Struma resection (synonyms: strumectomy; struma removal) is a surgical procedure for the treatment of thyroid enlargement (goiter, goiter) in which the thyroid gland is removed except for a remnant of varying size. Goiter, which is characterized by either uniform or nodular growth, can cause symptoms such as dyspnea (shortness of breath; breathlessness) or dysphagia (difficulty swallowing; dysphagia) due to esophageal stricture (narrowing of the esophagus). In adolescents and children, because of the increased risk of hypoparathyroidism (parathyroid hypofunction), the procedure should be performed only at specialized centers.
Indications (areas of application)
- Nodal goiter – depending on the number, size and location of nodular change of the thyroid gland, the surgical method for treatment is selected. If the criteria related to nodules are met for struma resection, it is indicated according to the guidelines.However, if the nodules are too extensive or too numerous, thyroidectomy is preferable to struma resection. Of great importance in determining the indication is the combined assessment of the disease of the thyroid gland using sonography and scintigraphy as imaging techniques. Meanwhile, the determination of the size of the struma is done sonographically.
- Goiter with displacement symptoms – due to the anatomical proximity of the esophagus (food pipe) and trachea (windpipe) to the thyroid gland, an enlarged thyroid gland can compress the two organs and cause the above-mentioned complaints.
- Drug treatment of a goiter without success – the conservative treatment of a diffuse goiter is possible by means of iodide, L-thyroxine or various combination preparations. This reduces the hormone secretion of TSH (thyroid-stimulating hormone) in the pituitary gland and inhibits the growth of goiter. If conservative treatment is unsuccessful, struma resection is indicated.
- Autonomous adenomas – removal by strumaresection is possible.
- Malignant goiter – in the treatment of malignant goiter strumaresection is indicated only with limitations. As a rule, the entire removal of the thyroid gland in terms of thyroidectomy is indicated.
Contraindications
- Unadjusted hyperthyroidism (hyperthyroidism).
- Severe underlying disease or significantly reduced general condition
Before surgery
- Preliminary examination for indication – after palpation (palpation) and sonographic imaging of the thyroid gland, hormone determinations (TSH, fT3, fT4, etc.) and, depending on the issue, a fine-needle biopsy are performed for further clarification.
- In the case of alternative access techniques, which are usually done 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).
- Preoperative examinations – in addition to the assessment of vital signs, an X-ray examination of the lungs (X-ray thorax) is performed and a blood count is made. Likewise, an examination of the most important kidney parameters (urea, creatinine, if necessary creatinine clearance) and the INR determination (blood clotting), if necessary, other laboratory parameters.
The surgical procedure
Anesthesia
- The form of anesthesia is intubation anesthesia.
Operation method
- Access to the surgical site should be above the jugular (jugular gutter).
- First, the isthmus (junction of the thyroid lobes) is cut so that the arteries below can be tied off.
- The thyroid gland is then opened to remove all but a defined amount of tissue from the capsule.
Intraoperative neuromonitoring (IONM): visual imaging of the recurrent nerve is the gold standard. Neuromonitoring is not mandatory. Note: Alteration of the nerve as revealed by intraoperative monitoring will force modification or termination of the surgery. This must also be discussed during patient education.
After surgery
- First, after Redon drainage is applied, a solid wound closure is sought. For this purpose, various methods and materials are available.
- Following the procedure, follow-up examinations must be performed to assess the success of the treatment and to check for possible complications. It is particularly crucial to check the vocal cord mobility, since the innervating (supplying) nerve is particularly vulnerable during surgery. The check can be performed by laryngoscopy directly at anesthesia induction or by checking the speech function. If recurrent paresis (vocal cord paralysis) is suspected, intensive medical monitoring of breathing is necessary. Calcium and parathyroid hormone levels should be determined 24 hours after the procedure. If hypocalcemia (calcium deficiency) is present, this indicates injury or complete removal of the parathyroid gland.
- Depending on the size and function of the thyroid remnant, hormone replacement therapy or to prevent recurrence of a struma recurrence (recurrence of a goiter) suppression therapy (thyroid function inhibiting therapy) is performed.
Possible complications
- Neck pain due to positioning
- Temporary (intermittent) or possibly permanent hoarseness due to a nerve lesion of the recurrent laryngeal nerve
- Dysphagia (difficulty swallowing).
- Allergic reactions up to anaphylactic shock
- Temporary or permanent soft tissue damage or scarring
- Lesions of adjacent organs such as the trachea or esophagus
- Bleeding
- Infections
- Unplanned removal of the parathyroid gland (Glandulae parathyroideae).