When is revision surgery indicated after thyroidectomy?

Updated: May 08, 2018
  • Author: Neerav Goyal, MD, MPH; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

In patients who initially had a hemithyroidectomy for a follicular adenoma seen on fine-needle aspiration, a chance exists that the surgical specimen pathology will yield a follicular adenocarcinoma. Additionally, with the prevalence of subtotal thyroidectomy until the 1970s, a population of patients may need reoperative thyroidectomy for recurrent benign or malignant conditions. Additionally, patients may need revision thyroid surgery if they present with paratracheal, central compartment, or lateral neck nodes. One of the significant challenges presented by a reoperative or revision surgery is the scarring present from the prior violation of the neck. [34]

For patients needing completion thyroidectomy, some surgeons advocate for early intervention within 5-7 days after the first operation, before significant inflammation and scarring occur in the surgical bed. Others argue that the surgery should occur 2-3 months later when induration in the area is reduced.

A preoperative evaluation including imaging and reviewing previous operative reports can help with surgical planning. Ultrasound can help localize recurrent disease or suspicious masses, while a CT scan or MRI can give better delineation of surgical planes. As mentioned before, the use of CT scanning with contrast should be discussed with the multidisciplinary team if radioactive iodine may be used postoperatively. If significant scarring exists, one can consider using a trap door technique, in which dissection is carried from the lateral border of the thyroid medially to the central compartment.

The parathyroid glands as well as the recurrent laryngeal nerves are especially at risk during revision thyroid surgery. Care should be taken to not avulse the vasculature of the parathyroids, and the inferior thyroid artery branches should be ligated one by one and not together to avoid injuring the branches supplying the parathyroids. Additionally, the surgeon should be prepared to autoimplant parathyroid tissue should an avulsion occur. [35, 34]


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