A 45-year-old woman has a solitary, nonfunctioning thyroid nodule and fine needle cytology is nondiagnostic. Which of the following is the initial surgical procedure of choice?

d. Total extracapsular thyroid lobectomy and resection of the isthmus

Total extracapsular thyroid lobectomy and isthmus resection is the procedure of choice when a decision has been made to surgically remove a thyroid nodule. The entire lobe with the isthmus is submitted for frozen-section pathologic examination if fine needle aspirate has not already resulted in a definitive diagnosis of carcinoma. In performing total lobectomy, both parathyroid glands are carefully preserved with their blood supply. This is done in the event that total thyroidectomy is necessary if either the frozen or permanent histologic sections confirm the presence of thyroid carcinoma. Total lobectomy offers the best opportunity for accurate histologic diagnosis and is associated with the lowest incidence of complications when the need for reoperation is considered. In one experience, 800 consecutive cases of total unilateral lobectomy were performed for benign or malignant nodules suspected of cancer, and no permanent recurrent laryngeal nerve palsies occurred. Primary total lobectomy is safer than a partial lobectomy followed by resection of the residual lobe after a delayed diagnosis of malignancy. Reoperation to complete a lobectomy is associated with a greater risk to both recurrent laryngeal nerve and the parathyroids on the ipsilateral side.

Although there is controversy as to whether a total lobectomy and isthmus resection or a total thyroidectomy is the best definitive operation for unilateral papillary carcinoma, a subtotal lobectomy is universally considered an inadequate operation. A definitive cancer operation can be accomplished with one procedure in 80% of the cases when a skilled thyroid pathologist is available for frozen-section interpretation.