Surgical therapy for goiter usually consists of a strum resection (which is incorrectly called a strumectomy), in which the thyroid gland is removed except for a remnant of varying size. The term strumectomy, on the other hand, refers to the removal of a complete organ under an ectomy. Complete removal of the thyroid gland is called thyroidectomy (synonym: total thyroid extirpation), and complete removal of one half of the thyroid gland is called hemithyroidectomy.
Indications for strum resection or thyroidectomy/hemithyroidectomy (synonym: lobectomy/complete removal of one of the two lobes) are:
- Large nodal goiter (if necessary, here depending on size. Number and location of nodes thyroidectomy indicated [gold standard]).
- Cold nodes (if malignant/malignant → hemithyroidectomy).
- Compression of the neck organs
- Goiter with autonomy (in latent or manifest hyperthyroidism → therapy by surgery, medication, radioiodine therapy or alternatively with percutaneous alcohol injection:
- The first stage of treatment is drug therapy (thiamazole or propylthiouracil);
- Surgery is indicated in case of large goiter causing mechanical problems, furthermore in case of existing cold nodule or after unsuccessful other forms of therapy.
Note: An alternative method of therapy is the infiltration of high percentage ethanol (ethanol) to obliterate solitary autonomous (independent) adenomas of two to four centimeters in size).
Further notes
- For thyroid nodules greater than 4 cm in diameter with indeterminate cytologic findings, lobectomy (complete removal of one of the two lobes) is probably usually sufficient as therapy.
- In older age or contraindications to surgery, radiotherapy can be performed as an alternative to surgery. For further indications for radioiodine therapy, see below “Further therapy/conventional non-surgical therapy methods”.
- After radioiodine therapy or surgery is usually a lifelong substitution therapy with thyroxine necessary!
- Conventional non-surgical therapy methods see under “Further therapy”.
Guideline recommendations:
- In adolescents and children, because of the increased risk of hypoparathyroidism (parathyroid hypofunction), the procedure should be performed only at specialized centers.
- In the case of alternative access techniques, which are usually performed for cosmetic reasons, the surgeon must explicitly inform the patient in the preliminary discussion that these are non-established and non-standard procedures.
- Information about alternatives: in the context of the extended duty to inform in thyroid surgery must also be referred to scientifically unproven alternatives to resection (eg, microwave ablation, see above).
- Intraoperative neuromonitoring (IONM): visual imaging of the recurrent nerve (laryngeal nerve; vocal nerve) is the gold standard. Neuromonitoring is not mandatory. Note: Alteration of the nerve revealed by intraoperative monitoring will force modification or abortion of the surgery. This must also be discussed during patient education.
- Metabolic monitoring: 24 hours after surgery, calcium and parathyroid hormone levels must be determined.
- Due to risk of postoperative bleeding: extension of inpatient stay to at least 36-48 hours. At the same time, medical staff must be qualified to deal with possible complications. Binding action algorithms should be available in the supervising hospital ward.
