Total thyroidectomy (TT) in Graves' disease (GD) has low recurrence and rapid resolution of hyperthyroidism, but not without potential complications. Lugol's solution (LS) is used in preoperative preparation, yet as most patients achieve euthyroidism before surgery, the benefit is a decrease in intraoperative bleeding.

Retrospective analysis consecutive patients (2019-2022), selecting the cohort summited to TT without cervical dissection to evaluate intra/post-operative outcomes when performed by the same surgeon, without LS. Sharp microdissection and ultrasonic device was used in all cases, some with IONM. Laryngoscopy at one-month, hypoparathyroidism, blood loss during/after surgery, incidental parathyroidectomies, surgical length and length of stay, were evaluated.

From 502 patients operated, with 714 recurrent laryngeal nerves at risk (RLNAR), the cohort of 161 (322 RLNAR) submitted to TT, 22 of which due to GD (44 RLNAR), was selected. Overall incidence of transient palsy of 0,56% and definitive of 0,28% were identified. IONM was used in 72,7% (16 out of 22) GD patients and 61,2% in the non-GD. No GD patient had loss of signal, none had dysphonia, and the 6 patients operated without IONM had normal laryngoscopy at 1 month. Four patients (2,48%) without GD referred paresthesis at week one, had normal calcium and PTH at week 4. No GD patients referred paresthesis; all had normal calcium and PTH at week 4. No cervical hematoma/seroma developed, there was no difference in intraoperative hemorrhage, length of stay or postoperative blood loss.

LS may reduce gland vascularity, but increases stiffness. Based on the absence of complications when LS is not used in GD, we challenge its necessity.