Surgical considerations for adult Graves’ disease: a narrative review of indications, perioperative challenges and postoperative outcomes

INTRODUCTION: Graves' disease (GD) is a systemic autoimmune disorder, ultimately caused by autoantibodies stimulating the TSH receptor (TSHR-Ab) on thyroid follicular cells. Novel targeted therapies are under investigation, but treatment of GD still relies on antithyroid drugs (ATDs), radioactive iodine, or thyroidectomy. AREAS COVERED: Narrative review of original articles, randomized clinical trials, systematic reviews and meta-analyses, guidelines on PubMed from inception to March 2026, using the following terms: GD, management of GD, thyroidectomy, hypoparathyroidism, hypocalcemia, recurrent laryngeal nerve injury, hematoma, near-infrared autofluorescence, indocyanine green angiography, Graves' orbitopathy, thyroid eye disease. EXPERT OPINION: Thyroidectomy is the least common treatment for GD. However, it effectively eradicates hyperthyroidism, if all thyroid tissue is removed. Preoperative preparation includes ATD treatment to restore euthyroidism whenever possible, iodine solution (controversial in patients rendered euthyroid prior to surgery), and vitamin D (with or without calcium), if deficient. In patients with risk factors for cardiovascular (CV) complications, thyroidectomy may prevent the CV risk associated with unstable/severe hyperthyroidism. Thyroidectomy is safe in the hands of skilled, high-volume surgeons, with a low incidence of the main complications, i.e. hypoparathyroidism, recurrent laryngeal nerve injury, and hematoma.