Thyroid surgery education and preparation
We take surgery very seriously and so should you. Please read (and re-read) the following summary. It would be impossible to cover every possible scenario, so never hesitate to ask questions. Good communication with your surgery team is critical to a successful and safe surgery.
The thyroid is part of the endocrine system and functions to produce thyroid hormone, which regulates metabolism. The gland is located in the midline of the neck over the trachea (windpipe). There is a right lobe, left lobe, and isthmus (center component). Removal of the gland is indicated for three main reasons. A total thyroidectomy is performed to remove the entire thyroid gland. A thyroid lobectomy is the removal of either the left or the right thyroid lobe. It is most commonly removed due to a nodule(s) in the gland that is either discovered because a “lump” is palpable to the patient or doctor, or it is noted on imaging like ultrasound or a CT scan. If the thyroid nodule(s) are suspicious for cancer, they thyroid lobe or entire gland is removed. Secondly, they thyroid may have multiple nodules on one or both lobes. Thyroid removal is indicated if this “goiter” is large enough to cause compression of the esophagus or trachea, which may cause difficulty swallowing or breathing troubles. Finally, thyroidectomy is occasionally necessary to remove a hyper-functioning gland that is overproducing thyroid hormone (i.e. Grave’s Disease). Thyroid surgery is performed under general anesthesia. A thyroidectomy is perfomed through an incision in the lower part of the neck in the midline.
Scheduling and Logistics
If you haven’t met with our scheduler yet, expect a call within the next day. If you have insurance questions, they can help you answer them. Keep in mind that you should also talk to the hospital about their charges as the majority of the fees are from the hospital.
For most patients the location of surgery will be PMC (Physicians Medical Center), 2990 Rodeo Park Dr E., Santa Fe (505) 428-5400. The hospital requires a pre-anesthesia testing (PAT) clinic visit at PMC. Your PAT appointment should be as soon as possible. Expect a call from them, and if you have not heard from them within 2 days, let us know. The PAT clinic number is (505) 913-4444. Our clinic number is (505) 982-4848.
The government requires that you are seen by your surgeon within 30 days before your surgery. If your surgery is scheduled more than 30 days out, you will need to return to clinic before surgery.
If you are on a blood thinner (aspirin, warfarin, Coumadin, Plavix, etc) discuss discontinuing this with your doctor. If it is not safe to stop your blood thinner, then it is not safe to have thyroid surgery. Blood thinners should be stopped a week before and after surgery. Also please stop anything that might have vitamin E, ibuprofen (Advil), Alleve, or similar medications.
Do not eat or drink after midnight. A small sip of water to take essential medications is ok. The pre-anesthesia clinic will tell you which medications are essential and should still be taken the morning of surgery.
Please shower the night before or morning of surgery. Do not wear make-up, hair-products, jewelry, or piercings. Be prepared to remove dentures, contacts, glasses, or hearing aids before surgery begins.
If you feel that you are getting sick within 2 weeks of surgery, call our clinic right away so we can consider re-scheduling.
If you are discharged the same day as your surgery, you must have a capable adult drive you home and stay with you that night. Your surgery will be cancelled if you are having an outpatient surgery and you do not have someone to drive you and be with you that night.
Most patients undergoing thyroid lobectomy (removing half) can go home the day of surgery, whereas most patients having total thyroidectomy will be admitted to the hospital. When admitted to the hospital, how long you stay depends on several things (blood pressure, calcium levels, general health, and extent of surgery). If you do not live in Santa Fe, you may need to get a hotel room the night of surgery in Santa Fe. There are several hotels that offer discounts and a list is available. The bottom line is to be prepared to stay overnight in the hospital, and, if you live out of town, also be prepared to get a hotel room.
Recovery time and activity
While it is difficult to estimate your exact recovery time, we generally recommend having two weeks off from work or other responsibilities. For the 2 weeks of recovery, you should not exercise, lift anything heavy, or travel. Walking is still strongly encouraged.
You will have general anesthesia which may make you nauseous or drowsy, particularly the first day. Do not drive a car*, operate heavy machinery, or sign legal documents for at least 24 hours AND until you are no longer taking prescription pain medicine. Alcohol is not recommended during the recovery period, particularly the first 24 hours. The combination of alcohol and acetaminophen (Tylenol) can be toxic to the liver. For a full discussion of anesthesia risks, you will meet and talk to your anesthesia team the day of surgery.
*In the case of thyroidectomy, you should also be able to turn your head to the side comfortably before you drive.
If a drain is placed you will need to follow-up for drain removal in 2-3 days at the SWENT clinic. Otherwise, follow-up is in 10-14 days at the SWENT clinic. At that time, your dressing and sutures will be removed. Your pathology results will typically take about a week and we will go over them at the 10-14 day appointment. We will also order blood work. After surgery, call our clinic (982-4848) to arrange your post-op appointment.
After having anesthesia, you will want to advance your diet slowly the first day to avoid nausea. We recommend softer foods because they will be easier to swallow.
Pain is very different from person to person. Some have minimal pain and take only acetaminophen (Tylenol); some have moderate or severe pain and require the prescribed narcotic pain medicine. Most have some moderate pain and need some narcotic painkillers. If you are having less pain, you can substitute acetaminophen (Tylenol) for the prescribed pain medicine. Keep in mind the prescription also has acetaminophen in it, and you don’t want to double-dose.
Narcotic pain medicine tips and safety:
- Don’t take narcotic prescription on an empty stomach. Wait at least 10 minutes after eating.
- If you become nauseous, don’t take any more narcotic pain meds until you feel better.
- Narcotics can cause sedation. They can be dangerous if overdosed or combined with other sedating medications. Do not take narcotics when drowsy.
- Narcotics (and Tums) can cause constipation. You can prevent this by taking docusate (an over-the-counter stool softener). You may also need a suppository such as dulcolax if you become constipated.
- Narcotics can cause itching. If this occurs, take a lower dose or take a non-sedating antihistamine (such as Claritin) to reduce this.
- Narcotics are not meant for long term use and can cause tolerance and dependence. We generally will not prescribe narcotics beyond 10 days after surgery.
After total thyroidectomy it is very common to have potentially low calcium for a week or so. (If only half your thyroid is removed it is very unlikely.) Low calcium after total thyroidectomy is so common that most patients will be placed on calcium (Tums) to prevent it. The reason calcium can be low is because the small parathyroid glands that control calcium levels often become stunned by removal of the thyroid. Some can even be attached to or within your thyroid gland. We will measure the level of this hormone in the recovery room, and this helps us predict how much your calcium might drop. If we are very concerned about it dropping, we may keep you in the hospital until we know it is stable. It is possible, although rare, to have calcium remain low indefinitely and to require calcium supplements long-term. Numbness or tingling in your hands or face are symptoms of low calcium. If this occurs, take an extra dose of Tums and contact us.
Need to take thyroid supplementation medicine
When removing half of the thyroid most (80%) of people will not need any thyroid medicine long-term. 20% will. Your hormone level should be measured a few weeks after surgery, and checked once a year and sooner if you develop severe fatigue.
When removing the whole thyroid (total thyroidectomy) you will need life-long thyroid supplementation. We usually will start this medicine (levothyroxine) immediately after surgery. The dose will need to be checked and adjusted by your endocrinologist or primary care provider starting 3-4 weeks after surgery.
Dressing and Drain
You will have a dressing that should be left in place until your follow-up appointment. Keep the dressing dry for the first 48 hours. After that you may get it lightly wet in a shower but do not swim or hot tub.
Sometimes a drain is placed. If you have a drain, keep it dry, empty and record the volume every 8 hours, and keep it under suction (you will be shown how to do this). The drain site must be kept dry until a full day after the drain is removed.
Mild swelling is normal. It usually comes on gradually over the first day and does not get bigger than the width of the incision. It usually takes a few weeks for this to go down. Swallowing may feel mildly tight or unusual during this healing process. You can place a cold compress over the incision to reduce swelling (be careful not to cause frostbite of the skin by having a barrier and not leaving a compress that is below freezing in place for more than 10 minutes at a time). Avoid laying down flat the first couple days; use pillows to help keep your head propped up.
Larger or more sudden onset of swelling can be from bleeding and can be a life-threatening problem. There may be a lot of swelling or breathing may feel tight. We may need to drain a collection of blood (hematoma) or even place a tracheotomy tube. Bleeding may occur in about 1 out of 60 patients. It is more likely to occur if blood pressure is elevated. When in doubt, proceed to the Emergency Room.
Having a scar is inevitable. The size depends mostly on the size of your thyroid and the difficulty in removing it. Usually the incision heals well, and the scar is subtle. Once your incision has healed and is strong (one month), you may massage it with a vitamin E scar cream to flatten it if necessary. There is a risk of having a scar you are not pleased with.
Since you will have a breathing tube placed during surgery, it is common to wake up with a raspy voice. The surgery also disturbs the muscles around your voice box which can cause some hoarseness. Less likely (about 1 out of 100) is injury to or weakness of a vocal nerve. This can cause a more severe hoarseness that often improves, but not always. Permanent hoarseness is one of the risks of thyroid surgery.
Blood clots are uncommon, but can be deadly. A blood clot in the legs is called a deep vein thrombosis (DVT). They can be deadly if the clot travels to the lungs (pulmonary embolism). People are at risk for DVTs up to a month after surgery. The risk is greater with any of the following: lack of movement, age over 40, obesity, dehydration, pregnancy, use of oral contraceptives, or prior blood clot. Some people are more likely to develop a DVT due to a genetic defect, but may not discover this until a DVT happens. Swelling or pain in your lower leg or behind your knee is usually how a DVT presents. If this happens, you should go to an emergency room immediately for evaluation. To prevent a DVT, wear compression stockings and start walking at least three times a day beginning the evening of your surgery. The quicker you regain mobility and the more mobile you are, the lower your risk.
It is possible, although rare, to have life-threatening breathing problems after thyroidectomy. Bleeding or damage to both vocal nerves can cause this. If this were to occur a tracheotomy (a breathing tube through the neck skin) may be necessary.
As with any surgery there is a risk of infection. This is a rare event, but could occur. Infection after surgery usually takes a few days to develop. Typical symptoms are increasing pain, swelling, and redness. Of course, call or come in if this is suspected.
With any surgery there is a small chance of death. Some of the possible causes were mentioned above: blood clot, bleeding, and breathing problems. We do not have very good data on this risk because it occurs so rarely. Averaging two recent studies suggests this risk could be one out of 1000 for thyroid surgery.1,2 We know that the more unhealthy a person is (high blood pressure, diabetes, emphysema, obesity), the greater the risk; conversely, healthier people will have a lower risk. To put this in perspective, the risk of dying in a car accident is one out of 10,000 per year.3
Reducing your risks
What can you do to reduce your risks with surgery?
- If you are obese, losing weight will reduce your risks. Consider delaying surgery to lose weight, if possible.
- If you smoke, stop for at least one week before and after surgery.
- With rare exceptions, you should not have thyroid surgery when pregnant.
- Sleep apnea. If you are at risk for having sleep apnea, you should be tested beforehand because the risk of anesthesia complications is greater in people with untreated sleep apnea. If you have sleep apnea, bring your CPAP to the hospital.
- Be aware and communicate.
Every surgery has inherent risks that are impossible to completely eliminate. The important thing is recognizing a problem and calling or seeking medical attention promptly. It is your responsibility to communicate with your doctor and medical team. We cannot help you if we do not get information and feedback from you. If you do not understand anything, you must speak up until you do. If you think we do not understand something, speak up until we do. When in doubt, ask. We are always happy to talk to or see you any time after surgery. If your surgeon is not available, one of the other doctors will be.
I have read and understand the above. I have discussed the risks, benefits, and alternatives to surgery with my doctor. My questions have been answered to my satisfaction.
Patient /Parent signature: _________________________________ Date: _________________
Pre-op nurse signature: __________________________________ Date: _________________
Physician signature: ___________________________________ Date: _________________
- Abraham CR, et al. A NSQIP risk assessment for thyroid surgery based on comorbidities. J Am Coll Surg. 2014 Jun;218(6):1231-7. doi: 10.1016/j.jamcollsurg.2014.01.055. Epub 2014 Mar 2.
- Weiss A, et al. Risk factors for hematoma after thyroidectomy: Results from the nationwide inpatient sample. 2014 Mar 14. pii: S0039-6060(14)00108-1. doi: 10.1016/j.surg.2014.03.015. [Epub ahead of print]
- West BA, et al. Motor Vehicle–Related Deaths — United States, 2005 and 2009. Morbidity and Mortality Weekly Report (MMWR) Supplements. November 22, 2013 / 62(03);176-178.