Evaluation of intracapsular total thyroidectomy as a safe method in benign thyroid diseases

INTRODUCTION

There is continuous evolution in surgical management of thyroid diseases, from highly morbid to highly sophisticated surgery with minimal or even no morbidity.¹ Total thyroidectomy was initially introduced by Theodore Kocher 1880.² The aim of surgical treatment in benign thyroid disease is to treat with the less complications rate and decrease recurrence rate.³ Nowadays there is uprising rate for total excision instead of subtotal excision in benign thyroid disease Muller et al reported that the rates of complications associated with total extracapsular thyroidectomy are 0.9% for recurrent nerve palsy 0.9% for hypocalcaemia, 0.9% for wound infection, and 0.6% for secondary haemorrhage.⁴ Our aim in this study is to evaluate safety and effectiveness of intracapsular technique in treatment of benign thyroid disease.

METHODS

This prospective study carried out in department of general surgery, Menoufia university hospital and Tala central hospital, from June 2018 to April 2019 on 58 patients with benign thyroid disease they underwent intracapsular total thyroidectomy each patient provided his/her written consent to participate in the study. Continuous variables were presented as means and standard deviation, while categorical variables were expressed as percentages. A p<0.05 was considered statistically significant.

All statistical tests and analysis were performed by statistical package SPSS version 22 for Windows, Armonk, NY: IBM Corp.

Menoufia Faculty of Medicine Ethics Committee approved this study.

Inclusion criteria

Inclusion criteria were presence of primary toxic goiter after recurrence or failure of medical treatment; presence of secondary toxic goiter; presence of simple multinodular goiter.

Exclusion criteria

Exclusion criteria were presence of clinically and preoperative evidence of malignant goiter; presence of thyroiditis; presence of recurrent thyroid disease.

Preoperative investigations

• • Routine tests CBC, LFTS, RFTS.
• • Thyroid hormones tests: freeT3, freeT4, and TSH.
• • Thyroid imaging: thyroid ultrasound and thyroid scan.
• • Fine needle aspiration cytology (FNAC) when needed.
• • Indirect laryngoscopy in all patients

Operative technique

Proper positioning of the patient was made and sterilization of the skin was made. An incision is made in the skin two fingers above the sternal notch between the medial borders of the sternocleidomastoid muscles. The width of the incision may be extended if the thyroid mass is large. Subcutaneous fat and platysma are divided using diathermy. A subplatysmal flap is made above the incision up to the level of the thyroid cartilage above, and the sternal notch down The fascia between the sternohyoid, omohyoid and sternothyroid muscles (strap muscles) is divided along the midline and the muscles is retracted laterally. The thyroid lobe is rotated medially by surgeon fingers to identify is the middle thyroid vein (it will be tightly stretched by the medial rotation of the gland), which is then ligated. Identify the superior thyroid artery as close to the superior pole of the thyroid. Great care should be taken while ligating the superior thyroid artery so as to avoid injury to the external laryngeal nerve. Ligation of the inferior thyroid veins at the lower pole. Longitudinal incision was made in an avascular area of the lower part of the thyroid capsule on the middle to distal part of the gland This longitudinal incision was extended with scalpel to open the whole capsule (Figure 1). Then the thyroid capsule was reflected off the gland with tissue forceps and the thyroid tissue was then moved away gently from the inside aspect of the thyroid capsule with a sterile tissue peanut to leave the capsule intact (Figure 2). Inferior thyroid artery was ligated from the inner aspect of the thyroid capsule (Figure 3). No attempts were made in looking for or identification of the recurrent laryngeal nerve from the outer aspect. No attempts were made to find parathyroid glands on each side of the thyroid lobe from the outer side for preserving intact blood supply to them removing of thyroid gland. Suction drain is put routinely in all our cases and left for 24 hrs or 48 hrs.

RESULTS

This study included 58 patients with non-malignant thyroid disease underwent surgical treatment. They all underwent intracapsular total thyroidectomy.

The patients mean age was 36.39±9.8 years range from (18-55) years. Twenty patients were males (34.48%) males and thirty eight were females (65.52) (Table 1).

From the 58 patients twenty eight patients were diagnosed with simple multinodular goiter twelve were primary toxic goiter and eighteen patients were diagnosed with secondary toxic goiter. In fifty eight patients was no postoperative recurrent laryngeal nerve injury found (0%)) (Table 2).

No postoperative hypocalcaemia manifestations found no postoperative SLN injury (low-pitched voice) found 3 (5%) patients wound was complicated with seroma. Operative blood loss mean was 110±50 ml the mean operative time mean was 89.1±10.5 min and hospital stay was 1.01±0.5 day (Table 3).

DISCUSSION

total thyroidectomy in benign thyroid disease is the new standard technique instead of subtotal thyroidectomy due to high risk of complications in reoperations due to recurrence in subtotal thyroidectomy.^5-6 So in seeking for more safe surgical technique intracapsular total thyroidectomy was a solution to minimize the complications of the total thyroidectomy in the traditional extracapsular technique which happens due to recurrent laryngeal nerve injury in lateral dissection or parathyroid glands injury these are the two major complications in the traditional extracapsular.^7-9 Many studies suggest that the new technique of intracapsular total thyroidectomy is a safe method in terms of recurrent nerve injury or parathyroid gland injury because in the intracapsular thyroidectomy the capsule is opened and thyroid tissue is enucleated from the capsule leaving the recurrent laryngeal nerve under the capsule and its blood supply intact also the parathyroid gland lies beneath the thyroid capsule and by the intracapsular technique the parathyroid is preserved and its blood supply. Sewefy et al made study on 224 patients 112 patients underwent intracapsular total thyroidectomy and 112 patients underwent extracapsular total thyroidectomy and found that by intracapsular method the complication of recurrent laryngeal nerve injury was 0% compared to 0.9% in extracapsular method and permanent hypocalcaemia was 0% in intracapsular method compared to 0.9% in extracapsular method.¹¹ Meer et al made retrospective study on patients on tertiary care center and complications was counted from this technique and found that 0% cases complicated from permanent recurrent laryngeal nerve damage and temporary neuropraxia was around 0.5% and The incidence of temporary and permanent hypocalcaemia was found to be around 0.7% and 0.2% respectively.¹² Dong y et al made retrospective study on 44 patients underwent thyroid capsular dissection and the result was 1 patient suffered from postoperative hoarseness of voice.¹³ Rageh et al made prospective study on 50 patients who all underwent intracapsular total thyroidectomy none of the patients 0% suffered from RLN palsy postoperative and there was no parathyroid gland complications.¹⁴ All of these studies suggest that the new technique is easy to learn and do by junior surgeons which make it perfect choice in secondary health centres like central hospital in which study was made because the previous studies was done only in highly specialized centres like universities hospitals or endocrine surgery centres only.¹¹ In the new technique time in searching for recurrent laryngeal is saved as in intracapsular dissection no time spent in searching for recurrent laryngeal nerve or parathyroid glands.¹⁴

CONCLUSION

Intracapsular total thyroidectomy is a safe method in treatment of benign thyroid disease and can be done easily in central hospitals and non-highly specialized centres.

ACKNOWLEDGEMENTS

We thank our colleagues from Department of Surgery, Menoufia faculty of Medicine and Department of Surgery, Tala central hospital for their assistance and comments that greatly improved the manuscript.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee by Menoufia ethical committee

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