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Table 1: Summary of the recommendations described according to their level of evidence and grade of recommendation. |
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Preoperative |
Level of evidence |
Grade of recommendation |
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Recommendation 1. The patient should have imaging studies and BAAD (fine needle aspiration biopsy) to determine the nature and staging of the thyroid lesion and suspicious adenopathies |
High |
Strong |
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Recommendation 2. Thyroid function status should always be checked. Ideally, all patients should be admitted to surgery euthyroid. In the case of hypofunction, it should be previously replaced. In the case of hyperthyroidism, optimal pharmacological treatment should be implemented (e.g., beta-blockers, methimazole, propylthiouracil, and Lugol, as the case may be) and cardiovascular risk should be evaluated |
High |
Strong |
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Recommendation 3. Subjective voice evaluation (Voice Handicap Index questionnaire) is recommended. Objective evaluation by laryngoscopy or translingual ultrasound should be performed in patients with dysphonia, dysphagia, previous surgery, or imaging suspicion of recurrent laryngeal nerve invasion |
Moderate- high |
Intermediate |
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Recommendation 4. Routine assessment of 25-OH vitamin D levels and replenishment of vitamin D, if necessary, is recommended to reduce the incidence of transient post-thyroidectomy hypocalcemia |
Moderate |
Intermediate |
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Intraoperative |
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Recommendation 5. The extent of thyroid resection should be adjusted to the ATA risk group and data on local invasion and lymph node metastasis |
Moderate-high |
Strong |
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Recommendation 6. Identifying and preserving the recurrent laryngeal nerves, superior laryngeal nerves, and parathyroid glands without compromising their integrity is recommended whenever possible |
High |
Strong |
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Recommendation 7. The use of advanced energy equipment (ultrasonic, advanced bipolar, mixed) is recommended to reduce blood loss and surgical time |
Moderate-high |
Strong |
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Recommendation 8. Intraoperative neuromonitoring is recommended since it has proven to be helpful in the functional preservation of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve in neck reoperations or cases of high risk for chordal dysfunction |
Moderate- high |
Intermediate |
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Recommendation 9. Routine use of drains in thyroid surgery is not recommended |
High |
Strong |
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Postoperative |
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Recommendation 10. Measuring serum calcium (ionized or corrected) and PTH in the immediate postoperative period is recommended. Immediate oral use of calcium with or without calcitriol can be implemented in those patients at higher risk of hypocalcemia |
High |
Strong |
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Recommendation 11. Measurement of serum magnesium levels and its replacement, if necessary, is recommended |
Low |
Weak |
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Recommendation 12. It is recommended that levothyroxine be started immediately postoperatively in patients with total thyroidectomy or pre-existing hypothyroidism. TSH levels should be monitored in the following 4-6 weeks to adjust this substitution scheme |
High |
Strong |