resurgery sample included 181 females
(77.7 %) and 52 males (22.3 %), mean age =56.25 years
(range 16–83 years), and median age =58.5 years.
Histology at the time of prior surgery had showed
benign disease in 161 cases (69.1 %) and malignancies in
72 (30.9 %).
The indications for resurgery were benign disease in 121
patients (51.9 %): neck compression in 76 (62.8 %), and
refractory hyperthyroidism in 45 (37.2 %). Malignancy
was documented in 89 patients (79.5 %) and suspected in
23 (20.5 %), and was the indication for resurgery (49.1 %).
A monolateral completion lobectomy was performed in
129 patients (55.4 %), for presumed benign disease in 60
cases (46.5 %), and for suspected malignancy in 69 (53.5 %).
A bilateral completion was performed in 74 patients (31.7 %),
for presumedbenign disease in 59 (79.7 %), and for suspected
malignancy in 15 cases (20.3 %). A dissection for central
nodal relapse was performed in 30 cases (12.9 %): monolat-
erally in 21 patients (70 %) and bilaterally in 9 (30 %).
At subsequent histology, the diagnosis of malignancy
was confirmed in 113 out of 233 cases (48.5 %), which
included 11 (9.2 %) of the 121 patients preoperatively rec-
ommended for resurgery for benign disease. For 120 patients
(51.5 %), the final diagnosis was benign disease.
Nine patients were lost to follow-up. Of the 224 fol-
lowed up patients, 123 (55 %) underwent a monolateral
completion and at histology, 58 (47.1 %) of them had
benign disease while 65 (52.9 %) malignant disease; 74
(33 %) had a bilateral completion procedure—after prior
monolateral surgery in 56 cases (75.7 %) and bilateral
procedures in the other 18 (24.3 %)—59 of these patients
had benign disease and 15 had malignancies and 27 (12 %)
underwent central dissection for nodal relapse, monolat-
erally in 20 cases and bilaterally in 7.
The incidence of postoperative hemorrhage was con-
sidered in all patients, while hypoparathyroidism and RLN
palsy were assessed in the followed up patients and were
eligible according to the criteria outlined below.
Our data were analyzed after separating the cases by
surgical procedure used at resurgery as follows: (A) mono-
lateral completion; (B) bilateral completion, after monolat-
eral (B1) or bilateral prior surgery (B2); and (C) lymph node
dissection. We also divided patients according to their final
histological diagnosis of benign or malignant disease.
To assess hemorrhage, we considered all patients
needing postoperative surgical revision for hemostasis. All
233 patients were eligible for this purpose.
To assess hypoparathyroidism, we assumed that patients
with serum calcium levels below 2.10 mmol/l (normal range
2.10–2.55) on the 2nd postoperative day were considered
cases of transient hypoparathyroidism and they were pru-
dentially discharged with oral calcium and vitamin replace-
ment therapy. Cases of hypoparathyroidism were considered
definitive if they still needed this replacement therapy a year
after resurgery. For the purposes of assessing hypoparathy-
roidism, 214 (95.5 %) of the 224 patients were considered
eligible, while 10 were ruled out: 6 of these patients already
had hypoparathyroidism from their previous surgery, and 4
patients underwent parathyroidectomy for prior hyperpara-
thyroidism as part of their resurgery procedure.
RLN palsy was assessed by video laryngoscopy in the
224 followed up patients, with a total of 305 nerves at
risk, 4 of which were not considered because of a docu-
mented monolateral palsy prior to resurgery due to their
previous surgical treatment. Finally, RLN palsy was con-
sidered on 301 nerves at risk (98.7 %) and it was defined to
be transient or definitive, depending on whether it had
regressed or persisted at 1-year follow-up.
Results
Postoperative hemorrhage (based on 233 patients)
Six of the 233 patients (2.5 %) underwent surgical revision
of the thyroid within 12 h for postoperative hemorrhage.
They included 2 (1.5 %) of the 129 monolateral
102 Endocrine (2014) 47:100–106
123
reoperations (A), 3 (4 %) of the 74 bilateral reoperations
(B), and 1 (3.3 %) of the 30 central dissections for nodal
relapse (C) (Table 1). Correlated with histology, these
cases of postoperative hemorrhage were 5 of the 120
patients (4.2 %) who underwent reoperation for benign
disease, and 1 of the 113 (0.9 %) who had resurgery for
malignancies.
Postoperative hypoparathyroidism (based on 214
patients)
Transient and definitive postoperative hypoparathyroidism
were recorded in 78 (36.4 %) and 7 (3.3 %) of the 214
eligible patients, respectively, in particular in 39 (32.5 %)
and 2 cases (1.7 %) in Group A (120 monolateral com-
pletions), 35 (48.6 %) and 4 (5.5 %) in Group B (72
bilateral completions), and 4 (18.2 %) and 1 (4.5 %) in
Group C (22 lymph node dissection). In Group B, 24
(43.6 %) and 3 patients (5.5 %) in group B1, and 11
(64.7 %) and 1 (5.9 %) in group B2 experienced transient
and definitive hypoparathyroidism, respectively (Table 2).
Correlated with histology showed that 45 (39.8 %) and 4
(3.5 %) of the 113 patients who underwent resurgery for
benign disease, and 33 (32.7 %) and 3 (3 %) of the 101
patients underwent resurgery for malignancies suffered
from transient and definitive postoperative hypoparathy-
roidism, respectively (Table 2).
Postoperative recurrent nerve injury (based on 301
nerves at risk)
RLN function was analyzed for the 301 RLNs at risk: 123
after monolateral resurgery (group A), 145 after bilateral
resurgery (group B), and 33 after lymph node dissection
(group C).
Transient RLN palsy occurred in 21 RLNs at risk (7 %)
and definitive RLN palsy in 5 (1.7 %).
Transient and definitive RLN palsy were diagnosed,
respectively, in 6 (4.9 %) and 1 (0.8 %) patients in Group
A, 14 (9.6 %) and 4 (2.7 %) in Group B [8 (7.2 %) and 1
(0.9 %) in Group B1 and 6 (17.1 %) and 3 (8.6 %) in
Group B2], and 1 (3 %) and 0 in group C (Table 3). Cor-
related to histology, the cases of transient and definitive
RLN palsy, respectively, involved 15 (8.7 %) and 3
Table 1 Incidence of postoperative hemorrhage in 233 patients
Number of patients Total 233 Group A 129 Group B 74 Group C 30 Benignancies 120 Malignancies 113
Postoperative hemorrhage 6 (2.5 %) 2 (1.5 %) 3 (4 %)
2 (3.6 %) (B1)
1 (5.5 %) (B2)
1 (3.3 %) 5 (4.2 %) 1 (0.9 %)
Table 2 Incidence of postoperative hypoparathyroidism in 214 patients
Number of patients Total 214 Group A 120 Group B 72 Group C 22 Benignancies 113 Malignancies 101
Transient hypoparathyroidism 78 (36.6 %) 39 (32.5 %) 35 (48.6 %)
24 (43.6 %) (B1)
11 (64.7 %) (B2)
4 (18.2 %) 45 (39 %) 33 (32.7 %)
Definitive hypoparathyroidism 7 (3.4 %) 2 (1.7 %) 4 (5.5 %)
3 (5.5 %) (B1)
1 (5.9 %) (B2)
1 (4.5 %) 4 (3.5 %) 3 (3 %)
Table 3 Incidence of RLN palsy in 301 nerves at risk
Nerves at risk Total 301 Group A 123 Group B 145 Group C33 Benignancies 173 Malignancies 128
Transient RLN palsy 21 (7 %) 6 (4.9 %) 14 (9.6 %)
8 (7.2 %) (B1)
6 (17.1 %) (B2)
1 (3 %) 15 (8.7 %) 6 (4.7 %)
Definitive RLN palsy 5 (1.7 %) 1 (0.8 %) 4 (2.7 %)
1 (0.9 %) (B1)
3 (8.6 %) (B2)
0 (0 %) 3 (1.7 %) 2 (1.6 %)
Endocrine (2014) 47:100–106 103
123
(1.7 %) of the 173 RLNs at risk in patients who had res-
urgery for benign disease, and 6 (4.7 %) and 2 (1.6 %) of
the 128 RLNs at risk in patients reoperated for malignan-
cies (Table 3).
Discussion
Theodor Kocher, surgeon and Nobel laureate, has influ-
enced thyroid surgery all over the world. He reduced
mortality in thyroid surgery not only with the hemostats
bearing his name, but also thanks to his realization that
bilateral preservation of thyroid tissue prevents cachexia,
parathyroid tetany, and bilateral recurrent nerve paralysis
[2]. On the other hand, the high recurrence rates after
subtotal thyroidectomy with the need for resurgery and the
high incidence of complications have reversed the surgical
trend in favor of a more radical approach, i.e., total thy-
roidectomy as the treatment of choice at primary surgery,
even for single and benign nodes. Total thyroidectomy is
not without complications [1,2], but allows to avoid res-
urgery in the majority of cases, therefore, reducing the total
number of complications and the psychological aversion of
patients toward a second-neck operation.
In literature, the incidence of transient hypoparathy-
roidism after reoperation has been reported to range from
0.6 [2]to39%[3], and the incidence of permanent
hypoparathyroidism between 0 [4] and 7.6 % [3].
Similarly, the incidence of transient RLN palsy after
reoperation has been reported to range from 0 [5,6]to
22.2 % [7], and the rates of definitive RLN palsy after
resurgery has been reported to range between 0 [4–6,8]
and 17.8 % [7].
The nodular goiter covers a spectrum from the unino-
dular or multinodular goiter to cysts and follicular lesions.
The principal problem in nodular goiter is to decide if the
surgical treatment is necessary and in these cases to indi-
vidualize the principal alternative therapies other than
surgery.
131-I therapy in toxic nodular goiter and percutaneous
ethanol injection therapy (PEIT) in toxic nodule or cystic
lesion are the principal alternative therapies in case of
failure of the pharmacological treatment. Except the cystic
lesion and the autonomous adenoma in which the preop-
erative diagnosis may conclude for benignity, in multino-
dular goiter the preoperative diagnosis could not be
conclusive. US and fine needle aspiration cytology (FNAC)
permit to avoid surgical treatment in case of the absence of
symptoms of compression or of hyperthyroidism.
In case of surgical treatment, the next question regards
the extension of surgery. At surgery, the frozen section
analysis in case of hemithyroidectomy is of aid to rule out
malignancy and to prevent the reoperation. The surgical
treatment of choice in case of uninodular goiter is lobec-
tomy, total thyroidectomy, or near total thyroidectomy is
the correct treatment of bilateral goiter.
The follicular lesion (FL) or Hurthle cell neoplasm
carries a 20–30 % risk of malignancy. FNAC cannot be
diagnostic in FL because specific criteria are required for
the diagnosis of follicular carcinoma particularly the
unequivocal demonstration of capsular penetration and
vascular invasion. Many molecular markers such as
Galectin-3, BRAF, and RAS have been evaluated to
improve diagnostic accuracy; however, hemithyroidectomy
is generally accepted as the minimum procedure for diag-
nosing follicular thyroid nodules. The principal reason is
the need to remove the lesion with the capsule intact as the
final diagnosis of cancer relies on careful examination of
the entire capsule for vascular or capsular invasion.
Another reason is that hemithyroidectomy allows safer
subsequent completion thyroidectomy without the need to
explore the ipsilateral operative bed. In order to avoid
reoperation, many authors suggest total thyroidectomy as
the treatment of choice, whereas other authors recommend
hemithyroidectomy as the treatment of choice with thyroid
totalization in case of diagnosis of cancer at histology
examination.
In a study conducted in 1999 on 203 thyroid resurgery
procedures out of 4,433 thyroid operations, Menegaux et al.
[9] reportedthat 90.2 % of their patients undergoing resurgery
came from other centers. Similarly, in our series, 70 % of
patients who need resurgery have had primary operation in
other centers. The incidence of transient hypoparathyroidism
was 36.6 %, a figure consistent with the report from Calo
`et al.
[3], who found an incidence of 39.1 % among 92 patients
undergoing resurgery, and with the data by Pironi et al. [10],
who reported an incidence of 47.3 % in 76 patients who
needed resurgery. In our series, the only statistically signifi-
cant difference in the rates of transient hypoparathyroidism
emerged when comparing the group of patients who had
bilateral reoperations (B) (48.7 % in B1 and 64.7 % in B2)
with those who were treated by monolateral reoperations
(A) (32.5 %) (p\0.05 at Fisher’s exact test). Moreover,
patients with transient hypoparathyroidism rapidly improved
during the following 1-2 months after resurgery, and only
3.4 % of them experienced definitive hypoparathyroidism;
this percentage was much higher after bilateral totalization
(Group B) than after monolateral totalization (group A) (5.5
vs. 1.7 %), though the difference was not statistically signif-
icant (p=N.S.). In our sample, transient hypoparathyroidism
was not increased in patients reoperated for nodal metastases
(group C) as reported by other authors [6,7,11,12]. More-
over, we did not observe a significant difference of transient
hypoparathyroidism comparing patients who underwent res-
urgery for malignant or benign thyroid disease (3.5 vs. 3 %,
respectively, p=N.S.).
104 Endocrine (2014) 47:100–106
123
RLN palsy in our series was transient in 7 % of cases
and definitive in 1.7 %. The incidence of transient RLN
injury showed a significant influence of the type of disease
(8.7 vs. 4.7 % of cases for benign vs. malignant disease,
p=0.04), but this difference was not correlated with the
cases of definitive RLN palsy (1.7 vs 1.6 %, respectively,
p=N.S.). Regarding the 5 cases of definitive RLN palsy,
4 (2.7 %) were observed in patients who underwent bilat-
eral reoperation (group B). In light of these data, it can be
speculated that bilateral resurgery is a risk factor for RLN
palsy and that total thyroidectomy ‘‘ab initio’’ may be
preferable to avoid this complication [13–17].
From the histological point of view, the rate of inci-
dental carcinoma in our series was 9.9 %, comparable with
the figures reported by other authors, 13 % [3], 11.4 % [9],
7.6 % [18], 9.3 % [19], and 15.6 % [20].
We recorded a postoperative hematoma compression
incidence of 2.5 %, similar to the data reported by Me-
negaux et al. [9] in 1999, i.e., 2.5 %. In our experience, this
complication occurred significantly more in bilateral res-
urgery (3.6 and 5.5 % for Groups B1 and B2, respectively)
than in the other patients’ groups. Similar data were
reported by other authors (ranging from 0.4 to 1.6 % [12,
21,22].
Calabro
`et al. [4] in 1988 reported 12.1 % of transient
hypocalcemia and 1.5 % of transient RLN palsy in a series
of 66 who had been first treated by lobectomy and who had
undergone prompt contralateral totalization (within
3 months from the first operation) because of postoperative
histopathological diagnosis of carcinoma. It is important to
note that all these patients underwent contralateral resur-
gery; this is in line with our data, that is that thyroid sur-
geon’s main goal should be to prevent the need for any
bilateral reoperation as first approach because resurgery in
this case is associated with a greater number of severe
complications. We also support Calabro
`’s suggestion to
prompt reoperate if necessary (diagnosis at definitive his-
topathology of malignancy), and to avoid the formation of
scars in the operated tissues which determined a greater
percentage of complications at resurgery.
Also, in the experience of Menegaux et al. who reop-
erated 203 patients for a benign thyroid disease derived
from a whole series of 4,433 patients recruited during a
8-years period, the authors observed that the highest inci-
dence of RLN palsy occurred in patients in whom primary
surgery involved both thyroid lobes rather than lobectomy
alone (prevalence of RLN palsy was 6.0 vs. 2.2 %,
respectively).
In 2007, Lefevre et al. [12] compared 685 cases of
resurgery for benign or malignant recurrent diseases (taken
from a total of 9,017 operations performed over a 14-year
period) with 5,104 primary total thyroidectomies; the
authors reported that factors associated to complications in
resurgery were (a) the presence of hyperthyroidism, (b) the
weight of the resected gland, and (c) the primary surgery
performed in both thyroid lobes.
In a recent large study by Vasica et al. [23] a whole
series of 12,354 thyroid surgical procedures collected
during a two decades period (from 1987 to 2009), the
factors involved in thyroid complications at resurgery were
investigated in a group of 528 patients. The author reported
a higher incidence of transient (4.2 vs. 2 %, respectively)
and definitive RLN impairment (1.6 vs. 0.5 %, respec-
tively) in the group of patients who had primary treated by
received bilateral lobectomy in comparison to the group of
patients who had been treated by primary thyroidectomy.
On the other hand, the authors did not find significant
difference between the two groups in terms of the inci-
dence of transient and permanent hypoparathyroidism.
Finally, it is worth noting that non-surgical approaches
have been proposed to cure nodular goiter [24,25]
Lobectomy thus represents the standard surgical
approach to benign monolateral thyroid disease. It poses a
risk to only one recurrent laryngeal nerve, and is unlikely
to cause hypoparathyroidism [4,9,24], so replacement
therapy may be avoided. In addition, should resurgery
prove necessary, it will carry much more limited morbid-
ity—irrespective of the disease involved.
Reoperation may also be facilitated by the contribution
of improvements in technique, refined over years of
experience; for instance, the ultrasound dissector has an
important role in helping to preserve parathyroid glands
situated in a ‘‘high’’ position, close to the thyroid capsule.
Lateral neck access, as described by Pelizzo et al. in
1993, represents a valid strategy that affords direct access
to the thyroid bed laterally to the pre-thyroid muscles,
thereby avoiding the wall of adhesions deriving from the
previous medial access [25]. Then, the inferior thyroid
artery can be identified and bound medially with an elastic
band to the vessel-nerve bundle lying up against the car-
otid. Traction on the artery makes it easier to identify the
recurrent laryngeal nerve that crosses over it; this ma-
noeuver is useful for subtending and tracking the nerve,
especially if follows a pre-vascular course. It is always
wise to begin bilateral totalization procedures from the
dominant or suspect side because then, if surgeons have
any doubts intra-operatively about whether the RLN is
intact on the most heavily involved side, they can defer
contralateral completion, pending the histology report, and
an assessment of cord motility.
Elective total thyroidectomy cannot always be supported
as an effective policy for preventing recurrences in patients
with a single, benign node; lobectomy is safer and has the
advantage of placing only one RLN at risk and inducing no
hypoparathyroidism, and therefore, possibly avoiding the
need for replacement therapy.
Endocrine (2014) 47:100–106 105
123
Immediate or metachronous thyroid resurgery is signif-
icantly less challenging if the previous operation involved a
standard lobectomy. Should resurgery prove necessary, a
contralateral totalization alone carries no greater risk than
the primary procedure, again risking only one RLN and
with the advantage of knowing whether or not the contra-
lateral nerve is intact.
As confirmed by the results reported here, the incidence
of complications in patients who undergo monolateral to-
talization after standard lobectomy for benign or malignant
disease is substantially the same of patients treated by
primary total thyroidectomy—meaning that the latter is not
always be indicated. In the event of bilateral totalization,
procedures that only involve one side (contralateral to a
prior lobectomy) carry a lower risk of complications than
bilateral completion thyroidectomies. The same consider-
ation can be made for monolateral versus bilateral central
lymph node dissection.
In conclusion, lobectomy, preferably associated with
extemporaneous histological examination, represents the
best minimal approach to thyroid resection.
Conflict of interest None.
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