**11. Choice of surgical procedure**

Bilateral subtotal thyroidectomy (STT), Dunhill procedure (DP), near total thyroidectomy (NTT) and total thyroidectomy (TT) are the four procedures that have been or are being performed for GD. STT, DP, NTT were the procedure of choice till 21st century due to said higher incidence of hypoparathyroidism, nerve damage or hematoma [15]. However, these have not been verified in recent large studies or meta-analysis [48]. A retrospective cohort study 8032 patients of benign thyroid disease having undergone STT or TT found no difference in temporary of permanent nerve damage and permanent hypoparathyroidism though temporary hypocalcemia was significantly higher in TT compared to TT (13.12% Vs. 2.7%) [49]. A similar trend has been seen in most other studies. TT for GD has been found to have lower rates of recurrent hyperthyroidism compared to other procedures (STT more than DP) [17, 50]. The nerve damage rates have been higher however hypocalcemia rates have been slightly higher though they do not reach statistical

significance [50]. The choice of surgical procedure did not have a difference in their effect on Graves' ophthalmopathy [17, 50]. RAI with steroid cover was found to be not inferior to surgery. The TT performed by trained surgeons at high volume center have no higher rates of these morbid complications. More and more TT are now being performed for benign diseases throughout world. Thomas WT et al. in an analysis of nationwide in patient analysis in US noted an increase in TT for benign diseases from 17.6% in 1993–1997 to 39.6 in 2003–2007 [51]. This trend is seen across the globe even in less developed regions [40, 52]. However TT may be avoided in in situations where lifelong thyroxine supplements may be un reliable, more common in the lesser developed countries [3]. Never the less, 2016 ATA guidelines for Hyperthyroidism suggest that a NTT of TT should be performed for GD if surgery is being contemplated [30].

## **12. Disadvantages of surgery**

Patients would require lifelong thyroxine replacement after thyroidectomy and compliance may be an issue in some. Also, potential risk of permanent hypoparathyroidism and recurrent laryngeal nerve damage or neck hematoma are present. However, in trained hands, their incidence is no higher than after surgery for euthyroid goiters. Vis a vis ATD and RAI, surgery is the least cost effective first line treatment of Graves' Disease [53, 54]. In recurrent GD after ATT, surgery was more cost effective than RAI or lifelong ATD to a large extent [55]. The cost implications are likely to vary across the globe depending on various factors.

#### **13. Surgical approach to thyroid**

Though conventionally, open thyroidectomy through a transverse collar incision is the standard of care, heightened cosmetic demands of patients along with refinements in surgical instruments and surgical training has resulted in significant shift favoring minimally invasive procedures. Meta-analysis of 846 cases between 1999–2011 by Zhang et al. concluded that endoscopic thyroidectomy provides better cosmetic satisfaction along with lesser blood loss at the expense of higher costs and operative time with acceptable rates of hypocalcemia and nerve compromise [56].

Robotic surgery is now a feasible option for Graves' Disease with comparable complication rates [57]. Also, larger glands can be excised via robotic technique. Retrospective analysis of 44 robotic TT via bilateral axillo- breast approach was no inferior when compared to 144 cases of open thyroidectomy in terms of recurrence, hypocalcemia and nerve damage on prolonged follow up of 35 months [58]. This is now a valid option for those concerned about cosmesis.

#### **14. Conclusion**

Etiology of hyperthyroidism has to be determined thoroughly to determine the line of management. Radioactive iodine ablation (RAI) or surgery is the main modality of treatment in GD. Anti-thyroid drug is essential to make the patient euthyroid prior to definitive therapy. Prompt discussion with patients regarding delayed outcome and retreatment in those who opt for RAI is mandatory. Surgical treatment of choice in the form of NTT or TT ought to be performed in a highvolume centre to reduce complication and recurrence. Toxic adenoma and TMNG are managed similarly to GD i.e., rendering euthyroid with ATDs, followed by

*Surgery for Graves' Disease DOI: http://dx.doi.org/10.5772/intechopen.96958*

definitive therapy. Extent of surgery in toxic solitary adenoma depends on radiology, nuclear imaging after malignancy is ruled out. Newer ablative therapies like RFA, EA, LTA are considered as a substitute for definitive therapy in selective patients. Nonetheless malignancy should always be treated by surgery.
