Conventional thyroidectomy
(minimal invasive approach)

Thyroidectomy is usually performed under general anaesthesia but regional anaesthesia with cervical block and sedation can be considered in selected patients. Direct approach by a small incision in the neck is regarded as a minimally invasive procedure. Depending on the size of the gland and the body build of the patient, a 3.5-5cm (usually 4-cm) incision is made along the skin crease in the anterior part of the neck near the chest bone or higher up near the throat. It is known as collar incision to provide the best cosmetic outcome because of its conformation to skin line and easily concealed position. The wound can be moved to different part of the thyroid gland to perform a bilateral operation (removal of left and right lobe of thyroid gland) and to deliver a substantial large goiter from a relatively small incision. Drainage is not required unless concomitant neck dissection has been performed for thyroid cancer. Patient would have minimal pain and trauma as well as a rapid recovery after the operation.

Thyroid surgery is a very safe procedure and should have minimal risk when performed by experienced endocrine surgeons. Wound infection or haematoma occurs in <1%. Recurrent laryngeal nerve palsy leading to hoarseness of voice should be <0.5%. The use of intraoperative neuromonitoring attempts to absolutely avoid this complication. Permanent hypoparathyroidism secondary to parathyroid gland injury (4 pea-like glands behind the thyroid gland with delicate blood supply) should be within 1-2% depending on the nature of the operation. Patient is required to have serum calcium and parathyroid hormone monitoring after the operation and calcium and/or vitamin D analogue supplement is prescribed when necessary.

The overwhelming majority of patients stays in the hospital overnight and is discharged the next day. Movement of neck is encouraged and shower is allowed. Follow-up appointment will be arranged one week after the operation for removal of tape from the wound and removal of suture is not required. Regular activities are allowed within 7-10 days after the operation. The neck scar heals nicely and becomes generally inconspicuous within 6-12 months.

Endoscopic thyroidectomy

Removal of thyroid gland is also feasible with the use of the endoscope with or without the assistance of robot (Da Vinci System). The main objective of endoscopic approach is to bring the incision out of the neck (extracervical) to other conceable part of the body, namely aerola of breast, chest wall, the axilla or the lip (transoral) to achieve improved cosmetic outcome. This procedure should not be regarded as minimally invasive because of the more extensive dissection required. Indications of operation are limited to small benign nodules or small size glands. The short term cosmetic outcome is better because of ability to hide the wound with usual clothing. However, since majority of the neck wound becomes inconspicuous in the longer-term, the advantage of endoscopic thyroidectomy remains cosmetic and should only be reserved for someone with concern about the potential poor cosmetic outcome of conventional thyroidectomy. The cost is substantially longer because of longer operating time and the use of expensive instruments.

Nonsurgical treatment of benign thyroid nodule

For patients with symptomatic or enlarging benign thyroid nodule reluctant for surgical treatment, ablative therapy using various energy sources including radiofrequency ablation (RFA, percutaneous laser ablation (LA), microwave ablation (MWA) or high-intensity focused ultrasound (HIFU) can provide an alternative treatment option. These procedures can be selectively performed for small benign nodules (usually <4-cm) under local or regional anaesthetics as day procedure either in hospital or clinic. However, the expected shrinkage of nodule size will be variable and recurrence will be expected in a certain proportion of nodules after treatment requiring either re-treatment or surgery. For benign cystic nodule of thyroid, ethanol injection can be considered for selected nodules to prevent recurrence.