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ORIGINAL ARTICLE
Year : 2016  |  Volume : 35  |  Issue : 4  |  Page : 445-448

Intracapsular total thyroidectomy: no more complications in benign thyroid diseases


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission15-Jun-2016
Date of Acceptance25-Jun-2016
Date of Web Publication28-Nov-2016

Correspondence Address:
Tarek M Rageh
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1121.194726

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  Abstract 


Introduction There is ongoing debate on the operative management strategies for benign thyroid diseases in terms of safety and efficacy.
Aim This study was conducted to evaluate the results of a new intracapsular thyroidectomy technique in the management of benign thyroid diseases.
Patients and methods This is a prospective study carried out in Department of General Surgery, Menoufia University Hospital, from May 2014 to March 2016 on 50 patients with benign thyroid disease who were treated with a new surgical procedure: intracapsular total thyroidectomy.
Results Fifty patients underwent intracapsular total thyroidectomy. There was no patient with transient or permanent recurrent laryngeal nerve injury and no complication of external laryngeal nerve injury. There was no complication of hypoparathyroidism with decreased operative time and hospital stay either.
Conclusion Intracapsular thyroidectomy is an effective and safe procedure for benign thyroid diseases and can be performed easily by junior staff.

Keywords: benign thyroid disease, intracapsular total thyroidectomy, intracapsular thyroidectomy complication


How to cite this article:
Rageh TM, El Gammal AS, Elsisi A, Gaber A. Intracapsular total thyroidectomy: no more complications in benign thyroid diseases. Egypt J Surg 2016;35:445-8

How to cite this URL:
Rageh TM, El Gammal AS, Elsisi A, Gaber A. Intracapsular total thyroidectomy: no more complications in benign thyroid diseases. Egypt J Surg [serial online] 2016 [cited 2020 Jun 4];35:445-8. Available from: http://www.ejs.eg.net/text.asp?2016/35/4/445/194726




  Introduction Top


Goiter is a common benign endocrine disease with an incidence of 5–12% in the female population and 2–5% in the male population [1]. Surgery is one of the main lines of treatment for goiter, and the procedures traditionally performed are total, near total, and subtotal extracapsular thyroidectomy [2]. The aim of surgical treatment in nonmalignant thyroid diseases should be to treat the disease with a low complication rate and to decrease the incidence of recurrence because the risk for permanent complications have been found to be higher in reoperations for recurrent disease than in primary cases [3]. There is increasing demand towards more radical excision instead of a subtotal resection for nonmalignant goiter [4]. However, Muller et al. [5] reported that the rates of complications associated with total extracapsular thyroidectomy are 0.9% for recurrent nerve palsy 0.9% for hypocalcemia, 0.9% for wound infection, and 0.6% for secondary hemorrhage. Several authors have reported that total thyroidectomy can be performed safely for the management of bilateral nonmalignant goiter but complications still occurred even with a meticulous surgical technique [6],[7].

Aim

The aim of this study was to evaluate the surgical outcome of intracapsular thyroidectomy as regards safety, efficacy, and postoperative complications in the management of benign thyroid diseases.


  Patients and methods Top


This is a prospective study carried out in Department of General Surgery, Menoufia University Hospital, from May 2014 to March 2016 on 50 patients with thyroid swelling who underwent intracapsular total thyroidectomy. Each patient provided his/her written consent to participate in the study. The Faculty of Medicine Ethics Committee approved this study.

Inclusion criteria

  1. Presence of primary toxic goiter after recurrence or failure of medical treatment.
  2. Presence of secondary toxic goiter.
  3. Presence of simple multinodular goiter.


Exclusion criteria

  1. Presence of clinically and preoperative biopsy-based evidence of malignant goiter.
  2. Presence of thyroiditis.
  3. Presence of recurrent thyroid disease.


Preoperative investigations

  1. Routine tests for fitness of patient.
  2. Thyroid function tests: free T3, free T4, and TSH.
  3. Thyroid imaging: thyroid ultrasound and thyroid scan.
  4. Pathological assessment: fine needle aspiration cytology (FNAC) when needed.
  5. Preoperative calcium level and indirect laryngoscopy in all patients.


Operative technique

After proper positioning and sterilization of the patient, a collar incision was made in the lower anterior neck, and after dissecting the subhyoid muscles the thyroid gland was exposed. Delivery of the thyroid lobe and ligation of the middle thyroid vein was executed. The upper pole of the thyroid (medial and lateral) was mobilized, with ligation of the superior thyroid vessels inside the capsule of the thyroid. Ligation of the inferior thyroid veins at the lower pole was also performed. A longitudinal incision was made in an avascular area of the lower part of the thyroid capsule on the middle to distal part of the gland ([Figure 1]). This longitudinal incision was extended with a pair of fine scissors until the whole thyroid capsule was opened ([Figure 2]). The incised thyroid capsule was reflected off the gland with tissue forceps and the thyroid tissue was then gently moved away from the inside aspect of the thyroid capsule with a sterile tissue peanut, leaving the thyroid capsule intact ([Figure 3]). The inferior thyroid artery was ligated from the inner aspect of the thyroid capsule with no attempt at searching for or identification of the recurrent laryngeal nerve (RLN) from the outer aspect ([Figure 4]). No attempt was made to identify and preserve the parathyroid glands on each side of the thyroid lobe; we preserve them with intact blood supply ([Figure 5] and [Figure 6]). A drain was left in each case and was removed on the third postoperative day, provided that the drainage volume was less than 50 ml/day.
Figure 1 A longitudinal incision is made in an avascular area of the lower part of the thyroid capsule on the middle to the distal part of the gland.

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Figure 2 This longitudinal incision is extended with a fine scissors until the whole thyroid capsule is opened.

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Figure 3 The incised thyroid capsule is reflected off the gland.

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Figure 4 Intracapsular ligation of the inferior thyroid artery.

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Figure 5 Total gland excised with remnant part of the thyroid capsule.

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Figure 6 Final thyroid specimen.

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  Results Top


This study included 50 patients with benign thyroid disease who were candidates for surgical interference. Intracapsular thyroidectomy was performed in all patients. The mean age of the patients studied was 28.8±10.2 years (range: 18–50 years). Thirty patients (60%) were women and 20 (40%) were men. Controlled primary toxic goiter was found in 10 (20%) patients, secondary toxic goiter in 15 (30%) patients, and simple multinodular goiter in 25 (50%) patients ([Table 1]). Wound complication − that is mild seroma formation − was seen in two (4%) patients in the subcutaneous plane, which recovered within 2 weeks. No patients experienced a change in voice (low pitched or hoarseness) (no external laryngeal nerve or RLN palsy) and no patients developed manifestations of hypocalcemia (hypoparathyroidism) ([Table 2]). The volume of blood loss was 100±40 ml. The operative time was 60±15 min ([Table 3]), and the length of hospital stay was 1±0.045 days ([Table 4]).
Table 1 Personal characteristics of the studied group (N=50)

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Table 2 Type of goiter in the studied group (N=50)

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Table 3 Operative complications in the studied group (N=50)

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Table 4 Mean±SD of blood loss, operative time, and hospital stay in the studied group (N=50)

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  Discussion Top


Thyroid surgery in recent years is generally considered quite safe owing to better preoperative preparation and proper surgical techniques that keep complications at a minimum (<2–3%) [8]. The traditional technique of bilateral thyroidectomy in benign thyroid disease is still the extracapsular maneuver with its variations and a large spectrum of complications according to the experience of the surgeon.

In this study, no patient developed a complication of RLN injury. The nerve lesion varies from irreversible persistent complication to transient dysfunction with good prognosis of complete recovery from several weeks to 2 years [9],[10]. Centers in which both total thyroidectomy and subtotal resection are performed only by experienced endocrine surgeons report rates of RLN palsy that range from 0.5 to 1% [11]. Another study revealed a higher rate of RLN palsy of up to 2.3% after total thyroidectomy [12]. This difference was due to the absence of postoperative RLN palsy on using our new intracapsular technique, which could be attributed to the complete excision of the glandular part from the inside of the capsule without any dissection in the outer surface of the capsule, especially in the lower part where the inferior thyroid artery and its branches are close to the RLN. Thus, intracapsular thyroidectomy can prevent nerve injury and this technique can be performed by junior staff who perform thyroidectomy occasionally.

Further, in our study no patients developed a complication of transient hypocalcemia or permanent chronic hyperparathyroidism. The risk for permanent hypoparathyroidism after any type of procedure is difficult to estimate from the available data, but a risk of about 9–10% should be expected after total thyroidectomy [12],[13], even though lower values of 0.5% have been reported in specialized centers [11]. Trupka and Sienel [14] reported that after thyroidectomy for large multinodular goiter, temporary hypocalcemia requiring calcium replacement occurred in 20% of patients. This usually occurs about 36 h postoperatively. Only up to 3% of patients remained permanently hypocalcemic [14]. This occurred during extracapsular thyroidectomy because of the different anatomical location of the parathyroid glands, which are particularly vulnerable to injury with extracapsular dissection, and due to exposure of the thyroid arteries and its branches as both parathyroid glands derive their blood supply from branches of this artery, which is prevented during intracapsular thyroidectomy with no incidence of parathyroid injury.

The operative time was 60±15 min with our intracapsular thyroidectomy technique. In a German multicenter study, total thyroidectomy took an average of 150 min [10]. This considerable difference in operative time was due to the fact that no time was lost in searching for or identification of the inferior thyroid artery, RLN, and parathyroid glands. Further, the length of hospital stay was 1±0.45 days, and in the study by Dener [15] the length of hospital stay was 2±0.13 days. Patients with an uncomplicated postoperative course can usually be discharged 1 or 2 days after surgery [16]. One point that may be raised against intracapsular thyroidectomy is the rare case where the specimen proves malignant. There will be a need for redo to remove the capsule left behind. The difficulty and outcome in such cases need to be addressed in further studies.


  Conclusion Top


Intracapsular thyroidectomy is an effective and safe method for the management of benign thyroid disease and an excellent alternative technique for total thyroidectomy that can be performed by junior staff.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Guraya SY, Al-Zobydi AH. Total and near-total thyroidectomy is better than sub total thyroidectomy for the treatment of bilateral benign multi-nodular goiter; a prospective analysis. Br J Med Med Res 2011; 1:1–6.  Back to cited text no. 1
    
2.
Ozbas S, Kocak S, Aydintug S, Cakmak A, Demirkiran MA, Wishart GC. Comparison of the complications of subtotal, near total and total thyroidectomy in the surgical management of multinodular goitre. Endocr J 2005; 52:199–205.  Back to cited text no. 2
    
3.
Harrison BJ, Maddox PR, Smitth DM. Disorders of the thyroid gland. In Cuschieri A, Steele RJ, Moosa AR, eds. Essential surgical practice. Vol. 2. 4th ed. London: Arnold; 2002. 95–110  Back to cited text no. 3
    
4.
Citqez B, Uludaq M, Yetkin C, Yuer E, Akgum I, Isqn A. Changes in choice of thyroidectomy for benign thyroid disease. Surg Today 2013; 43:625–631.  Back to cited text no. 4
    
5.
Muller PE, Kabus S, Robens E, Spelsberg F. Indications, risks, and acceptance of total thyroidectomy for multinodular benign goiter. Surg Today 2001; 31:958–962.  Back to cited text no. 5
    
6.
Friguglietti CU, Lin CS, Kulcsar MA. Total thyroidectomy for benign thyroid disease. Laryngoscope 2003; 113:1820–1826.  Back to cited text no. 6
    
7.
Bron LP, O’Brien CJ. Total thyroidectomy for clinically benign disease of the thyroid gland. Br J Surg 2004; 91:569–574.  Back to cited text no. 7
    
8.
Savargaonkar AP. Post-thyroidectomy haematoma causing total airway obstruction − a case report. Indian J Anaesth 2004; 48:483–485.  Back to cited text no. 8
    
9.
Jamski J, Jamska A, Graca M, Barczynski M, Wlodyka J. Recurrent laryngeal nerve injury following thyroid surgery. Przegl Lek 2004; 61:13–16.  Back to cited text no. 9
    
10.
Otto RA, Cochran CS. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation in predicting postoperative nerve paralysis. Ann Otol Rhinol Laryngol. 2002; 111:1005–1007.  Back to cited text no. 10
    
11.
Barczynski M, Konturek A, Hubalewski-Dydejczyk A, Golkowski F, Cichon S, Nowak W. Five-year follow up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter. World J Surg 2010; 34:1203–1213.  Back to cited text no. 11
    
12.
Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surgery. 2003; 133:180–185.  Back to cited text no. 12
    
13.
Unalp HR, Erbil Y, Akguner T, Kamer E, Derici H, Issever H. Does near total thyroidectomy offer advantage over total thyroidectomy in terms of postoperative hypocalcemia? Int J Surg 2008; 7:120–125.  Back to cited text no. 13
    
14.
Trupka A, Sienel W. Autotransplantation of atleast one parathyroid gland during thyroidectomy in benign thyroid disease minimizes the risk of permanent hypoparathyroidism. Zentralbl Chir 2002; 127:439–442.  Back to cited text no. 14
    
15.
Dener C. Complication rates after operations for benign thyroid disease. Acta Otolaryngol 2002; 122:679–683.  Back to cited text no. 15
    
16.
Diener MK, Seiler CM, von Frankenberg M, Rendel K, Schüle S, Maschuw K et al. Vascular clips versus ligatures in thyroid surgery-results of a multicenter randomized controlled trial (CLIVIT Trial). Langenbecks Arch Surg 2012; 397:1117–1126.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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