Chapter 1. Thyroidectomy and Neck Dissection

Thyroid Lobectomy

• Unilateral toxic nodule.
• Solitary adenoma or cyst.

Total Thyroidectomy

• Thyroid carcinoma.
• Graves' disease.
• Hashimoto thyroiditis.
• Multinodular goiter.
• Substernal goiter.

Neck Dissection

• Locally advanced head and neck carcinoma demonstrated by presence of nodal disease clinically, by preoperative imaging, or by sentinel node biopsy.

• Few contraindications exist for thyroidectomy or neck dissection.

Absolute (Neck Dissection)

• Randomly scattered dermal metastases precluding a full-thickness dissection.
• Intracranial extension of tumor from the neck.
• Tumor fixation to the skull base or the cervical spine.

Relative (Neck Dissection)

• Tumor fixation to the internal carotid artery.
• Locally advanced disease in the root of the neck.
• Periosteal invasion of the skull base.

• The patient should be supine.
• Airway management is of particular concern. Preoperative anesthesiology consultation should alleviate positioning concerns while ensuring proper airway safety during the procedure.
• A towel roll can be placed beneath the shoulder blades to facilitate neck extension.
• Arms may be tucked.

• For benign thyroid disease, thyroid hormone replacement is initiated if total thyroidectomy has been performed.
• For malignant disease, thyroid hormone replacement is deferred until after postoperative radioactive iodine scan.
• Postoperative calcium levels are monitored and calcium replacement is given empirically.
• Pain control should be initiated with intravenous agents initially; once swallowing is adequate, the patient can be transitioned to oral narcotics.
• Diet should be advanced progressively.
• Drains should be inspected for lymphatic leak, and patients instructed on drain care.
• Drains should be removed once output decreases to 30 mL or less per day.

• Nerve injury: spinal accessory nerve; recurrent laryngeal nerve injury (if central neck dissection is included in the procedure); brachial plexus.
• Vascular injury: internal jugular vein; carotid artery causing neck hematoma, which could potentially progress to airway compromise.
• Thoracic duct injury leading to lymphatic leak, possibly requiring operative intervention and thoracic duct ligation.
• Tracheal injury.
• Esophageal injury.
• Local disease recurrence.