The History of Thyroid Surgery

By Ben James, MD, MS, FACS
the history of thyroid surgery

The history of thyroid surgery represents an evolution of surgical technique and a vast expansion of our understanding of physiology. As an endocrine surgeon in the 21st century, it’s hard to imagine a time when patients with a large thyroid mass were considered too risky to operate on and when trying it was almost considered scandalous. Despite groundbreaking discoveries and surgical strides during the last 100 years, attempts at surgically removing the thyroid gland (thyroidectomy) were met with disaster and death for centuries. In fact, a common prescription in past centuries for an enlarged thyroid was to stroke a dead hand across the thyroid gland or rub toad’s blood on the neck!

While the first documented removal of the thyroid gland occurred over 1,500 years ago, it was not until the 12th century that a surgical technique was used to specifically address large thyroid glands, or “goiters.” In those days, surgeons used hooks to grasp and remove the thyroid gland in a piecemeal fashion. Given that general anesthesia was still many centuries in the future, patients were simply held down for this barbaric operation, and most patients died from bleeding. Attempts at thyroidectomy were pursued over the next 400 years with little success. Reportedly, one long-ago surgeon was even imprisoned after his patient died from such an endeavor.

The first series of successful thyroidectomies was documented in 1821 by a German surgeon named Johann Hedenus (1760-1836). Despite his achievement, the knowledge of Dr. Hendenus’s work had not spread until a century later in 1921. His operations could not be replicated by any other surgeon at the time. Different strategies for operating on the thyroid were under consideration and included variable incision sites, bloodletting and leaving the wound open.

Despite the rigorous, albeit cruel attempts at successful gland removal, little was actually known about the gland’s anatomy and function. Leonardo da Vinci was the first to show the thyroid as having two distinct sides or “lobes.” He believed that the gland existed to simply fill space in the neck. Others believed that the thyroid served to lubricate the neck or block blood from entering the brain. Some thought the thyroid gland was given to us by God to provide beauty – a “full” neck in women was considered to be quite attractive, something that was obvious in paintings during the 1500s and 1600s.

In the 19th century the discovery of iodine from burned seaweed led to the first step in treating large thyroid glands. Physicians in Switzerland began to experiment with using iodine to decrease the vascularity and size of the thyroid gland prior to surgery. Iodine is now recognized as having a critical function in being a central component of thyroid hormone.

Up until the mid 19th century, thyroid surgery was largely regarded as a high-risk surgery to be avoided at all costs. The mortality rate was a staggering 40%. One well known surgeon in Philadelphia went so far as to say “no honest or sensible surgeon… would ever engage in it.” However, despite its reputation, two surgeons in the 1800s to early 1900s set out to revolutionize thyroid surgery and bring it to the forefront of fundamental techniques still in practice today.

Theodor Billroth (1829-1894) was an Austrian physician largely considered the most prominent surgeon of his time. He was the first to perform an esophagectomy (removal of the esophagus) and has been called the “father of abdominal surgery.” Billroth was also an accomplished musician and was a close friend of Johannes Brahms. Billroth’s infectious personality brought throngs of trainees to study under him. He became the Chair of Surgery in Zurich in 1860 at the young age of 31. Seven years later, he was recruited to the University of Vienna as Professor of Surgery and remained there for the rest of his career.

As a young surgeon, Billroth attempted thyroid surgery, but when his mortality rate approached 40%, he abandoned the operation for nearly ten years. However, as he evolved in his operative skills and adopted the practice of antisepsis (using antiseptics to eliminate the microorganisms that cause disease) introduced by Joseph Lister in 1867, he decided to attempt thyroid surgery again. With these modifications, his patient mortality rate dropped to 10%.

Theodor Kocher (1841-1917), a Swiss surgeon, is believed to have advanced thyroid surgery more than any other physician in history. He visited Billroth and observed his technique in the operating room. While Billroth performed his thyroid surgeries at great speed, Kocher used a more meticulous approach and strongly promoted hemostasis - stopping the flow of blood - in addition to antisepsis during thyroid surgery. As a result, his mortality rate fell to less than 1%. While advancing the technique of performing thyroidectomy, Kocher also noted that his patients eventually developed what we now know as hypothyroidism. As a result of his work, Kocher was awarded the Nobel Prize in Medicine or Physiology in 1909.

William Halsted (1852-1922), the first Chair of Surgery at Johns Hopkins University, brought the techniques developed by Billroth and Kocher back to the United States and trained numerous future leaders in American surgery. Such trainees included Charles Mayo and Frank Lahey who eventually founded the Mayo Clinic and Lahey Clinic, respectively. These clinics began performing thousands of thyroidectomies a year with mortality rates under 1%.

Thyroid surgery is now considered a safe operation with a negligible mortality rate. The advances in thyroid surgery have included the use of smaller incisions and minimally invasive techniques. Open thyroidectomy as we know it today can be performed with incisions as small as 4 cm in length. Additionally, over the past twenty years, multiple remote access techniques have been developed to hide the incision site so that the scar from thyroid surgery is not visible on the neck. These techniques have included removing the thyroid by using “laparoscopic” instruments introduced through small incisions in the axilla, the top of the neck, or at the nipples.

In 2014, Dr. Angkoon Anuwong, a surgeon in Thailand, developed a technique whereby the thyroid gland is removed through an incision on the inside of the lower lip of the mouth. This technique is known as the Transoral Endoscopic Thyroidectomy Vestibular Approach, or TOETVA. This approach has seen a rapid adoption among endocrine surgeons with initial publications suggesting similar outcomes without increased risk of complications. Of all the innovative minimally invasive approaches to thyroid surgery, this approach has been touted as a revolutionary advancement in thyroid surgery since it leaves no skin scars at all and is expected to have lasting impact on the field of endocrine surgery.

Although it may appear as if techniques used in thyroid surgery today may have reached the ultimate refinement, history has demonstrated that new developments keep offering surprises - so we can only guess what is awaiting us in the future.