Even when suitable anesthetics became available, many surgeons believed that operations on the thyroid gland were too hazardous to be attempted. Especially for the most serious complication of thyroidectomy: bleeding [1].

Can thyroid gland be removed with a reasonable hope of saving the patient? Experience emphatically answers: no.

Should the surgeon be so adventurous or foolhardy to undertake the enterprise …

… every stroke of his knife will be followed by a torrent of blood and lucky will it be for him if his victim lives long enough to enable him to finish his horrid butchering …

[…] No honest and sensible surgeon would ever engage in it.

Samuel D. Gross (1805–1884), Professor of Surgery, Jefferson Medical College, Philadelphia

System of Surgery

Appalling results of thyroid surgery led, in 1646, to the imprisonment of a surgeon for his work [2].

In 1850 – given the miserable outcomes of thyroidectomies – the French Académie Royale de Médecine forbade any operation on goiter [3, 4].

During the 1860s to the 1880s the introduction of improved anesthesia, new methods of infection prophylaxis, and improved hemostasis technique would provide the impetus for an important change.

The early history of hemostasis – as outlined beautifully by Samuel Clark Harvey in 1929 – starts with the use of crude ligatures, cautery, hot oil, and caustic substances to control hemorrhage [5].

The first effective hemostatic forceps were introduced only in 1874 by Thomas Spencer Wells (1818–1897) in London and by Jules Emile Péan (1830–1898) in Paris [5].

The use of such devices began much earlier in Europe than in the United States. William Steward Halsted (1852–1922) witnessed thyroid surgeries using dozens of hemostats while in Europe during 1879. His only prior experience with their use, during thyroid surgery in the United States, had occurred at the Roosevelt Hospital of New York under Henry Berton Sands (1830–1888). At that time, the entire American hospital had only two hemostats at their disposal [4]. Halsted championed the use of hemostats in his country upon his return to the United States late in 1879.

Forceps had a marked influence on outcomes of thyroid surgery [6].

Incidence of morbidity with thyroid surgery decreased significantly after standardization of the capsular dissection technique by Thompson in 1973 [7], and total thyroidectomy is increasingly accepted for the treatment of cancer and benign thyroid diseases.

New technologies for the prevention and control of bleeding were gradually introduced in surgical practice over the past century: electrical scalpel (1924), bipolar forceps (1940s), and recently the radio frequency and ultrasonic scalpel (2000s).

A critical problem for the surgeon in the operating room has been always oozing blood, where cautery and suture ligation are not feasible. For this reason, over the past decades, means such as lasers (CO₂, Argon, and Nd-YAG), and spray-electrocoagulation have been introduced. Topical agents have also been developed to promote hemostasis in a wide variety of surgical procedures where the control of bleeding may result particularly difficult or impossible (coagulopathies and platelets dysfunction, parenchymal tissues, bony surfaces, etc.). Most of these topical agents were originally developed to improve wound healing in soldiers with severe burn injuries during World War I, World War II, and Vietnam and Korea War [8].

Currently, hypoparathyroidism and recurrent laryngeal nerve palsy are the most frequent postoperative complications associated with thyroid surgery. In terms of severity, postoperative hemorrhage is a rare but potentially lethal complication, occurring in 0.3–2 % of cases [9–13].

Hemorrhage correlated with a thyroidectomy usually occurs within 24 h, and the most significant hematomas become apparent after 6–8 h [14].

More in detail, the time of occurrence of the postoperative hematoma would be in:

The intraoperative bleeding hampers the vision of the operative field and of the delicate anatomical structures, complicating the surgical dissection: it can cause indirect morbidity related to injury of the recurrent nerves and lesions of the parathyroid glands.