[Safety-driven radical approaches in routine thyroid surgery: roles and challenges]

Introduction: In thyroid surgery, the primary objectives are to facilitate effective hormone replacement therapy and to prevent recurrent diseases. Thyroid lobectomy is often the optimal approach to achieve these goals. Objective: This study aims to establish the criteria for safety-driven radicality and identify the appropriate surgical approaches. Methods: A total of 2215 thyroid surgeries were performed between 2001 and 2003. Among these, 86.1% were uni- or bilateral lobectomies, and 12.3% were near-total resections. Substernal extension was observed in 28.9% of cases, and recurrent disease was found in 5.3%. Partial sternotomy was required in 1.8% of cases. Results: Of the 2215 thyroid specimens analyzed, 27.9% were tumors, 19.6% showed hyperplasia, and 18.1% exhibited inflammation. Among the 216 cases of papillary carcinoma, the occult form was present in 42.1%, encapsulated form in 30.1%, multinodular form in 26.4%, bilateral involvement in 12.5%, and mixed appearance in 8.3%. Lymph node involvement in the central region was detected in 41% of cases. Co-occurrence of tumors with Hashimoto’s thyroiditis was significantly more common than with hyperplasia. Transient laryngeal nerve paresis occurred in 3.3% of cases, while permanent paresis was observed in 0.49%. Discussion: Radicality in thyroid surgery aims to minimize residual tissue while ensuring the functional integrity of nerves and parathyroid glands. These objectives are challenged by tissue inflammation, cancer, substernal extension, recurrent disease, and undetected metastases in the central paratracheal lymph nodes. Our analysis of routine lobectomies with meticulous nerve preparation revealed a significantly higher incidence of recurrent laryngeal nerve paresis in cases involving recurrent disease. Conclusion: Maintaining blood-free surgical conditions, cooling the nerves during preparation, meticulous dissection of nerves at the superior pole of the thyroid, and experience in excising non-inflammatory thyroid tissue are crucial for achieving safety-driven radicality. These practices are effective not only in cancer cases but also in the presence of hyperplasia, inflammation, and recurrent disease. Orv Hetil. 2024; 165(39): 1548–1557.