Thyroidectomy under local or general anesthesia?

What is thyroidectomy under local anesthesia?

Thyroidectomy is the operation that removes all or part of the thyroid, the gland at the base of the neck that regulates metabolism. It is performed mainly for goiter, hyperthyroidism and thyroid cancer.

For decades the anesthetic standard for thyroidectomy has been general anesthesia: the patient is asleep, the muscles are relaxed with paralyzing agents such as neuromuscular blockers, and the airway is protected by a tube (orotracheal intubation).

The alternative studied here is local infiltration anesthesia, also called "anterior field block": the surgeon infiltrates the anesthetic into the tissues of the neck, while the anesthesiologist supports the patient with light sedation and monitors them throughout the operation. The patient stays awake or nearly so, breathes on their own and can talk.

Why it is being discussed now

The number of operations is huge: in the United States 450,000 to 500,000 thyroidectomies are performed every year, and in Europe the figures range from more than 4,000 in Austria to 60,000 in Germany. As a result, even a small benefit for each operation carries great weight for the healthcare system. General anesthesia carries cardiovascular and respiratory risks, especially in older people, and lengthens the hospital stay. This is why local anesthesia has attracted interest precisely for the frailest patients. What was missing, however, was a quantitative synthesis of the studies: this review is the first to provide one.

A bit of history of thyroid surgery

For a long time thyroid surgery was an extremely high-risk operation. The turning point came at the end of the nineteenth century with the Swiss surgeon Theodor Kocher, who received the Nobel Prize in Medicine in 1909 for his work on the physiology, pathology and surgery of the thyroid. The comparison between local and general anesthesia has accompanied this surgery ever since, and today it is topical again for different reasons: faster recovery, same-day surgery and costs.

How the study was conducted

The authors searched four large databases for studies directly comparing local and general anesthesia in thyroidectomy, following the PRISMA guidelines. Of the 1,785 articles found, five remained: two randomized trials and three cohort studies, for a total of 508 patients, conducted in India, the United States, South Korea and Uganda. The risk of bias was assessed with the Cochrane tools (RoB 2 for the randomized trials, ROBINS-I for the others), and the overall quality of the evidence with the GRADE method.

Thyroidectomy under local anesthesia: what are the results?

Time in the operating room

Pooling four studies, local anesthesia shortens the time in the operating room by about 18 minutes (mean difference −18.3 minutes). The figure is fragile, however, because the studies differ greatly from one another (95% heterogeneity). The reason is that the advantage appears only in the cohort studies (−28.9 minutes), while in the two randomized trials the difference disappears (+2.0 minutes, not significant). In one of the randomized trials, moreover, the glands removed under general anesthesia weighed much more (63.9 g versus 26.9 g): the more complex operations ended up under general anesthesia, and this alone is enough to make them longer. The authors themselves therefore consider this result a hypothesis, not a conclusion.

Complications

Injuries to the recurrent laryngeal nerve, which controls the vocal cords, were identical in the two groups (risk ratio 1.00, in 316 patients). Breathing difficulties were very rare: three episodes in 358 patients, two with local anesthesia and one with general anesthesia. Note, however: with so few events the quality of the evidence is low, and the authors say so clearly: finding no difference does not prove that the two techniques are equally safe. Readers who want to learn more about the risk to the voice can read our article on vocal cord paralysis after thyroidectomy.

Hospital stay and costs

Here the result is consistent across all the studies that measured them. In two Indian studies the average hospital stay fell from about 71-75 hours to about 39-40 hours with local anesthesia, and in one of the two 26% of patients were discharged within 24 hours. In the US study, in a same-day surgery setting, patients operated on under local anesthesia were discharged after 165 minutes on average, compared with 229 minutes. As a result, costs also fall: the same study estimated a saving of 315 dollars per patient, and in the Indian studies the overall cost of the hospital stay was more than halved.

Patient satisfaction

Satisfaction is high with both techniques. In the US study, 93% of patients operated on under local anesthesia and 89% of those under general anesthesia were satisfied with their anesthesia, and between 89.7% and 96.6% of patients would recommend the same anesthesia to others.

What it means for the patient, and the advantages of the procedure

When patients ask me whether they can have thyroid surgery "while awake", I explain that the answer depends mainly on the type of operation: a small gland and a simple operation lend themselves to local anesthesia, while a large goiter or an extensive tumor almost always require general anesthesia, which ensures control of the airway and complete immobility. This study does not change that rule, but it adds a concrete piece of data: where local anesthesia is appropriate, patients go home sooner and satisfaction remains high.

There is also a less well-known advantage. With the patient awake, the surgeon can check the voice during the operation and immediately notice a problem with the laryngeal nerve. The authors point out, however, that where electrical nerve monitoring under general anesthesia is available, it remains the most reliable tool.

What are the potential limitations of local anesthesia in thyroid surgery?

A first limitation is that much depends on the setting in which the operation takes place: in several countries an anesthesiologist is present in every operating room, while in others the anesthesiologist is not present in all the rooms of the operating suite, and an assistant, a nurse or an anesthesia technician, acts in their place. In these latter cases, procedures under sedation, such as local anesthesia for thyroidectomy, tend to carry more risk, because they are supervised not by an anesthesiologist but by an assistant.

The other aspect to consider is that local anesthesia, especially when performed by a surgeon, carries a certain probability of failure, meaning that not all of the operated area is fully anesthetized, with the potential need to give additional local anesthetic during the operation or to switch to general anesthesia.

In either case, the patient should be specifically informed of this when giving informed consent to the procedure.

Thyroidectomy under local anesthesia: the message for doctors and clinicians

The evidence is still limited: five studies, the oldest conducted between 1996 and 2003, with a moderate to high risk of bias even in the randomized trials. The advantage in operating time does not hold up when only the randomized trials are considered, while the advantage in hospital stay and costs is consistent. What matters for the choice is the preoperative anesthesia assessment, with the ASA class and the anatomy of the airway. The practical message is simple: for selected patients, local anesthesia is a reasonable option and deserves to be offered. The technique must always be evaluated within the context of the staff resources available.

References

1. Hamzah KA, Eladl HH, Elfiqi S, Elsehsah AAS, et al. Local infiltration anesthesia (anterior field block) vs. general anesthesia for thyroidectomy: effects on operative time, complications, and cost — a GRADE-assessed systematic review and meta-analysis with subgroup analysis. Frontiers in Surgery. 2026. doi:10.3389/fsurg.2026.1697921. PubMed