The number of newly diagnosed thyroid nodules has risen dramatically worldwide since 1990. The incidence in Switzerland has also tripled in the last 10 years. However, the increase in incidence also reflects today's good diagnostics and modern methods of examination. It is thus possible to detect early stages of malignant nodules at a time when they are curable. The incidence rate of early carcinomas and the frequency of malignant thyroid nodules has also increased significantly in recent years. With every 7th thyroid nodule, we find a so-called early stage of a malignant carcinoma. In Switzerland, this affects 15 cases per 100,000 persons and continues to show an upward trend. As a direct consequence, much smaller thyroid nodules are of course diagnosed and considered for invasive treatment with thermal ablation or minimally invasive surgery. Due to this early detection of small but conspicuous nodules and due to the nowadays excellent established methods of diagnosis, such as fine needle punctures and high-resolution ultrasound, which are not very troublesome for the patient, even small nodules are increasingly treated.
In contrast to thermal ablation, surgery is particularly important for the patient when it is a matter of eliminating a malignant disease or when the nodule exceeds the extent of a fundamental ablation indication. In recent years, new techniques have also been sought to treat small nodules with the least visible scar possible and significant progress has been made in the minimally invasive treatment of malignant nodules. The development of minimally invasive approaches (buttonhole surgery) does not stop at the surgery of the thyroid gland. The use of state-of-the-art surgical robots or video-assisted buttonhole methods is nowadays established and offered to our patients in select cases. These procedures, however, are only recommended by experienced, specialized surgeons in highly frequented thyroid centers, whereby the expenditure of time and therefore the anesthesiological burden are greatly increased.
1. Standard access for all benign small tumors that exceed the size for thermal ablation.
2. Facial surgical aesthetic approach with small scar (4 cm) and beautiful results.
3. Short period of general anesthesia in experienced hands (60 - 90 minutes).
4. Very low complication rate, in particular avoidance of permanent vocal cord nerve damages or parathyroid injuries.
5. Intraoperative functional tests of the vocal cord nerve are possible due to the minimally invasive approach.
6. Short hospitalization time of 2 to 3 days.
For the safety of our patients and with the requirement of a correct resection size as well as an aesthetically best possible result, minimally invasive surgical techniques are nowadays also required for malignant nodules.
Thyroid surgery, one of the oldest general surgical operations, has changed considerably in recent years. Today, it belongs to the field of specialized medicine, which now requires the qualification of specialized surgeons.
The surgical requirement continues to focus on avoiding damages to the vocal cord nerve. Whereas damage rates of about 10 % and more were assumed in the past, today we speak of 1 % and less. Ideally, it is possible to achieve a vocal cord damage rate that tends towards 0 %. The basis for this is the proven experience of specialized thyroid surgeons and thus a safer preparation of the organ. Today, thyroid surgery should no longer be performed with the naked eye, but with a magnifying glass and microscopic magnification. The application of neuromonitoring represents a further significant advance in the protection of the vocal cord nerve. This technique is used during surgery to check nerve function in order to intraoperatively distinguish nerve tissue from other tissue. Today, it can be assumed that the problem of vocal cord damage has essentially been solved by these two measures. Unfortunately, the laryngeal nerve is not yet sufficiently considered and spared.
The protection of the parathyroid glands has become increasingly important in recent years. In the age of frequent osteoporosis, the protection and maintenance of the function of the four small parathyroid glands, which are located directly on the thyroid gland, are extremely important. They are responsible for the human calcium balance and thus essentially form the basis of an intact bone structure. Since the failure of the parathyroid glands is certainly more drastic for a patient than a one-sided vocal cord paralysis, all efforts should be directed towards maintaining their function. This includes the clean intraoperative preparation and identification of the parathyroid glands, the careful examination of the thyroid preparation after its removal and a possible reimplantation of the parathyroid glands into the neck musculature. The protection of the parathyroid glands has become increasingly important.
The quality assessment of modern thyroid surgery cannot be determined solely by the rate of permanent vocal cord paralysis or parathyroid failure. The extent of thyroid resection is important for the patient and the prognosis of his or her thyroid disease. It seems easier and safer to perform only a partial removal of the thyroid gland. In the long run, however, this outdated practice leads to high recurrence rates and thus to second interventions, which increase the rate of vocal cord paralysis or permanent parathyroid damage. The concept of partial resection of thyroid glands, strumectomy, no longer meets international standards.
Accordingly, nowadays, the entire affected thyroid lobe is always removed from a unilaterally nodular thyroid gland. In the case of bilateral nodular thyroid gland disorders, total bilateral thyroid flap resection is performed. Thanks to a primary and well-planned preparation of the vocal cord, laryngeal nerve, and parathyroid glands, permanent damage to these structures is much less frequent.
The interdisciplinary consultation and cooperation of a team consisting of a surgeon, a neck surgeon, and a pathologist clearly improves the diagnosis of the surgery and prevents unnecessary interventions. Thanks to the intraoperative assessment by the neck surgeon, the safety of the patient and the quality can be significantly increased.
In the difficult cases of dubious thyroid carcinomas, the team is completed by a pathologist present in the surgery room and his or her microscopic diagnostics. A second intervention in the case of overlooked carcinomas is thus unnecessary. The chances of curing thyroid cancer are very good. Since younger patients are affected in most cases, the life expectancy is several decades. A significantly higher life expectancy can be achieved through appropriate interdisciplinary treatment than with other malignant tumor diseases.
Most important for patients is the cosmetically favorable positioning of the neck incision. The aesthetic, minimally invasive surgical technique has also brought enormous progress in thyroid surgery. Instead of a previously 6 to 10 cm long incision, an incision of 2 to 3 cm is now sufficient to remove the thyroid gland, which can also be placed in the neck fold and remains practically invisible. Today, incision lengths of more than 3 cm are only required in a few exceptional cases for carcinomas.
PROF. DR. MED. CLAUDIO A. REDAELLI
Specialist in surgery FMH,
especially visceral surgery and endocrine surgery
Zurich Visceral Surgery, Klinik Hirslanden
Witellikerstrasse 40, 8032 Zurich
Phone: +41 44 387 3080