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How long is thyroid or parathyroid surgery?
What does it entail?

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This depends on the skill of the thyroid surgeon, the type of surgery being performed, and the severity of the disease. In the hands of experienced surgeons like Dr. Brady, a thyroid lobectomy (partial thyroid removal) typically takes about 45 minutes to one hour. A total thyroidectomy can take about 45 minutes to 90 minutes depending on the degree of difficulty of the operation and whether lymph nodes are removed at the same time. Minimally invasive parathyroidectomy (MIP) is shorter, usually lasting only about 20 minutes if the diseased gland is localized or slightly longer if Dr. Brady needs to visualize and evaluate all 4 glands. At times, parathyroid surgeries can last longer, especially for reoperations or if the diseased gland is not in the suspected location. All of these surgeries require a general anesthetic, meaning that a patient is given a sedative to put them to sleep. A breathing tube is placed by an anesthesiologist, who monitors the patient throughout the procedure. Patients typically spend 1-2 hours in the recovery room and then will be either discharged home or admitted overnight to the hospital. The great majority of patients undergoing a partial thyroid removal or parathyroid surgery do not have to stay in the hospital overnight. If a patient has a total thyroidectomy, Dr. Brady will determine whether they require a hospital stay. Many patients having a total thyroidectomy have been able to go home on the same day as surgery, therefore avoiding an overnight hospital stay.

What is a minimally invasive radioguided parathyroidectomy or MIRP?

This type of parathyroid surgery involves an injection with a radioactive substance called sestamibi (radioisotope technetium-99m) by the radiology department before surgery. The sestamibi tracer will be taken up quickly by the thyroid and parathyroid glands. Over time, the thyroid loses or clears the tracer before the parathyroid glands. If a patient has an enlarged parathyroid gland, it will hold onto the sestamibi even longer and therefore can be picked up by a probe in the operating room. Once the enlarged parathyroid is removed, Dr. Brady or Dr. Sabra can get a count (or level) of radioactivity compared to background tissue. It can help thyroid surgeons detect locations of parathyroid lesions that may be hard to find. For example, if a patient requires a reoperation for a failed parathyroid surgery or if the parathyroid gland is found to be ectopic (not in its normal anatomic location), this type of procedure is extremely helpful. Dr. Brady and Dr. Sabra, who specialize in thyroid and parathyroid operations, use this type of injection selectively as it is may not be needed in straightforward cases where the adenoma is seen well on parathyroid scan prior to surgery. It can carry an added cost to the patient and their procedure.

Is thyroid surgery painful?

Neck surgery in general is considered to be minimally painful. That being said, Dr. Brady or injects local anesthesia for every patient to ensure adequate pain control after thyroid and parathyroid surgery. They also prescribe pain and nausea medications to use at home as needed. Additionally, it is fine to take Tylenol, Motrin, or ibuprofen postoperatively to improve comfort and decrease inflammation.

What are the risks?

There are 2 main risks of thyroid and parathyroid surgery that a surgeon should discuss with any patient that is preparing for a thyroid or parathyroid operation.

The risk of permanent recurrent laryngeal nerve injury is approximately 1% in the hands of experienced thyroid or parathyroid surgeons like Dr. Brady. This type of injury causes hoarseness of the voice and can be temporary or permanent. Temporary hoarseness occurs about 20% of the time and takes anywhere from a few days to several months to resolve completely. There is also a risk of injury to the external branch of the superior laryngeal nerve that can result in loss of tone in the voice or inability to yell or sing. Dr. Brady Dr. Sabra uses a nerve monitoring system to identify, protect, and evaluate these nerves during every thyroid and parathyroid operation.

Another risk of thyroid surgery is injury to or inadvertent removal of normal parathyroid glands. In the hands of an experienced thyroid or parathyroid surgeon, that risk is about 2% or less. The parathyroid glands control calcium metabolism in the body, which can lead to problems with muscle contraction. This type of complication can be temporary or permanent. If this occurs, patients can become hypocalcemic (low blood calcium levels) and may require daily calcium supplements.

To an inexperienced surgeon, parathyroid glands can be very difficult to differentiate from the surrounding tissue. The way the parathyroid gland feels to touch and looks under magnification is critical in differentiating parathyroid tissue from its surrounding tissue. This is where Dr. Brady's years of experience and expertise become critical to the success of the operation. Having done hundreds of thyroid and parathyroid surgeries over the past 15 years in practice in Austin, Texas have given them the ability to identify subtle differences between parathyroid tissue and its surrounding tissues, such as fat or lymph nodes. They also routinely takes the specimen to the pathology department and look under the microscope with the pathologist to ensure adequate and successful surgery is done. Normal parathyroid glands must be preserved and not removed as inadvertent removal can require life-long daily calcium supplementation.

How long will my incision or scar be? And how do I protect it after surgery?

For the majority of Dr. Brady’s surgeries, they prefer the minimally invasive approach. Dr. Brady takes their patients’ surgeries very seriously, and on occasion, she teams up with Dr. Jennifer Walden, a renowned plastic surgeon in Austin, Texas. Thyroid and parathyroid surgery should never be compromised by the incision length. At times, depending on the size of the thyroid or parathyroid, they may have to enlarge the incision slightly to perform safe surgery. Their standard thyroid lobectomy or complete thyroidectomy incision is 4 cm or less. That is less than 2 inches. The incision for minimally invasive parathyroidectomy is 2 cm or less, smaller than 1 inch. Dr. Brady ALWAYS hides the incision in a natural skin fold of the neck so that the scar is barely visible once it is healed. They have performed a number of reoperations on the neck in patients with disease recurrence after unsuccessful surgery performed by other parathyroid doctors. They will typically use the same incision site and revise it to improve patient’s cosmetic outcome.

For the first 24-48 hours after surgery, ice packs are recommended to the neck wound and limitation of heavy lifting or exercise for about 5 days. Our patients may resume normal daily activity the day after surgery if there are no issues. We allow our patients to shower the next day and get the wound wet. If the patient has steri-strips (white strips) placed on the wound, these usually stay in place until the postoperative visit with me at about 10-14 days. We will remove these strips at that visit. Some patients have Dermabond (surgical glue) placed on the wound and this will usually stay on for 2-3 weeks. After the postoperative visit, we recommend daily sunscreen application to the wound every morning for 6 months. Zinc oxide is preferred. The other option is to avoid sun exposure, but many find that nearly impossible in the beautiful city of Austin, Texas! In the evening, a scar prevention cream (such as Mederma or any generic equivalent) can be applied to prevent further scar formation. We also recommend daily multi-vitamins as they will assist with wound healing and scar prevention.

How will my life change after surgery?

Patients do very well after thyroid surgery and usually don’t need to take thyroid hormone unless the entire thyroid gland is removed. Usually a patient has their thyroid function checked several weeks after the operation to ensure that the remaining thyroid is producing adequate amounts of thyroid hormone for the body. Depending on their thyroid levels and how they are feeling, patients may need extra thyroid hormone. In our experience, patients that are followed by their physicians regularly do not experience any weight gain or other symptoms of hypothyroidism (low thyroid). If a patient has complete removal of the thyroid gland, they will be required to take a thyroid pill everyday to maintain their metabolism. Those diagnosed with thyroid cancer typically have excellent long-term survivals rates of 97-98%.

Will I need radioactive iodine treatment after my thyroid surgery?

Thyroid cancer is primarily treated with surgery. At times, radioactive iodine is needed after a thyroid operation. Most times, an endocrinologist and the thyroid surgeon determine whether a patient needs radioactive iodine by evaluation of the pathology report. Radioactive iodine can be recommended for certain patients depending on the size of the thyroid tumor or if the patient has extensive disease involving lymph nodes or growth beyond the thyroid gland. This treatment is given in a pill form several weeks after thyroid surgery and does require specific protocols on administration. Radioactive iodine will kill any remaining microscopic thyroid cells in the body that might be remaining.

Will I need an oncologist or chemotherapy if I am diagnosed with thyroid cancer?

An oncologist is not necessary with a diagnosis of thyroid cancer and this type of caner is not sensitive to chemotherapy. Typically an endocrinologist and an endocrine surgeon follow a thyroid cancer patient over the long term. They will see the patient regularly and obtain thyroid ultrasounds and blood work to make sure the thyroid cancer has not recurred or come back. One blood test they follow is a thyroglobulin level (a test for thyroid tissue present in the body.) After a complete thyroidectomy and lymph node excision, the thyroglobulin level should be zero since there is no longer thyroid tissue in the body. If the number increases, the thyroid surgeon or endocrinologist will obtain a thyroid ultrasound and thyroid scan to look in the body for where the thyroid tissue or cancer has come back. If it comes back in lymph nodes in the lateral neck (most common scenario), the patient will need a lateral neck dissection and Dr. Brady, local thyroid and parathyroid surgeon in the Austin area, can perform this surgery to remove the lymph nodes in this area.

What is laryngoscopy? When would a thyroid patient need it?

Laryngoscopy is a procedure where a doctor inserts a scope into the patient’s nose and advances it into the back of the throat to visualize the vocal cords. This can be done in the office or the operating room. Dr. Brady does not believe every thyroid patient needs a direct laryngoscopy and they only recommend this procedure to certain thyroid patients as it is an added cost and can be uncomfortable for the patient. The patients that would need laryngoscopy are those that have had prior thyroid, parathyroid or other neck surgery. Also, patients that have recent hoarseness from enlarging thyroid nodules or an aggressive thyroid cancer need laryngoscopy. Recent data out of Japan was presented at the American Association of Endocrine Surgeons meeting in 2014 demonstrating that ultrasound can be used to visualize the cords accurately and without any added cost or discomfort to the patient. This can be done when a thyroid patient is seeing Dr. Brady for the first time in the office.

What labs will be important to order?

Dr. Brady will order certain lab levels on every thyroid and parathyroid patient. The reason for this is that these patients commonly have problems with both organs. They feel that if they have problems with both, these can both be addressed in the same operation. The labs that they check routinely are calcium levels, parathyroid hormone (PTH) level, thyroid stimulating hormone (TSH) level, free T4 (thyroxine) level, and a vitamin D level.

Is it important to follow up after a diagnosis of thyroid cancer?

If a patient is diagnosed with thyroid cancer, long-term surveillance is essential. Patients with thyroid cancer are typically followed at least yearly with ultrasounds, thyroglobulin, and thyroid stimulating hormone (TSH) levels. The main treatment for thyroid cancer is SURGERY, but sometimes a patient will require radioactive iodine to burn tiny thyroid cancer cells that might still be present in the body. This radiation treatment is actually offered in a pill that the patient swallows. After the entire thyroid and lymph nodes nearby are removed, a patient must be on thyroid replacement hormone for life to maintain their normal metabolism. The goal of this medical therapy for thyroid cancer patients is to keep the TSH very low or suppressed so that the thyroid cancer does not return or keep the few cancer cells that may be still in the body from growing or dividing. We follow thyroglobulin levels as a marker for possible thyroid cancer recurrence.

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