Thyroid Surgery: The Importance of Experience

There are some unique challenges to thyroid surgery, mainly related to the structures that surround the thyroid. There is a delicate nerve called the recurrent laryngeal nerve (RLN) which runs behind the thyroid and goes to the voice box. If this nerve is stretched, injured or damaged during surgery then hoarseness or breathiness of the voice can result. The rate of injury in this surgery is directly related to the amount of experience that the surgeon has. Recently the American Thyroid Association cited a problem in that over 80% of thyroid operations were being performed by low- or intermediate-volume surgeons. What they noted was that low-volume and intermediate-volume surgeons had higher complication rates than high-volume surgeons. They broke down the experience of these different types of surgeons according to the number of surgeries they did each year. Low-volume surgeons perform less than 10 cases per year, sometimes only 1 or 2 cases per year. An intermediate surgeon would perform between 10 and 100 cases per year, whereas a high-volume surgeon does an excess of 100 cases per year. Their data shows that high-volume surgeons (who clearly have more experience in doing this delicate operation) have lower rates of complications. They cited overall complication rates for experienced high-volume surgeons at 7.5%. This is substantially higher than my own experience but not as surprising as what you see when you look at intermittent-volume surgeons who the ATA states have a 13.4% complication rate. Even worse, low-volume surgeons have complication rates as high as 18.9%. This is from a statistically significant study put out by the Healthcare Utilization Project nationwide inpatient sampling incorporating over 6,000 surgeons in the study. The ATA concluded from this data that patients should be referred to high-volume thyroid surgeons, particularly if the case is considered to be extensive or complex. They also noted that even high-volume surgeons have a higher rate of complications when a total thyroidectomy is performed vs. a more limited lobectomy. They did cite that high-volume surgeons saw their rates of complications go from 7.5% for lobectomy to 14.5% for total thyroidectomy. Still, experience matters here as low-volume surgeons saw complication rates of 11.8% rise to 24% for total thyroidectomies. The bottom line from all this data is that the amount of surgeries that are done is critical in developing techniques which are meticulous and are more likely to avoid injury to delicate structures such as the recurrent laryngeal nerve and the parathyroid glands. The experience the surgeon has determines the risk of injury that you face if you need thyroid surgery, so choose wisely!