Meei Yeung

Recurrent laryngeal nerve injury in thyroid surgery: a review

Recurrent laryngeal nerve palsy (RLNP) is an important and potentially catastrophic complication of thyroid surgery. Permanent RLNP occurs in 0.3–3% of cases, with transient palsies in 5–8%. A literature review and analysis of recent data regarding RLNP in thyroid surgery was performed, with particular focus on the identification of high‐risk patients, the role of intraoperative identification and dissection of the nerve, and the role of intraoperative neuromonitoring (IONM) and optimal perioperative nerve assessment. In conjunction with the review, data from the Monash University/Alfred Hospital Endocrine Surgery Unit between January 2007 and October 2011 were retrospectively analysed, including 3736 consecutive nerves at risk (NAR). The current literature and our data confirm that patients undergoing re‐operative thyroid surgery and thyroid surgery for malignancies are at increased risk of RLNP. Intraoperative visualization and capsular dissection of the RLN remain the gold standard for intraoperative care during thyroid surgery for reducing RLNP risk. IONM should not be used as the sole mechanism for identifying and preserving the nerve, although it can be used to aid in the identification and dissection of the nerve, and may aid in nerve protection in high‐risk cases including cancer surgery and re‐operative surgery.

Follicular thyroid cancer: minimally invasive tumours can give rise to metastases.

Background:  The histological characteristics of follicular thyroid carcinomas (FTCs) are important predictors of prognosis, and lesions can be classified as either minimally invasive follicular carcinoma (MIFC) or widely invasive follicular carcinoma (WIFC) based on histopathological characteristics. There has been controversy surrounding the histological classification of FTC, which can present challenges to clinicians attempting to deliver accurate prognostic information to their patients. The aim of the present study was to examine cases of metastatic FTC for characteristics that may predict aggressive tumour behaviour.

Diagnostic lobectomy is not routinely required to exclude malignancy in thyroid nodules greater than four centimetres

Background:  Surgical excision has been recommended as a diagnostic test for thyroid nodules ≥4 cm, due to the supposedly higher rate of cancer in larger nodules and the higher reported false‐negative rates of fine‐needle aspiration cytology (FNAC) testing (>10%). The aims of this study are to determine the prevalence of thyroid cancer in nodules ≥4 cm, to examine if a relationship between increasing nodule size and malignancy rate was present and to study the accuracy of preoperative FNAC diagnosis.

HEMITHYROIDECTOMY: A HEURISTICS PERSPECTIVE

Heuristics describe the multiple small steps required for successful surgery, which are often taken for granted, enabling key manoeuvres, their correct order and their timely performance. Successful hemithyroidectomy is dependent on correct siting of the incision; tension to allow elevation of sub‐platysmal flaps without damaging anterior jugular veins; strap muscle division with preservation of the ansa cervicalis; recognition of the importance of the sub‐sternothyroid plane; superior mobility of the thyroid lobe, involving freeing the superior strap muscle layer and dissection of the pyramidal lobe; division of the isthmus to assist anteromedial mobility; dissection of the lateral thyroid space to free the posterior ‘v’ lip of the superior pole; medial to lateral dissection of the avascular cricothyroid space with preservation of the external laryngeal nerve, prior to ligation of the superior thyroid vessels; anteromedial rotation of the thyroid lobe with elevation of any retrosternal component; capsular dissection of the inferior pole with preservation of vascularity of the inferior parathyroid gland; dissection of the thyroid lobe off the recurrent laryngeal nerve, especially above the inferior thyroid artery in the region of greatest risk to the nerve, the region of the ligament of Berry; preservation of a vascularized superior parathyroid gland; capsular dissection, creating windows between vessels enabling their precise control, thereby minimizing haemorrhage. This paper aims to emphasize these heuristic components of thyroidectomy.

The role of fine-needle aspiration cytology in the surgical management of thyroid cancer.

Background:  Diagnosis of thyroid malignancy relies on clinical assessment, imaging and fine‐needle aspiration cytology ‘FNAC’ of thyroid nodules. The purpose of this study was to evaluate how effective synoptically reported FNAC is in clinical practice in diagnosing thyroid cancer. We also examined the effectiveness of using preoperative FNAC results to plan the type of operation for treating thyroid cancer.

Surgery for parathyroid microadenomas: patient characteristics, localization success and operative cures

In recent years, patients with primary hyperparathyroidism (PHPT) are being diagnosed earlier, with milder elevations in parathyroid hormone (PTH) and serum calcium. We aimed to investigate whether adenoma size reflects biochemical severity of presentation and influences localization of pre‐operative scans.

Total thyroidectomy for pressure symptoms in patients with Hashimoto's thyroiditis: Thyroidectomy for Hashimoto's thyroiditis

Hashimotos thyroiditis (HT) is rarely on its own the indication for thyroidectomy. However, surgery in patients with HT will be undertaken when there is malignancy and may be required for pressure symptoms. Therefore, this study aimed to investigate the indications for surgery in HT patients.

Temporal analysis of thyroid cancer management in a Melbourne tertiary centre

The American Thyroid Association (ATA) management guidelines for thyroid cancer were revised in 2009. The aim of this study was to determine if management of thyroid cancer in our institution has changed in accordance with the introduction of the revised ATA guidelines (ATA2009 ), and to compare the characteristics and management of thyroid cancer in a Melbourne endocrine surgery unit over a 7‐year period.