Thyroidectomy

History of thyroidectomy

Abdul Kasan Kelebis Abis performed the first recorded thyroidectomy in AD 500 in Baghdad, followed by Abu Al-Qasim in Spain in AD 952. These surgeries were primitive and fraught with high mortality due to a lack of antisepsis, anaesthesia, and effective bleeding control. Surgeons like Albert Theodor Billroth and Theodor Kocher revolutionized thyroidectomy. Kocher introduced the collar incision, preserved the strap muscles whenever possible and through its meticulous technique and systematic artery ligation, reduced mortality rates from 12.6% in 1870 to 0.2% by 1898. He is known as the “father of modern thyroid surgery” and won a Nobel Prize in 1909.

Types of Thyroid Surgeries

Indications of Tracheostomy

Thyroid surgery is primarily indicated under four broad categories referred to as the four C’s, along with hyperthyroidism:

1. Cancer Thyroid: Surgery is essential for confirmed thyroid malignancies.
2. Suspicion of Cancer: Thyroid neoplasms are identified on Fine Needle Aspiration Cytology (FNAC) or when thyroid nodules present with risk factors for malignancy.
3. Compressive Symptoms: Enlarged thyroid glands can exert pressure on the trachea, oesophagus, or major veins, leading to difficulty breathing (dyspnoea), swallowing (dysphagia), or thoracic-inlet syndrome. Positive Pemberton’s sign, where raising the arms causes respiratory distress, facial suffusion, and neck vein engorgement, indicates compression.
4. Cosmetic Concerns: Large nodules or multinodular goitres that are cosmetically unacceptable require surgical intervention.
5. Hyperthyroidism: Conditions like autonomous thyroid nodules or Graves’ disease warrant surgery, particularly in cases of pregnancy or when radioiodine therapy is contraindicated.

Preoperative Work-Up for Thyroid Surgery

1. Informed Consent: Obtain comprehensive consent after explaining risks, benefits, and alternatives to surgery.
2. Detailed Patient History: Include symptoms of thyroid dysfunction, compressive symptoms (e.g., dyspnea, dysphagia), history of radiation exposure, drug history or family history of thyroid disorders.
3. Thorough Physical Examination: Assess thyroid size, nodularity, consistency, cervical lymph nodes, and tracheal compression signs.
4. Thyroid Function Tests: Evaluate TSH, T4, and T3 levels. Ensure the patient is euthyroid to reduce the risk of thyroid storm in thyrotoxic patients. Treat and stabilize thyrotoxicosis preoperatively.
5. Laryngeal Function Assessment: Perform indirect laryngoscopy and voice assessment to detect vocal cord paralysis or dysfunction. Preoperative identification of recurrent laryngeal nerve palsy (RLNP) is critical to prevent bilateral vocal cord paralysis and predict invasive thyroid malignancy.
6. Fine Needle Aspiration Cytology (FNAC): Perform FNAC to evaluate thyroid nodule histology and determine malignancy potential.
7. Thyroid Peroxidase (TPO) Antibodies: Assess TPO levels when autoimmune conditions like Graves’ disease are suspected.
8. Calcitonin Level: Measure serum calcitonin if medullary thyroid carcinoma is suspected.
9. Baseline Serum Calcium: Establish baseline calcium levels to monitor potential parathyroid dysfunction postoperatively.
10. Ultrasound of Thyroid/Neck: Evaluate nodule size, number, and consistency (solid or cystic). Assess cervical lymph nodes: suspect malignancy if nodes appear enlarged, round, and lose hilar echogenicity.
11. Thyroid Scintigraphy (Thyroid Scan): Indicated for patients with suspected autonomous thyroid nodules or to identify functional nodules.
12. CT Scan of Chest: Perform when tracheal compression or retrosternal goitre is suspected.
13. Preoperative Surgical Fitness Investigations: Routine investigations to assess patient readiness:
    • Haemogram
    • Urine analysis: routine and microscopic
    • Fasting Blood Sugar
    • Blood Urea/Creatinine
    • Chest X-ray: assess pulmonary and tracheal status
    • ECG: evaluate cardiac function
    • Echocardiography: if indicated for cardiac assessment

Tracheostomy Steps of operation:

1. Anaesthesia: Thyroid surgery is done under general anaesthesia.

2. Positioning of the Patient: The patient is placed supine, supported by a soft shoulder pad and a head ring to facilitate optimal neck extension, enhancing surgical exposure and stabilising the head.

3. Kocher Incision: After infiltrating local anaesthesia into the skin crease, a horizontal cervical incision is made in the skin crease or approximately two finger-breadths above the suprasternal notch. The incision extends between the anterior borders of the sternocleidomastoid muscles, ensuring adequate access and visualisation. The incision traverses the skin and subcutaneous tissue. For female patients with heavy breasts, the incision is placed slightly higher to minimise hypertrophic scarring caused by tension near the manubrium.

4. Elevation of Flaps: The skin incision is extended down to the platysma muscle. This muscle is more easily identifiable in the lateral portions of the incision. The platysma muscle is incised with precision because the upper flap will be dissected in a plane along its deep surface. The subplatysmal flaps are elevated from the thyroid cartilage superiorly to the suprasternal notch inferiorly. This dissection, performed in an avascular plane, minimises bleeding risks. The anterior jugular veins within the superficial fascia are identified and safeguarded to prevent post-operative haemorrhage or oedema of the flap. Once elevated, the flaps are either sutured back or held in place with a self-retaining Joll’s retractor to maintain optimal exposure.

5. Separation of Strap Muscles: A midline incision is made in the superficial cervical fascia, extending from the thyroid cartilage to the suprasternal notch. The midline is most accurately identified by palpating the thyroid cartilage prominence and the trachea or by locating the space between the right and left anterior jugular veins. The sternohyoid and sternothyroid muscles are carefully separated to expose the thyroid gland and facilitate entry into the avascular paracarotid tunnel. For large thyroids, partial division of the strap muscles can be done at the junction of the upper 1/3rd and lower 2/3rd of these muscles to avoid damaging the ansa cervicalis nerve. It improves surgical exposure for dissection and visualisation of the superior vascular poles. Additionally, ligamentous fibres of the sternocleidomastoid muscles may be separated to facilitate access to retrosternal goitres.

6. Dissection of the Middle Lateral Thyroid Lobe and Vascular Ligation: To enhance the exposure of the paracarotid tunnel, the thyroid lobe is retracted medially while the sternothyroid muscle is drawn laterally. Excessive traction on the thyroid lobe is avoided to minimise the risk of bleeding from the middle thyroid vein, which could hinder the identification of the inferior parathyroid gland and the recurrent laryngeal nerve. Though the middle thyroid vein is present only in approximately 15–20% of patients, surgeons should exercise caution to identify and ligate it properly. The middle thyroid vein drains into the internal jugular vein. Inferior thyroid veins forming an anterior venous plexus over the trachea must also be ligated and divided with precision. Additionally, the thyroidea ima artery, if present, should be carefully managed to avoid accidental injury.

7. Dissection of the Inferior Pole, Ligation of Vessels, and Identification of the Recurrent Laryngeal Nerve (RLN): The surgical process proceeds to the dissection of the inferior pole of the thyroid gland. This involves ligation of the inferior thyroid artery, a branch of the thyrocervical trunk, which supplies both the thyroid gland and the parathyroid glands. The artery runs medially behind the internal carotid artery before taking a horizontal course to the thyroid gland. It is critical to ligate the artery close to the thyroid gland to preserve the blood supply to the parathyroid glands.

Identification of the Recurrent Laryngeal Nerve (RLN). The RLN is located in or lateral to the tracheoesophageal groove and runs closer to the trachea on the left side compared to the right. On the right, the nerve’s more oblique and lateral course makes it more susceptible to injury. The RLN may pass anterior, posterior, or through the inferior thyroid artery, necessitating careful dissection to preserve it. Injury to the RLN can result in vocal cord dysfunction, ranging from mild hoarseness to life-threatening stridor in cases of bilateral injury.
Anatomical Triangles for RLN Identification. Key anatomical landmarks aid in identifying the RLN:

• Beahrs Triangle (Riddle’s Triangle)
  • Medial border: Recurrent laryngeal nerve.
  • Lateral border: Common carotid artery.
  • Superior border: Inferior thyroid artery.
• Lore’s Triangle
  • Medial border: Trachea/oesophagus.
  • Lateral border: Retracted strap muscles.
  • Superior border: Lower pole of the thyroid gland.

The apex of Lore’s Triangle points inward at the thoracic inlet, where the RLN passes. On the right, it traverses the triangle obliquely, while on the left, it ascends along the tracheoesophageal groove. Approaches to Identify RLN

• Lateral Approach: Involves identifying the RLN within Beahrs or Lore’s Triangle.
• Superior Approach: This approach locates the nerve at the cricothyroid junction at its entry into the larynx, which is particularly useful in revision surgery or cancer cases with extensive nodal involvement.
• Inferior Approach: Recommended for large goitres or revision surgeries, enabling nerve identification in an undisturbed area.

 Identification and Preservation of Parathyroid Glands. With the gland mobilised medially, the parathyroid glands are identified, along with the recurrent laryngeal nerve (RLN). The parathyroid glands lie external to the thyroid capsule beneath the pretracheal fascia. Inferior parathyroids are present inferior to the inferior thyroid artery and lie anterior to the plane of the recurrent laryngeal nerve. In contrast, superior parathyroids are present superior to the inferior thyroid artery and lie posterior or deep to the plane of recurrent laryngeal nerve and are relatively uniform in their position. Their position, however, can vary significantly, ranging from the hyoid bone to the mediastinum. Care must be taken to avoid damaging the glands, indicated by a change in its colour to a darker appearance. If inadvertently removed, the parathyroid glands can be sliced into small pieces (smaller than 1 mm) and reimplanted into the sternocleidomastoid muscle (preferably contralateral side) or brachioradial muscle of the forearm after histological confirmation via a frozen section. It is useful to remember that in normal saline fat floats and parathyroid tissue sinks, although this is not a 100 per cent reliable test for parathyroid tissue.

8. Dissection of the Superior Thyroid Pedicle and Upper Pole: With the inferior pole mobilized, the focus shifts to the superior aspect of the thyroid gland. To enhance access, the sternothyroid muscle is divided near its upper part, exposing the superior thyroid artery and vein for ligation. These vessels are tied off individually and as close to the gland as possible to prevent inadvertent damage to the external branch of the superior laryngeal nerve (EBSLN).

The EBSLN, originating from the vagus nerve, runs near the superior thyroid vessels and provides motor innervation to the cricothyroid muscle. Injury to this nerve may result in subtle yet significant voice changes, such as loss of high pitch and vocal fatigue, which can severely impact professional voice users. To prevent such complications, identify the EBSLN in Joll’s triangle (sternothyrolaryngeal triangle).

Boundaries of Joll’s triangle:

• Medial border: The midline of the neck.
• Lateral border: The superior pole of the thyroid gland and the superior thyroid vessels.
• Roof: The attachment of the strap muscles to the thyroid cartilage.

Inferior traction on the thyroid gland facilitates the preservation of the nerve. Identifying and protecting the EBSLN during this step is critical to minimising functional complications and optimizing surgical outcomes

9. Dissection of the Berry Ligament and Separation of the Thyroid Lobe from the Trachea: The Berry ligament is a dense connective tissue structure that anchors the thyroid gland to the trachea. At this step, careful dissection is performed to separate the thyroid lobe from the trachea while preserving the recurrent laryngeal nerve (RLN), which is most vulnerable in this region. The ligament is dissected using precise and controlled bipolar diathermy. To ensure safety, the bipolar diathermy blades should rest on the thyroid gland, away from the nerve. Following diathermy, the ligament is divided with a size 15 scalpel blade, providing enhanced precision and minimizing the risk of nerve injury.

10. Division of the Isthmus (for Hemithyroidectomy): The Isthmus is separated from the anterior tracheal wall, doubly clamped and then divided to ensure complete removal. The cut surface of the isthmus on the contralateral side is ligated with 3/0 chronic catgut by continuous interlocking suture for haemostasis. The pyramidal lobe should always be identified, dissected and excised together with the thyroidectomy specimen. The pyramidal lobe if present, is dissected and excised alongside the thyroidectomy specimen to avoid the need for adjuvant RAI, or sampling to exclude the possibility of local recurrence.

11. Irrigation of the Wound: The surgical site is irrigated thoroughly with normal saline or a diluted antiseptic solution such as betadine. For thyroid cancer cases, antiseptics like betadine are avoided to prevent interference with histopathological evaluation or adjuvant therapies.

12. Hemostasis: The wound is cleared of clots to inspect for any active bleeding points. The Valsalva manoeuvre is performed by the anaesthetist through intermittent positive-pressure ventilation. This helps identify venous oozing or small bleeding vessels, which are promptly controlled.

13. Drainage: To prevent hematoma formation, suction drainage is applied. Proper drainage reduces the risk of complications such as airway obstruction or infection and ensures a smooth postoperative recovery.

14. Closure of the Wound: The wound is closed in layers for optimal healing and cosmetic results. The strap muscles are approximated using 3/0 vicryl sutures. Similarly, the platysma layer is closed with 3/0 vicryl sutures, followed by subcutaneous sutures. Subcuticular sutures are used to enhance the cosmetic appearance of the incision. Steristrips are applied along the incision lines to strengthen them further and promote a neat closure.

Postoperative Care

After thyroid surgery, patients should be positioned with the head elevated at a 45-degree angle for the first 4 hours to minimize swelling and enhance breathing. Vocal cord function should be assessed promptly, especially if there is any suspicion of recurrent laryngeal nerve (RLN) injury. Prophylactic anticoagulant therapy to prevent venous thromboembolism should be initiated 24 hours after surgery and continued until discharge.

Management

• Intravenous Steroids: Administered during the first 24 hours to alleviate pain and act as an antiemetic.
• Antibiotics: Intravenous antibiotics are recommended to prevent infection.
• Analgesia: Opiates are preferred over nonsteroidal anti-inflammatory drugs to reduce the risk of postoperative bleeding.
• Diet: A normal diet may be resumed 4 hours post-surgery.
• Drain Management: Drains may be removed if the volume is ≤20 mL at 24 hours or ≤10 mL at 8 hours.
• Suture Removal: Sutures are typically removed 7–10 days postoperatively, promoting optimal healing and cosmetic results.

Complications

1. Hematoma: A critical and potentially life-threatening complication due to tracheal compression, resulting in hypoxia, brain injury, or death. Prompt evacuation of hematoma is essential upon diagnosis.
2. Airway Obstruction: This can result from hematoma, tracheomalacia, laryngeal oedema, or thickened vocal cords. Severe obstruction may necessitate tracheostomy.
3. Recurrent Laryngeal Nerve (RLN) Injury. Intra-operative visualization and neural monitoring of the recurrent laryngeal nerve (rln) reduce injury rates. Post-operative laryngoscopy is crucial for early identification of vocal cord paralysis, with various treatments available, including injections, thyroplasty, and reinnervation, typically the ansa cervicalis to the distal RLN stump.
4. External Branch of Superior Laryngeal Nerve (SLN) Injury. Post-operatively, inquire about voice strength, pitch and fatigue; if present suspect ebsln injury, and perform videostroboscopy and speech therapy.
5. Wound Infection: Appropriate surgical techniques and antibiotic prophylaxis are necessary to minimize this risk.
6. Hypertrophic Scar or Keloid Formation: A carefully placed collar incision in a natural skin crease can improve cosmetic outcomes. Lower incisions carry a higher risk of hypertrophic scarring.
7. Hypocalcemia: Occurs due to parathyroid gland removal or devascularization. Symptoms include numbness and tingling of lips, hands and feet. In such cases, the calcium level may be less than 8.0 mg/dL. The critical period is 24–96 hours after operation. Always check for serum calcium levels postoperatively. It may require calcium and vitamin D supplementation by oral or i.v. route depending on the severity of hypocalcaemia.
8. Pneumothorax: Rarely occurs due to pleural injury in the lower neck during surgery.
9. Hypothyroidism: Commonly manifests 4–6 weeks postoperatively, requiring long-term thyroid hormone replacement therapy.
10. Thyroid Storm: A rare but life-threatening condition caused by the release of excessive thyroid hormones. Preoperative administration of antithyroid drugs is essential to restore euthyroid status and prevent this complication.
11. Seroma. Seromas occur in 1–7% of cases and often occur after large goitre or thyroidectomy surgery. They are managed conservatively, with observation or aspiration of the fluid using the sterile technique for pain relief. Most resolve in 6–8 weeks, though if there is a concern of infection, the aspirated fluid should be sent for culture and antibiotics should be started.
12. Infection. Infection of the surgical site is rare (<1%). Superficial infections are treated with local care and oral antibiotics, while deep infections require incision, drainage, iv antibiotics.

———— End of the chapter ————

High-Yield Revision Points 

• Thyroidectomy is indicated mainly for 4C + hyperthyroidism.
• Kocher incision is the standard collar incision.
• Most dangerous complication: postoperative neck hematoma.
• RLN injury causes hoarseness, bilateral injury causes stridor.
• RLN is most vulnerable near Berry ligament.
• EBSLN injury causes loss of high pitch and vocal fatigue.
• Ligate superior thyroid vessels close to gland to protect EBSLN.
• Ligate inferior thyroid artery close to gland to preserve parathyroid blood supply.
• Hypocalcaemia occurs typically within 24–96 hours.
• Pemberton’s sign suggests retrosternal goitre.
• Always perform preoperative laryngoscopy to document vocal cord status.
• Parathyroid autotransplantation can be done into SCM or forearm.
• Subtotal thyroidectomy has higher recurrence, therefore total/near-total is preferred in many cases.

NEET PG-Style MCQs

1. The surgeon known as the father of modern thyroid surgery who won the Nobel Prize in 1909 is: A. Billroth B. Kocher C. Halsted D. Lister
2. Pemberton’s sign is positive in which condition? A. Hyperthyroidism B. Retrosternal goitre with thoracic inlet compression C. Thyroid cancer D. Hypoparathyroidism
3. The most common nerve injured during thyroidectomy is: A. External branch of superior laryngeal nerve B. Recurrent laryngeal nerve C. Phrenic nerve D. Spinal accessory nerve
4. Injury to the external branch of the superior laryngeal nerve causes: A. Hoarseness B. Loss of high pitch and vocal fatigue C. Stridor D. Dysphagia
5. The critical period for developing postoperative hypocalcaemia is: A. 0-6 hours B. 24-96 hours C. 5-7 days D. 2-4 weeks
6. The Berry ligament attaches the thyroid gland to which structure? A. Oesophagus B. Trachea C. Cricoid cartilage D. Hyoid bone
7. The triangle used to identify the external branch of the superior laryngeal nerve is: A. Beahrs triangle B. Lore’s triangle C. Joll’s triangle D. Pirogoff’s triangle
8. A parathyroid gland inadvertently removed during thyroidectomy should be: A. Discarded B. Sliced into small pieces and reimplanted into sternocleidomastoid C. Sent for histopathology only D. Frozen and used later
9. The most life-threatening complication of thyroidectomy is: A. Hypocalcaemia B. Recurrent laryngeal nerve injury C. Haematoma D. Hypothyroidism
10. Which artery must be ligated close to the thyroid gland to preserve parathyroid blood supply? A. Superior thyroid artery B. Inferior thyroid artery C. Thyroidea ima D. Middle thyroid vein

MCQ Answers: 1-B, 2-B, 3-B, 4-B, 5-B, 6-B, 7-C, 8-B, 9-C, 10-B

Clinical Case Scenarios for Practical Exams

Case 1. A 45-year-old woman presents with a 3 cm thyroid nodule found incidentally on ultrasound. FNAC shows Bethesda Category IV (follicular neoplasm). She is euthyroid with no compressive symptoms. Most likely diagnosis: Follicular thyroid neoplasm (indeterminate for malignancy). Best next step: Diagnostic hemithyroidectomy with intraoperative frozen section.

Case 2. A 60-year-old man undergoes total thyroidectomy for multinodular goitre. Six hours postoperatively, he develops progressive neck swelling, respiratory distress, and stridor. Most likely diagnosis: Postoperative haematoma with airway compromise. Best next step: Immediate bedside opening of the wound and evacuation of haematoma, followed by emergency return to operating room if needed.

Case 3. A 35-year-old woman who had total thyroidectomy for Graves’ disease complains of perioral numbness and tingling in her fingers 48 hours after surgery. Serum calcium is 7.2 mg/dL (normal 8.5-10.2). Most likely diagnosis: Postoperative hypocalcaemia due to parathyroid injury or devascularisation. Best next step: Oral calcium and calcitriol supplementation; intravenous calcium if severe symptoms or very low calcium levels.

Case 4. A 50-year-old professional singer undergoes thyroid lobectomy. Postoperatively, she complains that she cannot hit high notes and her voice tires easily. Laryngoscopy shows normal vocal cord movement. Most likely diagnosis: External branch of superior laryngeal nerve injury. Best next step: Videostroboscopy to confirm diagnosis and referral for voice therapy.

Frequently Asked Questions in Viva

• What is the most common complication after thyroidectomy? Temporary hypocalcaemia is the most common complication, occurring in 10-30% of patients, though permanent hypocalcaemia occurs in less than 2% of cases when performed by an experienced surgeon.
• How long does it take to recover from thyroidectomy surgery? Most patients return to normal activities within 2 to 3 weeks after surgery, but complete healing and scar maturation take several months.
• Can you live a normal life without a thyroid gland? Yes, patients can live a completely normal life by taking daily thyroid hormone replacement medication (levothyroxine) to maintain normal metabolism.
• What is the difference between total thyroidectomy and hemithyroidectomy? Total thyroidectomy removes the entire gland and is indicated for bilateral disease or cancer, while hemithyroidectomy removes only one lobe and is used for benign unilateral nodules or diagnostic purposes.
• How is the recurrent laryngeal nerve protected during surgery? The nerve is protected by meticulous dissection, identification using anatomical landmarks (Beahrs and Lore’s triangles), and sometimes intraoperative nerve monitoring.
• What should I do if I develop neck swelling after thyroidectomy? Any significant neck swelling after thyroid surgery is a potential haematoma and medical emergency; return to the hospital immediately for evaluation.
• When can I resume my voice-intensive profession after thyroid surgery? Most patients can resume normal speaking within 1-2 weeks, but professional voice users should wait 4-6 weeks and may benefit from voice therapy.

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Download full PDF Link: Thyroidectomy Best Lecture Notes Dr Rahul Bagla ENT Textbook

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• G.J. Romanes, Cunningham’s Manual of Practical Anatomy: Head and Neck and Brain.
• David J. Terris, Textbook of Thyroid and Parathyroid Diseases Medical and Surgical Management.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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FAQs

1. What is the recovery time for thyroidectomy? Most people recover fully within 2-4 weeks, but this varies depending on the individual and the extent of the surgery.
2. Will I need to take medication for life after thyroidectomy? If your entire thyroid is removed, you’ll need lifelong thyroid hormone replacement therapy.
3. Can thyroidectomy affect my voice permanently? While rare, permanent voice changes can occur if the vocal cords are damaged. Most voice changes are temporary.
4. How soon can I return to work after a thyroidectomy? Many people can return to work within 1-2 weeks, depending on the nature of their job and recovery progress.

5. Is thyroidectomy a common procedure? Yes, it is a widely performed and generally safe surgical procedure with high success rates.