Challenges of Thyroidectomy for Large Goiters: Our Experience in Goiter Endemic Areas of the Democratic Republic of Congo

Background: Large goiters are common in regions where iodine deficiency is endemic. They lead to technical challenges for surgeons performing a Kocher cervicotomy, due to the anticipated difficulties of dissection and the increase of postoperative complications. Focusing on our experience in goiter-endemic areas, we offer tips and techniques to overcome these challenges. Patients and methods: This is a prospective study conducted in hospitals across the North Ubangi and South Ubangi provinces of the DRC from July 2023 to October 2025. The study included 104 patients over a two-year period; all the patients underwent a thyroidectomy. The study parameters included age, sex, surgical indications, treatment before surgery, weight of the surgical specimens, and complications. Results: The majority of patients (37.5%) fell within the 41 - 50 age groups. Women were most affected by goiter (95.2%), with a sex ratio of 0.04. Total thyroidectomy was the most frequently performed procedure (68.3%) for large multinodular goiters. A positive correlation was found between the duration and volume of the goiter (r = 0.234; p = 0.042). The range of 501 - 600 g was the most represented (60%). The mean weight of the thyroid gland postoperatively was 550 ± 50 g. The largest goiter in the series weighed 980 g and spent 42 years. The majority of large goiters (83.7%) were operated on using a cervicotomy technique at the junction of the lower and middle thirds, combined with a cruciform aponeurotomy. The conversion rate for Kocher cervicotomy was 9.6%. More than 80% of patients had sought indigenous treatment prior to surgery. Most complications were minor. We observed 4 cases of acute hemorrhage and 2 of them (1.9%) required blood transfusion. 3 cases (2.8%) of transient recurrent laryngeal nerve paralysis, 3 cases of hypocalcemia (2.8%) and 1 death (0.9%). Conclusion: Large goiters are common in regions with endemic iodine deficiency and cause technical challenges for surgeons due to the anticipated difficulty of dissection and the increase of surgical complications. A cervicotomy performed at the junction of the middle and lower thirds, combined with a cruciform aponeurotomy provides excellent exposure and facilitates dissection, thereby reducing both perioperative and long-term postoperative complications.