Surgery for Benign Goiter

  • Kerstin LorenzEmail author


Surgery for benign goiter is an infrequent surgical procedure. Country and regional variations in surgical treatment of benign goiter are influenced by disease-specific differences as well as by health system-related factors. Thyroid surgery is therefore performed with regional variations by specialized endocrine, general, and ENT surgeons.

Surgery for benign euthyroid conditions is selected according to the underlying disease; however, corresponding or prevalent thyroid functional status and response to previous therapy may further influence the surgical concept for the individual patient. For nodular goiter, extent of resection is directed by number, localization, and distribution of affected areas within each thyroid lobe. Preoperative work-up generally includes laboratory assessment and thyroid ultrasonography at minimum. Functional status and organ volume in large goiter with possible retrosternal extension may be further investigated with nuclear medicine or radiological imaging. Assessment of preoperative vocal cord function is regarded as obligatory.

Key issues of thyroid surgery are preservation of the recurrent laryngeal nerves (RLN) and parathyroid glands (PG) as well as cautionary measures to prevent postoperative hemorrhage and recurrent goiter. Intraoperative neuromonitoring (IONM) is an established technique that may assist in limiting injury of the RLN, while intraoperative functional assessment of the PG with fluorescent techniques awaits further investigations regarding their value for PG preservation in thyroid surgery. Postoperative management focuses on observation of the typical complications of thyroid surgery, namely, airway management (recurrent laryngeal nerve palsy (RLNP)), hypocalcemic symptoms (hypoparathyroidism), and any signs of bleeding in the early postoperative phase. Follow-up after thyroid surgery assesses remaining thyroid function or adequate thyroid hormone substitution and possible signs of goiter recurrence. Surgery for recurrent goiter may be very challenging and is associated with significantly elevated complication rates; however, in specialized experienced centers, good surgical results at low complications rates are achieved.


Thyroid surgery Multinodular goiter Thyroiditis Intraoperative neuromonitoring Hypoparathyroidism 


  1. 1.
    Agarwal G, Agarwal V. Is total thyroidectomy the surgical procedure of choice for benign multinodular goiter? An evidence-based review. World J Surg. 2008;32:1313–24.CrossRefPubMedGoogle Scholar
  2. 2.
    Krohn K, Führer D, Bayer Y, Eszlinger M, Brauer V, Neumann S, Paschke R. Molecular pathogenesis of euthyroid and toxic multinodular goiter. Endocr Rev. 2005;26:504–24.CrossRefPubMedGoogle Scholar
  3. 3.
    Maneck M, Dotzenrath C, Dralle H, Fahlenbrach C, Paschke R, Steinmüller T, Tusch E, Jeschke E, Günster C. Complications after thyroid gland operations in Germany: a routine data analysis of 66,902 AOK patients. Chirurg. 2017;88:50–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Moalem J, Suh I, Duh QY. Treatment and prevention of recurrence of multinodular goiter: an evidence-based review of the literature. World J Surg. 2008;32:1301–12.CrossRefPubMedGoogle Scholar
  5. 5.
    Musholt TJ. Total thyroidectomy for nodular goiter. Chirurg. 2010;81:603–11.CrossRefPubMedGoogle Scholar
  6. 6.
    Studer H, Derwahl M. Mechanisms of nonneoplastic endocrine hyperplasia-a changing concept: a review focused on the thyroid gland. Endocr Rev. 1995;16:411–26.PubMedGoogle Scholar
  7. 7.
    Bonnema SJ, Fast S, Hegedüs L. The role of radioiodine therapy in benign nodular goitre. Best Pract Res Clin Endocrinol Metab. 2014;28:619–31.CrossRefPubMedGoogle Scholar
  8. 8.
    Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;16:1–133.CrossRefGoogle Scholar
  9. 9.
    Haugen BR. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: what is new and what has changed? Cancer. 2017;123:372–81.CrossRefPubMedGoogle Scholar
  10. 10.
    Musholt TJ, Clerici T, Dralle H, Frilling A, Goretzki PE, Hermann MM, Kussmann J, Lorenz K, Nies C, Schabram J, Schabram P, Scheuba C, Simon D, Steinmüller T, Trupka AW, Wahl RA, Zielke A, Bockisch A, Karges W, Luster M, Schmid KW. Interdisciplinary task force guidelines of the German Association of Endocrine Surgeons German Association of endocrine surgeons practice guidelines for the surgical treatment of benign thyroid disease. Langenbecks Arch Surg. 2011;396:639–49.CrossRefGoogle Scholar
  11. 11.
    Delbridge L. Total thyroidectomy: the evolution of surgical technique. ANZ J Surg. 2003;73:761–8.CrossRefGoogle Scholar
  12. 12.
    Dralle H, Lorenz K, Machens A. State of the art: surgery for endemic goiter-a plea for individualizing the extent of resection instead of heading for routine total thyroidectomy. Langenbeck’s Arch Surg. 2011;396:1137–43.CrossRefGoogle Scholar
  13. 13.
    Gough IR, Wilkinson D. Total thyroidectomy for management of thyroid disease. World J Surg. 2000;24:962–5.CrossRefGoogle Scholar
  14. 14.
    Dralle H. Identification of the recurrent laryngeal nerve and parathyroids in thyroid surgery. Chirurgische Arbeitsgemeinschaft Endokrinologie der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie und für die Deutsche Gesellschaft für Chirurgie. Chirurg. 2009;80:352–63.CrossRefGoogle Scholar
  15. 15.
    Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surgery. 2003;133:180–5.CrossRefGoogle Scholar
  16. 16.
    Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, Dralle H. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg. 2000;24:1335–41.CrossRefPubMedGoogle Scholar
  17. 17.
    Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A. German IONM study group intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008;32:1358–66.CrossRefPubMedGoogle Scholar
  18. 18.
    Dralle H, Lorenz K. Intraoperative neuromonitoring in thyroid surgery. Chirurg. 2010;81:612–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Dralle H, Lorenz K, Schabram P, Musholt TJ, Dotzenrath C, Goretzki PE, Kußmann J, Niederle B, Nies C, Schabram J, Scheuba C, Simon D, Steinmüller T, Trupka A, Surgical Working Group for Endocrinology. Intraoperative neuromonitoring in thyroid surgery. Recommendations of the Surgical Working Group for Endocrinology. Chirurg. 2013;84:1049–56.CrossRefPubMedGoogle Scholar
  20. 20.
    Lorenz K, Dralle H. Intraoperative neuromonitoring in thyroid surgery. In: Dralle H, editor. Endocrine surgery. Evidence and experience. Stuttgart; 2014. p. 88–111.Google Scholar
  21. 21.
    Randolph GW, Dralle H, International Intraoperative Monitoring Study Group, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccolli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Sloan T, Van Slycke S, Snyder S, Takami H, Volpi E, Woodson G. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011;121(Suppl 1):S1–16.CrossRefPubMedGoogle Scholar
  22. 22.
    Schneider R, Sekulla C, Machens A, Lorenz K, Nguyen Thanh P, Dralle H. Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring. Br J Surg. 2015;102:1380–7.CrossRefGoogle Scholar
  23. 23.
    Schneider R, Randolph G, Dionigi G, Barczyński M, Chiang FY, Triponez F, Vamvakidis K, Brauckhoff K, Musholt TJ, Almquist M, Innaro N, Jimenez-Garcia A, Kraimps JL, Miyauchi A, Wojtczak B, Donatini G, Lombardi D, Müller U, Pezzullo L, Ratia T, Van Slycke S, Nguyen Thanh P, Lorenz K, Sekulla C, Machens A, Dralle H. Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: the International Neural Monitoring Study Group’s POLT study. Laryngoscope. 2016;126:1260–6.CrossRefGoogle Scholar
  24. 24.
    Tonacchera M, Pinchera A, Vitti P. Assessment of nodular goitre. Best Pract Res Clin Endocrinol Metab. 2010;24:51–61.CrossRefPubMedGoogle Scholar
  25. 25.
    Gotway MB, Higgins CB. MR imaging of the thyroid and parathyroid glands. Magn Reson Imaging Clin N Am. 2000;8:163–82.Google Scholar
  26. 26.
    Higgins CB, Auffermann W. MR imaging of thyroid and parathyroid glands: a review of current status. AJR Am J Roentgenol. 1988;151:1095–106.CrossRefGoogle Scholar
  27. 27.
    Higgins CB, McNamara MT, Fisher MR, Clark OH. MR imaging of the thyroid. AJR Am J Roentgenol. 1986;147:1255–61.CrossRefGoogle Scholar
  28. 28.
    Olbricht T. Schilddrüsensonographie. Nuklearmedizin. 1995;18:79–86.Google Scholar
  29. 29.
    Russ G, Leboulleux S, Leenhardt L, Hegedüs L. Thyroid incidentalomas: epidemiology, risk stratification with ultrasound and workup. Eur Thyroid J. 2014;3:154–63.CrossRefPubMedGoogle Scholar
  30. 30.
    Weber AL, Randolph G, Aksoy FG. The thyroid and parathyroid glands. CT and MR imaging and correlation with pathology and clinical findings. Radiol Clin N Am. 2000;38:1105–29.CrossRefPubMedGoogle Scholar
  31. 31.
    Magri F, Chytiris S, Chiovato L. The role of elastography in thyroid ultrasonography. Curr Opin Endocrinol Diabetes Obes. 2016;23:416–22.CrossRefPubMedGoogle Scholar
  32. 32.
    Pusztaszeri M, Rossi ED, Auger M, Baloch Z, Bishop J, Bongiovanni M, Chandra A, Cochand-Priollet B, Fadda G, Hirokawa M, Hong S, Kakudo K, Krane JF, Nayar R, Parangi S, Schmitt F, Faquin WC. The Bethesda system for reporting thyroid cytopathology: proposed modifications and updates for the second edition from an international panel. Acta Cytol. 2016;60:399–405.CrossRefPubMedGoogle Scholar
  33. 33.
    Baloch ZW, Fleisher S, LiVolsi VA, Gupta PK. Diagnosis of “follicular neoplasm”: a gray zone in thyroid fine-needle aspiration cytology. Diagn Cytopathol. 2002;26:41–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Erkan M, Canberk S, Kilicoglu GZ, Onenerk M, Uludokumaci A, Gunes P, Atasoy T. Avoidance of unnecessary fine-needle aspiration with the use of the thyroid imaging reporting data system classification and strain elastography based on the Bethesda system for reporting thyroid cytopathology. Mol Clin Oncol. 2016;5:625–30.CrossRefPubMedGoogle Scholar
  35. 35.
    Sughayer MA, Abdullah N. The Bethesda system for reporting thyroid cytopathology: a meta-analysis. Acta Cytol. 2017;61:172.CrossRefPubMedGoogle Scholar
  36. 36.
    Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, Cronan JJ, Beland MD, Desser TS, Frates MC, Hammers LW, Hamper UM, Langer JE, Reading CC, Scoutt LM, Stavros AT. ACR thyroid imaging, reporting and data system (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017;14:587–95.CrossRefPubMedGoogle Scholar
  37. 37.
    Ulisse S, Bosco D, Nardi F, Nesca A, D'Armiento E, Guglielmino V, De Vito C, Sorrenti S, Pironi D, Tartaglia F, Arcieri S, Catania A, Monti M, Filippini A, Ascoli V. Thyroid imaging reporting and data system score combined with the new Italian classification for thyroid cytology improves the clinical management of indeterminate nodules. Int J Endocrinol. 2017:9692304.Google Scholar
  38. 38.
    Reinwein D, Benker G, König MP, Pinchera A, Schatz H, Schleusener A. The different types of hyperthyroidism in Europe. Results of a prospective survey of 924 patients. J Endocrinol Investig. 1988;11:193–200.CrossRefGoogle Scholar
  39. 39.
    Buckley JA, Stark P. Intrathoracic mediastinal thyroid goiter: imaging manifestations. AJR Am J Roentgenol. 1999;173:471–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Huins CT, Georgalas C, Mehrzad H, Tolley NS. A new classification system for retrosternal goitre based on a systematic review of its complications and management. Int J Surg. 2008;6:71–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Khan MN, Goljo E, Owen R, Park RC, Yao M, Miles BA. Retrosternal goiter: 30-day morbidity and mortality in the transcervical and transthoracic approaches. Otolaryngol Head Neck Surg. 2016;155:568–74.CrossRefPubMedGoogle Scholar
  42. 42.
    Nankee L, Chen H, Schneider DF, Sippel RS, Elfenbein DM. Substernal goiter: when is a sternotomy required? J Surg Res. 2015;199:121–5.CrossRefPubMedGoogle Scholar
  43. 43.
    Pieracci FM, Fahey T. Substernal thyroidectomy is associated with increased morbidity and mortality as compared with conventional cervical thyroidectomy. J Am Coll Surg. 2007;205:1–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Wheeler MH. Clinical dilemma. Retrosternal goitre. Br J Surg. 1999;86:1235–6.CrossRefPubMedGoogle Scholar
  45. 45.
    White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg. 2008;32:1285–300.CrossRefPubMedGoogle Scholar
  46. 46.
    Wuhrmann F. Die Struma intrathoracica. Dtsch Z Chir. 1896;43:1–117.CrossRefGoogle Scholar
  47. 47.
    Karkouti K, Rose DK, Wigglesworth D, Cohen MM. Predicting difficult intubation: a multivariable analysis. Can J Anaesth. 2000;47:730–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Lombardi D, Müller U, Pezzullo L, Ratia T, Van Slycke S, Nguyen Thanh P, Lorenz K, Sekulla C, Machens A, Dralle H. Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: the International Neural Monitoring Study Group’s POLT study. Laryngoscope. 2016;126:1260–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Lorenz K, Abuazab M, Sekulla C, Schneider R, Nguyen Thanh P, Dralle H. Results of intraoperative neuromonitoring in thyroid surgery and preoperative vocal cord paralysis. World J Surg. 2014;38:582–91.CrossRefPubMedGoogle Scholar
  50. 50.
    Steinmüller T, Ulrich F, Rayes N, Lang M, Seehofer D, Tullius SG, Jonas S, Neuhaus P. Surgical procedures and risk factors in therapy of benign multinodular goiter. A statistical comparison of the incidence of complications. Chirurg. 2001;72:1453–7.CrossRefGoogle Scholar
  51. 51.
    Lehwald N, Cupisti K, Willenberg HS, Schott M, Krausch M, Raffel A, Wolf A, Brinkmann K, Eisenberger CF, Knoefel WT. Standard-radical vs. function-preserving surgery of benign nodular goiter-a sonographic and biochemical 10-year follow-up study. Langenbeck’s Arch Surg. 2009;394:279–83.CrossRefGoogle Scholar
  52. 52.
    Phitayakorn R, McHenry CR. Follow-up after surgery for benign nodular thyroid disease: evidence-based approach. World J Surg. 2008;32:1374–84.CrossRefGoogle Scholar
  53. 53.
    Brauckhoff M, Machens A, Sekulla C, Lorenz K, Dralle H. Latencies shorter than 3.5 ms after vagus nerve stimulation signify a non-recurrent inferior laryngeal nerve before dissection. Ann Surg. 2011;253:1172–7.CrossRefGoogle Scholar
  54. 54.
    Vidal Fortuny J, Belfontali V, Sadowski SM, Karenovics W, Guigard S, Triponez F. Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery. Br J Surg. 2016;103:537–43.CrossRefPubMedGoogle Scholar
  55. 55.
    Casella C, Pata G, Nascimbeni R, Mittempergher F, Salerni B. Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy? World J Surg. 2009;33:261–5.CrossRefGoogle Scholar
  56. 56.
    Barczyński M, Randolph GW, Cernea CR, Dralle H, Dionigi G, Alesina PF, Mihai R, Finck C, Lombardi D, Hartl DM, Miyauchi A, Serpell J, Snyder S, Volpi E, Woodson G, Kraimps JL, Hisham AN, International Neural Monitoring Study Group. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope. 2013;123(Suppl 4):S1–14.CrossRefGoogle Scholar
  57. 57.
    Bellantone R, Lombardi CP, Bossola M, Boscherini M, De Crea C, Alesina P, Traini E, Princi P, Raffaelli M. Total thyroidectomy for management of benign thyroid disease: review of 526 cases. World J Surg. 2002;26:1468–71.CrossRefGoogle Scholar
  58. 58.
    Bergenfelz A, Jansson S, Kristoffersson A, Martensson H, Reihner E, Wallin G, Lausen L. Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbeck’s Arch Surg. 2008;393:667–73.CrossRefGoogle Scholar
  59. 59.
    Karamanakos SN, Markou KB, Panagopouos K, Karavias D, Vagianos CE, Scopa CD, Fotopoulou V, Liava A, Vagenas K. Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2043 procedures. Hormones. 2010;9:318–25.CrossRefGoogle Scholar
  60. 60.
    Hegedüs L, Bonnema SJ, Smith TJ, Brix TH. Treating the thyroid in the presence of Graves’ ophthalmopathy. Best Pract Res Clin Endocrinol Metab. 2012;26:313–24.CrossRefGoogle Scholar
  61. 61.
    Kahaly GJ, Bartalena L, Hegedüs L. The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective. Thyroid. 2011;21:5855–91.CrossRefGoogle Scholar
  62. 62.
    Benker G, Olbricht T, Windeck R, Wagner R, Albers H, Lederbogen S, Hoff HG, Reinwein D. The sonographical and functional sequelae of de Quervain’s subacute thyroiditis: long-term follow-up. Acta Endocrinol. 1988;117:435–41.CrossRefGoogle Scholar
  63. 63.
    Lorenz K, Gimm O, Holzhausen HJ, Kittel S, Ukkat J, Thanh PN, Brauckhoff M, Dralle H. Riedel’s thyroiditis: impact and strategy of a challenging surgery. Langenbeck’s Arch Surg. 2007;392:405–12.CrossRefGoogle Scholar
  64. 64.
    Lorenz K, Sekulla C, Kern J, Dralle H. Management of postoperative hemorrhage following thyroid surgery. Chirurg. 2015;86:17–23.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Visceral, Vascular, and Endocrine SurgeryMartin-Luther-University of Halle-WittenbergHalle (Saale)Germany

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