Competence through excellence
Surgery of the thyroid gland is a traditional focus of the Martha-Maria Hospital in Munich. The typical complications of thyroid surgery, such as vocal cord nerve injury resulting in a voice disorder or parathyroid injury resulting in a calcium deficiency in the blood, are reduced to a minimum using the latest techniques. To avoid vocal cord nerve injury, we have always depicted the vocal cord nerve during surgery. In addition, since 1998 we have regularly performed so-called neuromonitoring of the vocal cord nerve during all thyroid and parathyroid operations. We have the greatest experience with this method worldwide.
With the so-called neuromonitoring of the vocal cord nerve, we are now able not only to visualize and spare the nerve in its course, but also to assess its function with a high degree of probability, which was previously not possible in thyroid surgery. Neuromonitoring-oriented we have developed special surgical strategies, especially for problem cases. In order to avoid injury to the parathyroid glands, these are also made visible during the operation to protect them. If the blood circulation is damaged, individual parathyroid glands are immediately removed and then reimplanted into the cervical musculature, thus ensuring that their function is maintained. In order to assess whether the removed thyroid tissue is benign or malignant, we have the option of performing a fine-tissue frozen section examination. The pathologist can then communicate directly with the surgical team by telephone within 30 minutes. This enables us to obtain precise information about the tissue removed. In addition to the safety of the patient and the functional surgery, we are also interested in cosmetically favorable scar formation in our patients. For this reason, very small skin incisions are made - if possible - or the operation is performed in a minimally invasive way.
Thyroid gland nodule
The thyroid gland plays a central role in the body's metabolism. A dysfunction can have less or very serious consequences for the organism.
The thyroid gland is a small, butterfly-shaped gland located below the larynx. It produces hormones that regulate our metabolism and energy balance, and ensures that a minimum amount of energy is available to enable our body to function properly. Problems related to the thyroid gland are among the most frequently described complaints.
Thyroid nodules are changes in thyroid tissue that occur relatively frequently in a normal thyroid gland and are usually no larger than one centimeter. They are often located on the edge of the thyroid gland, and patients may feel a thickening in the neck. If they reach a certain size or if the patient is rather thin, the change may also be visible from the outside.
Thyroid nodes are harmless in 95 percent of cases. They are usually not associated with any further consequences for the patient. Nevertheless, it is important to consult a doctor as soon as a palpable thickening occurs, since in five percent of cases the node is usually hidden behind cancer. Various imaging techniques are used to assess the nodules, such as scintigraphy or sonography.
If various suspicious findings coincide in these examinations, the risk of finding cancer in the nodules can also rise to over 20 percent.
There are different types of thyroid nodes: Colloidal nodules, cysts, inflammatory nodes, adenomas and thyroid cancer. In some cases, the nodes can produce thyroid hormones that lead to hyperthyroidism, which increases the metabolic processes associated with weight loss, heart palpitations, sleep disorders, etc. These nodes are called "hot nodes" or "autonomous adenomas".
With the help of a blood sample, the thyroid gland values in the blood can be checked and an appropriate diagnosis made.
The parathyroid glands are small organs that fit more or less tightly to the thyroid gland and regulate the body's calcium metabolism. The regulation takes place via the hormone of the parathyroid gland, the so-called parathyroid hormone.
Surgery of the parathyroid glands is usually necessary if there is an overproduction of the parathyroid hormone. If this overproduction is caused by enlargement of the parathyroid glands for reasons that are not obvious, the resulting disease is called primary hyperparathyroidism. In this case, either only one gland (about 80 percent) or two glands (about two percent) or all four glands (17 percent) may be affected. The disease is almost always benign, in rare cases there is an inherited disorder. Depending on the number of diseased glands, different surgical procedures are chosen.
It is important to leave enough healthy parathyroid tissue to ensure that calcium metabolism continues to function and to remove all diseased tissue. The possible positional variations of the parathyroid glands and the recognition of diseased tissue require a very experienced surgeon, especially for this type of surgery. At Martha-Maria Hospital Munich, this experience is given to a high degree by the large number of operations we perform.
In addition to the experience, some special devices are indispensable in parathyroid surgery, for example the possibility of cold preservation of parathyroid tissue. This tissue can be preserved for years and, if necessary, after thawing, can be implanted into the human musculature to resume normal function.
A further newer procedure in parathyroid surgery, which we have also been using since 1998, is the measurement of parathyroid hormone during surgery, the so-called Quick Parathyroid Hormone Test. This parathormone measurement can be used to measure the success of the operation at an early stage during the operation.
If the appropriate conditions are met, minimally invasive parathyroid operations are also possible.
If the overproduction of parathyroid hormone is due to reactive reasons (such as chronic kidney failure or if calcium cannot be absorbed into the body through the intestine), we speak of reactive hyperparathyroidism. In this case all four parathyroid glands are always diseased and enlarged. They are either removed except for a small, normal-sized residue (subtotal parathyroidectomy) or all parathyroid glands in the neck area are removed and part of the tissue is implanted into the muscles of the forearm in the same session (total parathyroidectomy plus autologous transplantation). During these operations, cryopreservation of the parathyroid tissue is then of great importance to the patient.
Paralysis of the vocal cord nerves (recurrent paresis) is one of the dreaded complications in thyroid and parathyroid surgery. A unilateral recurrent paresis leads to a standstill of one vocal cord. In most cases, the voice is then hoarse. The frequencies given in the literature vary from less than one percent to more than 20 percent in second and multiple operations (recurrent surgery). Paralysis of both vocal cord nerves often results in respiratory distress, which may require a tracheotomy.
However, the majority of vocal cord paralyses that occur during surgery on the thyroid or parathyroid gland regress. To keep the risk of recurrent paresis as low as possible, we monitor the vocal cord nerve by means of neuromonitoring. For this purpose, the vocal cord nerve (nervus recurrens) is electrically stimulated by a probe during the operation. The stimulation causes the muscle supplied by the nerve - here the vocalis muscle - to contract. This muscle is located in the larynx and moves the vocal cord. An electrode placed in this muscle derives corresponding signals and displays them acoustically. In this way it is possible to localize the vocal cord nerve and to check its integrity during the operation.
Operations on the adrenal glands and pancreas complete the endocrine spectrum. Problem-oriented, the operations are performed in a minimally invasive or open surgical manner. The safety of our patients with avoidance of the typical complications is of particular concern to us, in addition to successful and functional therapy. Neuromonitoring is used during the operation to avoid vocal cord injuries.
During the operation, histological frozen section examination can also be used to determine whether the tissue removed is benign or malignant. The pathologist who performs this histological examination has a laboratory in the hospital so that the result is available in the shortest possible time.
Expertise in thyroid surgery
It is recommended in all guidelines that thyroid and parathyroid surgery should only be performed in specialized clinics
To show our specialization, we would like to display the number of operations performed in our clinic (see also publication in "The Oncologist" or under Publications).
From 1.1.2015 to 30.6.2015 the following thyroid gland operations were performed at our clinic:
- 1228 thyroid gland surgeries in total
- 74 recurrence operations
- 129 Thyroid carcinomas
- 10 Medullary thyroid carcinomas
- 111 Primary hyperparathyroidism