Struma resection
The goiter resection (also known as a partial goiter resection and "goiter operation" ) is an operation to treat an enlarged thyroid gland in which the thyroid gland is removed except for a remnant of different sizes. After the first descriptions of the surgical technique most frequently used today, it is also referred to in full as "bilateral subtotal goiter resection according to Enderlen-Hotz". Occasionally in use, but factually incorrect, is the term strumectomy , since an ectomy is the removal of a complete organ. The complete removal of the entire thyroid gland is called a thyroidectomy (synonym: total extirpation of the thyroid gland ), and the complete removal of one half of the thyroid is called a hemithyroidectomy .
indication
The goiter resection is used in diffuse and nodular struma , as well as in Graves' disease .
The diffuse goiter can generally be treated conservatively at first. Here, iodide , L-thyroxine, or any combination whereby the used of the two substances, TSH production of the pituitary gland ( the hypophysis ) is throttled. The indication for surgery is made if, despite conservative therapy, the goiter increases in size, which leads to subjective complaints such as tightness, difficulty swallowing or even constriction ( stenosis ) of the trachea with impaired breathing ( stridor ). The appearance of lumps in a known diffuse goiter leads to the indication for surgery. The development of hyperfunction ( hyperthyroidism ) with originally normal hormone production ( euthyroidism ) is also an indication for surgery.
More details on conservative treatment in the main article goiter .
In nodular goiter , the size, number and location of the nodules determine whether a goiter resection is sufficient or whether a thyroidectomy is indicated. This occurs when the nodular changes are so extensive that not only healthy thyroid tissue can be left behind.
In many cases, a complete resection ( hemithyroidectomy ) is performed on one side and a subtotal resection on the other. This operation is called the Dunhill operation after it was first described .
In exceptional cases, if a single ( solitary ) cyst or adenoma is present, the resection can be omitted and the nodule can be enucleated using a narrow seam of healthy thyroid tissue.
In certain cases, radioiodine therapy can be considered as an alternative therapy method. If there is a choice between surgery and radioiodine therapy, the following arguments speak for the operation: suspected malignancy ( malignancy ), overactive thyroid gland caused by iodine ( hyperthyroidism ), pregnancy and breastfeeding , active eye involvement in Graves' disease ( endocrine orbitopathy ), signs of compression of the neighboring structures ( Trachea : stridor , esophagus : pronounced swallowing disorder , neck vessels: upper congestion ), larger cold areas of the thyroid or fear of radioactivity in the patient . The following arguments speak against radioiodine therapy: If the thyroid has already been operated on or if there is already (unilateral) paralysis of the vocal cord nerve ( recurrent palsy ), in older patients or with severe concomitant diseases, if the thyroid is relatively small or the patient is afraid of the operation suffers. Adolescent age is no longer considered a contraindication .
For the treatment of malignant goiter, an enlargement caused by thyroid cancer , goiter resection is only conditionally suitable; thyroidectomy is carried out regularly here . If a residual thyroid gland of less than 5 ml is left and a malignant nodule is found in the removed part of the thyroid gland that has been completely removed in the healthy part, then the residual thyroidectomy can be omitted and radioiodine therapy can be continued.
Preliminary examinations
The examinations leading to the indication for surgery are described in the main articles Examination of the Thyroid Gland and Goiter .
The general pre-operative examinations include the clinical physical examination with measurement of blood pressure and pulse , the X-ray examination of the lungs and the organs of the chest ( thorax ) as well as the preparation of an EKG . A blood sample is taken to determine the blood count , electrolytes , blood clotting , kidney function and CRP (to rule out inflammation ).
The special examinations before a goiter resection include a repeated determination of the thyroid hormones as well as an examination by the ear, nose and throat doctor to assess the mobility of the vocal cords .
execution
Operating principle
First, is the isthmus , so the narrow body bridge between the two thyroid lobes, under go dull and after hemostatic suturing severed. This is followed by the presentation and targeted ligation of the upper pole vessels ( arteria thyroidea superior and its accompanying veins). The thyroid gland is then largely detached from the environment and the associated blood vessels ( arteria thyroidea inferior and the accompanying veins , especially the large, laterally branching Kocher vein) are severed after ligature. The connective tissue attachment to the windpipe (trachea) is left, the thyroid gland is opened at this point and peeled out within its capsule except for a remnant which, depending on the findings, should have a size of 1 to 5 cm³. The connective tissue capsule is closed by suturing over the rest. The opposite side then proceeds in the same way.
Elimination of pain
The anesthesia is now the standard for Strumaresektion. Until the beginning of the 1970s, the operation was also performed under local anesthesia , as there was a fear of air embolism of the lungs if a large vein was accidentally opened. The awake patient could counteract this by actively pressing. The danger is at a modern pressure ventilator with PEEP not (positive end expiratory pressure).
storage
The patient is positioned with the upper body straightened to about 30 °, the head rests tilted backwards in a bowl so that the neck is overstretched and the thyroid is easily accessible. The flat back position with a slightly hyperextended cervical spine is also common.
Access
Standard is the Kocher collar cut, a five to seven centimeter long, slightly curved cross-section about two cross fingers above the jugulum . The incision is marked on the awake patient before the operation and, if possible, placed in the course of a skin fold for cosmetic reasons. The skin and subcutaneous fatty tissue are severed and pushed up and down by the muscles. The anterior neck muscles ( sternohyoid muscle ) are divided in the midline and pushed off on both sides by the thyroid gland, which is now freely accessible. In the case of very large thyroid glands, transverse transection of the short, straight neck muscles is sometimes necessary. In extreme exceptional cases , a thyroid gland that is strongly extended retrosternally can only be triggered by means of a partial sternotomy (longitudinal division of the upper part of the breastbone).
Wound closure
Before the wound is closed, Redon drains are inserted to drain blood or wound secretions . The wound is closed in three layers : muscles and subcutaneous tissue are each closed with absorbable sutures, the skin with monofilament plastic sutures . The skin is often closed using the cosmetically favorable intracutaneous suture technique . Alternatively, adaptation plasters or tissue adhesives can also be used .
Rapid section examination
If organizationally possible, nodules that are macroscopically suspicious for carcinoma and found during resection of the goiter should be subjected to a histopathological high-speed section examination in order to immediately expand the operation to a thyroidectomy , if necessary . If this is structurally not sensible or possible (e.g. long distance to the nearest pathology ), the patient must be informed in advance about a possibly necessary second operation.
Risks
Unspecific surgical risks
Bleeding during (intraoperative) or after the operation (postoperatively) can be threatening due to the good blood flow to the thyroid gland; in the event of foreseeable difficulties (recurrent goiter), blood reserves are provided in advance .
Due to the good blood circulation, wound infection and wound expansion occur very rarely, are easy to recognize and treat, but usually leave behind very poor cosmetic results. Postoperative thromboses and pulmonary embolisms are also rare due to the rapid mobilization of the patient.
Specific operational risks
The incidence of serious complications is low for a trained surgeon and should not exceed one percent (based on recurrent palsy and hypocalcaemia).
Damage to the recurrent nerve
A complete severing of the vocal cord nerves ( recurrent laryngeal nerve ) leads to permanent paralysis of the vocal muscles ( recurrent palsy ) with persistent hoarseness. Damage caused by crushing or overstretching the nerve, etc. The like also leads to a temporary functional failure , but is mostly reversible , so it heals without special therapy. Recurrent palsy on both sides can - due to the closure of the glottis due to the lack of tension in the vocal muscles - lead to complete obstruction of the trachea with an acute risk of suffocation. This may make it necessary to create a permanent tracheostoma . The exact representation of the recurrent laryngeal nerve is therefore mandatory today according to the guideline . Neuromonitoring is therefore usually used to avoid recurrent injury .
Injury to the superior laryngeal nerve is very rare, as it is easier to avoid in terms of surgery .
Damage to the parathyroid glands
The unintentional removal of or damage to the parathyroid glands (epithelial cells, parathyroid gland), which in many cases are very difficult to identify, leads to derailment of the calcium metabolism ( hypocalcaemia ) with the consequence of tetany , which, however, is usually remedied by supplying calcium can and is not permanent ( see also hypoparathyroidism ). Epithelial cells that have been removed or cut off from the circulation are retransplanted ( autologous transplantation ) by sewing them into a muscle (e.g. sternocleidomastoid muscle ).
Special features of recurrent goiter
The resection of the goiter in a previously operated thyroid gland ( recurrence of the goiter) often presents the surgeon with a difficult task, since it is much more difficult to trigger the thyroid gland due to scarring . The anatomical conditions are often atypical: the recurrent laryngeal nerve takes an unpredictable course. The parathyroid glands can often hardly be identified. The risk of bleeding also increases due to the atypical course of the vascular supply.
For these reasons, the complication rate - related to recurrent paresis and hypocalcemia - increases tenfold in operations for recurrent goiter compared to the first operation.
Postoperative controls and follow-up care
The mobility of the vocal cords is demonstrated either by laryngoscopy directly when anesthesia is released or by checking the phonation (for this purpose the patient is simply asked to speak) in order to detect recurrent palsy immediately. If there are signs of recurrent palsy, breathing must be monitored by intensive care medicine.
The serum calcium level is determined on the first postoperative day; if it is significantly lower, damage to the epithelial cells must be assumed and calcium must be added if necessary.
In case of doubt, rebleeding ( hematoma ) can be distinguished from simple postoperative swelling by means of sonography .
If there are no complications, the patient can get up on the evening of the day of the operation and drink fluids. You can eat normally from the first postoperative day and mobility is not restricted. Usually only small amounts of pain relievers are required. Extreme turning movements of the head are only advised against for the first 10 to 15 days in cases in which the neck muscles had to be incised transversely due to the size of the goiter. The drains are removed on the 2nd, and discharge from hospital at the earliest on the 3rd, usually on the 4th or 5th day after the operation. The skin suture is removed after about a week. The remaining scar is still noticeable for the first eight to twelve weeks and only then develops its final width and color. Ideally, the end result would be difficult to see a fine line in a fold of skin, but the extent of scarring varies from patient to patient.
Follow-up care consists of regular monitoring of thyroid hormones and TSH . If renewed lump formation is suspected, ultrasound examinations and , if necessary, a new scintigraphy are carried out.
Depending on the size and function of the remnant of the thyroid gland, hormone replacement therapy ("substitution") or - to avoid recurrence of goiter (see above, recurrent goiter) - therapy that inhibits thyroid function ("suppression") is carried out using tablets. Details on this in the main article goiter .
Comparison with thyroidectomy
The advantage of goiter resection compared to thyroidectomy is, on the one hand, that it is somewhat easier to perform with a somewhat shorter operation time. For experienced surgeons, this difference is hardly significant.
On the other hand, a small part of the functioning thyroid tissue remains, so that the patient is not completely dependent on the drug substitution of thyroid hormones . However, to prevent a relapse, thyroid hormone must be administered anyway, possibly in smaller quantities.
The advantage of thyroidectomy is the reliable prevention of recurrences.
Minimally invasive goiter resection
Since the end of the 1990s, goiter resection has also been increasingly performed using a minimally invasive technique. The procedure is called MIVA-T (minimally invasive video-assisted thyroidectomy) in Anglo-American usage . For this purpose, an approximately 2 cm long incision is made a little higher than with Kocher's collar incision, over which the operation is carried out using a 5 mm rod optic and video monitor. So far, however, mainly smaller (<2 cm) nodules and diffuse goiters with a volume of less than 25 ml have been treated with this. Large comparative studies to assess the method are still pending; so far only a number of individual studies have been found. Since 2003 and 2008, the ABBA (Axillo-Bilateral-Breast-Approach) and EndoCATS (Endoscopic-Cephallic-Access-Thyroid-Surgery) methods have been available endoscopic goiter resections that leave no visible scars and that allow the removal of unilateral goiter flaps to allow a size of 50 ml. In 2008, Witzel et al. the transoral access to the thyroid, which is a prerequisite for NOTES thyroid resection without visible scars on the neck.
history
In 1791 the French surgeon Pierre-Joseph Desault performed the first described struma resection.
The struma resection was carried out - at that time under the name strumectomy, which is no longer common today - in 1876 by the Swiss surgeon and Nobel Prize winner (1909) Emil Theodor Kocher as a total extirpation (i.e. in the sense of today's terminology more like a thyroidectomy ) and in 1878 under the title "extirpation of a Struma retrooesophagea ”published. In the following 10 years he made a significant contribution to improving the surgical technique and was able to reduce the mortality rate as a result of total extirpation considerably. In 1883, Kocher published that total extirpation could lead to a condition similar to cretinism . This could be prevented by leaving some thyroid tissue in the patient's body. The Kocher collar cut and the Kocher clips , which are still used today, are named after Emil Theodor Kocher .
In 1884 von Rehn performed the first thyroid resection for hyperthyroidism in Germany.
literature
- H.-D. Röher: Surgery of the thyroid gland. In: B. Breitner: Chirurgische Operationslehre Volume 1, HD Röher (Hrsg.): Surgery head and neck. 2nd Edition. Urban & Schwarzenberg, Munich / Vienna / Baltimore 1990, ISBN 3-541-14412-2 .
- V. Bay, P. Matthaes: Thyroid. In: F. Baumgartl, K. Kremer, HW Schreiber (ed.): Special surgery for the practice. Volume 1, Georg Thieme Verlag, Stuttgart 1973, ISBN 3-13-445301-0 , p. 482 ff.
- S2k guidelines for the operative therapy of benign thyroid diseases of the German Society for General and Visceral Surgery (DGAV). In: AWMF online (as of 2010)
Individual evidence
- ↑ Original work: E. Enderlen, G. Hotz: Contributions to the anatomy of the goiter and goiter surgery. In: Z Angew Anat. 3, 1918, pp. 57-79; (P. 1). Quoted from: K. Oberdisse, E. Klein, D. Reinwein: The diseases of the thyroid. Georg Thieme Verlag, Stuttgart 1990.
- ^ F. Grünwald , C. Menzel: Radioiodtherapy. In: T. Kuwert, F. Grünwald, U. Haberkorn, T. Krause: Nuclear medicine. Stuttgart / New York 2008, ISBN 978-3-13-118504-4 .
- ↑ AWMF guideline 031/002: Radioiodine therapy in differentiated thyroid carcinoma
- ↑ Frank Bauer: The influence of the ligature of the inferior thyroid artery on the complication rates in the surgery of benign goiter . Evaluation of surgical quality assurance in East Germany 1998, p. 36ff., Uni-halle.de
- ↑ Walter Exler: Surgical treatment and results of benign recurrent goiter from the years 1981–2000 in the St. Trudbert Hospital, overview of 132 cases . Tübingen 2004, uni-tuebingen.de . In this work recurrent paresis of> 10% and hypocalcemia of up to> 20% are given.
- ↑ cf. J. Schabram, C. Vorländer, RA Wahl: Differentiated operative strategy in minimally invasive, video-assisted thyroid surgery results in 196 patients. In: World Journal of Surgery . Volume 28, Number 12, December 2004, pp. 1282-1286, ISSN 0364-2313 . doi: 10.1007 / s00268-004-7681-0 . PMID 15597231 .
- ↑ K. Shimazu, E. Shiba, Y. Tmaki, S. Takiguchi, E. Tanigushi, S. Ohashi, S. Noguchi: Endoscopic thyroid surgery through axillo-bilateral-breast-approach. In: Surg Laparosc Endosc Percutan Tech. 13 (3), Jun 2003, pp. 196-201.
- ↑ HM Schardey, M. Barone, S. Pörtl, M. von Ahnen, T. von Ahnen, S. Schopf: Invisible Scar endoscopic dorsal approach thyroidectomy: a clinical feasibility study. In: World J Surg. 34 (12), Dec 2010, pp. 2997-3006. doi: 10.1007 / s00268-010-0769-9 .
- ↑ K. Witzel, BHA von Rahden, C. Kaminski, HJ Stein: Transoral access for endoscopic thyroid resection . In: Surgical Endoscopy . tape 22 , no. 8 , August 1, 2008, ISSN 0930-2794 , p. 1871-1875 , doi : 10.1007 / s00464-007-9734-6 .
- ↑ J. DuBose, R. Barnett, T. Ragsdale: Honest and sensitive surgeons: the history of thyroid surgery. In: Current surgery. Volume 61, Number 2, 2004, pp. 213-219, ISSN 0149-7944 . doi: 10.1016 / j.cursur.2003.07.021 . PMID 15051267 .
- ↑ a b Emil Theodor Kocher . In: Encyclopedia Britannica online , accessed February 9, 2008.
- ↑ a b I. W. Müller u. a .: The Chronicle of Medicine . Chronik-Verlag, 1993, ISBN 3-611-00273-9 , p. 314.
- ↑ J. Glamsch: Intraoperative neuromonitoring of the recurrent laryngeal nerve with the help of the Neurosign® 100 during operations on the thyroid gland . Dissertation. Würzburg 2002, p. 1. From: K. Oberdisse, E. Klein, D. Reinwein: The diseases of the thyroid . Georg Thieme Verlag, Stuttgart 1990, opus-bayern.de .
