Thyroid and endocrine surgery
Goitre | Thyroid nodules | Thyroid cancer | Hyperthyroidism | Hypothyroidism | Thyroidectomy | Hyperparathyroidism | Adrenal surgery | Neuromonitoring
The range of endocrine surgery at the Pyramid Clinic includes thyroid, parathyroid and adrenal gland surgery. Complex findings are discussed with specialists in endocrinology, taking an interdisciplinary approach, and indications are assessed together.
The thyroid gland is located below the larynx and surrounds the trachea. This small, butterfly-shaped organ fulfils a vital role, being responsible for the production, storage and release of thyroid hormones. These hormones regulate numerous metabolic processes as well as the energy balance of the body’s cells.
A goitre refers to an enlarged thyroid gland. In the past, goitre was very common in Switzerland due to a deficiency of iodine in the diet. Since iodine is a fundamental component of the thyroid hormone, iodine deficiency leads to a lack of effective thyroid hormone in the body. The body detects this deficiency and reacts by stimulating the growth of the thyroid gland. Uncontrolled thyroid growth or changes in the thyroid gland happen on a much smaller scale today. Sometimes the glandular changes are not visible, and can only be felt by hand or possibly only detected by ultrasound. Nowadays these changes are interpreted as benign tumours of the thyroid gland, which are caused by mutations in the genetic material of the cells. Small nodules on the thyroid are common in young women.
If isolated nodules or lumps occur in the thyroid gland, these require further investigation. Formation of nodules in the thyroid gland is very common and is due to excessive production of thyroid hormone. This causes uncontrolled but benign growth of thyroid cells. In the vast majority of cases, thyroid nodules are benign. However, as they increase in size and take up more space, these benign changes can displace neighbouring organs. If a malignant condition is suspected and if there are large nodules causing displacement, surgery is necessary. We offer minimally invasive video-assisted thyroidectomy (MIVAT) to meet the high cosmetic demands in these cases. With appropriate surgical expertise, this cosmetically favourable method can be used as an alternative to the classic throat incision. In this new endoscopically assisted method, the incision is reduced to a length of 2 to 3 cm and is barely visible if it correctly follows a skin crease.
The incidence of thyroid cancer in the population has risen sharply in the last 30 years. One of the reasons for this is the increased ability to detect cancers when they are very small and at a very early stage. It is important to distinguish between the four types of carcinoma, because they are treated using different therapeutic approaches. The prognosis for each type also differs. To summarise, 90% of thyroid carcinomas are curable. This means that thyroid cancers are significantly more treatable than most other cancers in other organs.
The increased production of thyroid hormones by individual nodules (autonomous adenoma) or by the thyroid gland as a whole (Graves’ disease) causes an overactive thyroid. Typical symptoms include weight loss, a fast pulse and restlessness. In this situation, it is important for an endocrinologist to be involved in the treatment. Drug treatment to restrict the thyroid gland will be indicated. However, surgery is often necessary for definitive treatment of symptoms.
Graves’ disease is an autoimmune disease. It occurs when a receptor on the thyroid cells is not recognised by the immune system as being generated by the body itself. Antibodies are then produced which activate the receptor and lead to excessive hormone formation. The disease causes symptoms including restlessness, rapid heartbeat and weight loss. Sleep disorders and diarrhoea are also typical. The disease often causes the eyeballs to protrude prominently, a symptom known as exophthalmos.
Hypothyroidism is a deficiency of thyroid hormones, often associated with autoimmune disease or thyroid inflammation. This deficiency leads to various complaints such as fatigue, sensitivity to cold, constipation and muscle weakness. It is treated by administering thyroid hormones in the form of medication.
At the Pyramid Clinic, we currently offer conventional thyroid gland removal as well as the minimally invasive method. Both methods are safe and well proven. Minimally Invasive Video Assisted Thyroidectomy (MIVAT) is now the most widely used minimally invasive procedure in neck surgery. It is established as the preferred method for the removal of small thyroid glands and small nodules. Minor nodular changes of up to 2 cm in particular can be operated using a method that is painless, less invasive and cosmetically advantageous. Surgical access to the thyroid gland is achieved using the smallest possible horizontal skin incision to the neck of 2 to 3 cm. In order to carry out the surgical processes, the surgeon introduces an endoscope that provides an enlarged display of the area onto a screen. This reveals the parathyroid glands and the laryngeal nerve, enabling them to be protected during surgery. Minimally invasive procedures are not only cosmetically more favourable. The smaller the incision, the less pain the patient will experience after the operation and the shorter the recovery period or hospital stay.
Hyperparathyroidism is the overactive function of one or more parathyroid glands. The four parathyroid glands are about the size of a lentil and are attached to the thyroid capsule. They are adjacent to the thyroid gland but have a completely different function, serving to regulate the balance of calcium in the blood. Problems arise if the parathyroid glands carry out their task too well. The parathyroid glands can then develop into independent hormone generators (parathyroid adenoma), and the body becomes flooded with parathyroid hormone (PTH). When PTH is released into the blood by the glands, the concentration of calcium in the blood increases as a result. Excessively high levels lead to a complex of symptoms that is often associated with severe fatigue, depression and reduced functioning. Muscle pain is also typical. This is very limiting and does not respond well to anti-inflammatory drugs.
The symptoms decrease after surgical removal of the parathyroid gland (parathyroidectomy) which was producing excess hormones. Patients often feel much more capable and fatigue decreases. They frequently describe a feeling of having had a heavy weight removed from their shoulders after the surgery. Chronic damage to the kidneys, blood vessels and bones is resolved when calcium metabolism returns to normal. Parathyroidectomies are regularly carried out using endoscopic assistance and a minimally invasive approach. The incision can be limited to a maximum of 2 cm and after a few months is hardly visible.
A highly specialised surgeon is required for successful parathyroid surgery. After resection of a parathyroid adenoma, normalisation of the PTH/calcium metabolism is assessed by collection of intraoperative blood samples and communicated to the surgical team in the operating theatre. In simple terms, the operation is successful if the PTH value drops by more than 50% after removal.
The Pyramid Clinic provides the surgeon with another valuable tool for monitoring the success of parathyroid surgery. With intraoperative fluorescence imaging using an infrared camera, overactive parathyroid tissue can be better distinguished from normal parathyroid tissue. This avoids a situation where the parathyroid tissue that is independently producing excess hormones remains in the body, which can lead to a recurrence of the disease.
Surgery of the adrenal gland is rare – so the expertise of the surgeon is all the more important. The most frequent indications for surgical removal of the adrenal gland, also known as adrenalectomy, are large tumours (incidental tumours) and hormone-active tumours, so-called adenomas, which are mostly small in size. In the case of active tumours, comprehensive preoperative diagnostics by an experienced endocrinologist are of the utmost importance. The endocrinologist will coordinate the diagnostic imaging and interventional radiological procedures based on hormone results from laboratory tests. These days, adrenalectomies can almost always be performed laparoscopically.
The function of a neuromonitor is to monitor nerve function during surgery using electromyography. Using the latest generation of neuromonitor, the risk of injury to the laryngeal nerves, which control vocal cord function, is reduced to a minimum. Problems with temporary hoarseness after surgery can thus be significantly reduced. In order to avoid damage to the parathyroid glands, which are embedded in the surface of the thyroid gland, imaging is used during the procedure and care is taken to ensure there is no injury to their blood supply. The risk of postoperative hypocalcaemia is estimated based on a parathyroid hormone test on the first postoperative day and calcium substitution may be begun, depending on the result. Emergency readmission due to tetany (involuntary muscle contraction) can thus be eliminated.