Outpatient and Minimally Invasive Approaches Or Safe and Effective Options for Thyroid and Parathyroid Surgery

Our outpatients did very well, commented Dr. Terris. Complication rates were low and comparable for both groups (2 vs 1, p = 1.0). Mean estimated blood loss was lower for outpatients than for inpatients (17.8 ± 14.0 cc vs 29.4 ± 22.1 cc, p = 0.02). No patients suffered permanent recurrent laryngeal injury.

Historically, one of the reasons surgeons have been reluctant to perform thyroid and parathyroid surgery on an outpatient basis is the concern for bleeding, which necessitates the placement of a surgical drain. Use of the Harmonic ACE™, a device that utilizes frictional energy rather than electrical energy, in conjunction with a small incision, has virtually eliminated this worry. We now use the Harmonic ACE exclusively to control blood supply to the gland. It is very hemostatic, and when we’re done, there’s a very dry field, said Dr. Terris. By using the Harmonic ACE and minimal access, we can avoid need for the drain. This eliminates a potential source of postoperative infection. Dr. Terris has given lectures sponsored by the manufacturer of the Harmonic ACE, but has no stock or financial stake in the outcome of the company.

The Harmonic ACE also helps shave operative time by about 20 to 30%. Savings in time by using the harmonic device are offset, in part, by the increased time needed when using a minimally invasive approach.

Another potential drawback to outpatient thyroid surgery is the fear of life-threatening hypocalcemia. To avoid this problem, in a novel approach, patients in this study were placed on a prophylactic calcium supplementation regimen consisting of a 3-week taper of oral calcium carbonate (600 mg TID for the first week, 600 BID for the second week, and 600 every day for the third week), and ionized calcium levels were monitored postoperatively. Even if parathyroid hormone levels were low because of dissection, it didn’t matter because we maintained the calcium level by supplementation, said Dr. Terris.

The typical patient profile for minimally invasive thyroidectomy is the young woman with thyroid nodules of unclear malignant potential or a very low-risk cancer. These patients typically do not have very enlarged glands, says Dr. Terris.

But outpatient thyroid surgery is not for all patients. Inpatient stays are still warranted for medically infirm patients with significant coexisting conditions, patients who have undergone concomitant procedures requiring admission, and patients who may prefer hospitalization. Open incisions are usually necessary for patients with giant goiters.