Total thyroidectomy

Why are we operating?

Removing the thyroid while sparing the four glands and two nerves hiding against it: an operation defined by the structures it must not touch.

Indication: Thyroid cancer, compressive goitre, refractory thyrotoxicosis.

The operation in 4 steps

1. 01Access

   Collar incision in a skin crease, subplatysmal flaps, straps separated in the midline and the gland exposed.

   Why: The collar crease pays the cosmetic debt of neck surgery in advance; the midline is the bloodless route to a gland that bleeds from everywhere else.

2. 02Mobilisation and vessel control

   Each lobe is mobilised; superior pole vessels are taken close to the gland, middle and inferior veins as met.

   Why: Close to the gland is the rule for every tie, because everything important in this neck lives millimetres away: the external laryngeal nerve rides with the superior pole vessels, and the parathyroids draw their supply from below.

3. 03The recurrent nerve and the parathyroids

   The recurrent laryngeal nerve is identified in the tracheo-oesophageal groove and traced to the larynx; the parathyroids are found and swept off the capsule with their blood supply.

   Why: This step is the operation. The nerve is safest seen and followed, never assumed; the parathyroids' whole vascular supply hangs on threads that careless diathermy cooks. Both errors are silent on the table and loud at breakfast.

4. 04Haemostasis and closure

   The bed is checked dry through a Valsalva, layered closure follows, and the airway plan is explicit before leaving theatre.

   Why: A neck haematoma after thyroidectomy is an airway emergency measured in minutes: it obstructs by venous congestion, and the treatment is opening the wound at the bedside, which every carer of this patient must know.

Danger zones

• Recurrent laryngeal nerve

  The nerve is thread-thin, variable, and lies exactly where the gland's blood supply is ligated; traction, diathermy heat and blind clamping in a bloody field are its enemies.

Anatomy you need

The thyroid and the parathyroids behind it, the glands this operation must take and the ones it absolutely must not.

What can go wrong

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.