Selection of a thyroid operation balances the underlying diagnosis, preservation of thyroid function, recurrence risk, and risks to the recurrent laryngeal nerve and parathyroid glands.
Factors guiding procedure selection
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Consider the preoperative diagnosis, when known, and the risks of thyroid failure, recurrent laryngeal nerve injury, recurrence, and hypoparathyroidism.
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The underlying condition—including Graves’ disease, multinodular goitre, or differentiated thyroid cancer—also influences the choice of operation.
Extent of resection and thyroid function
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Total and near-total thyroidectomy leave insufficient tissue for normal thyroid function, so thyroid replacement therapy is necessary.
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In two-thirds of patients with negative antithyroid antibodies, one thyroid lobe maintains normal function.
Remnant growth and repeat surgery
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Subtotal resection for colloid goitre or Graves’ disease carries a risk of later growth of the remnant. A second operation years later greatly increases the risk to the recurrent laryngeal nerve and parathyroid glands.
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Total thyroidectomy should be considered in young patients.
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Leaving the least affected lobe untouched may be preferable to subtotal resections because it permits a straightforward lobectomy later if required.
Surgical balance in Graves’ disease
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Preserving large remnants increases the risk of recurrent toxicity. Removing too much thyroid tissue is therefore preferable to removing too little.
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Thyroid failure should not be regarded as treatment failure, whereas recurrent toxicity is.