Intraoperative complications of neck surgery are uncommon and rarely life-threatening and exact anatomical knowledge and precise dissection are most important for prevention. Anatomical variants (e.g. non-recurrent nerve, extralaryngeal branching) predispose to damage of the recurrent laryngeal nerve. The use of intraoperative neuromonitoring (IONM) can prevent bilateral nerve damage but in cases of accidental nerve damage primary reconstruction can improve vocal cord function. Autotransplantation of parathyroid tissue can reduce the rate of hypoparathyroidism but cannot be postulated as a routine measure. Intraoperative bleeding can usually be well controlled and greater danger for the patient emanates from early postoperative bleeding for which many techniques (clip, ligature, vessel sealing) can be employed for prevention. Lesions of the thoracic duct can be controlled by clip, ligation or stitch. Smaller lesions of the trachea and esophagus can be secured with direct suture or muscle flap plasty. In cases of larger lesions plastic reconstruction or organ replacement can be necessary.

Recurrent laryngeal nerve palsy is an intrinsic complication of thyroid surgery. Prevention of nerve palsy is considered to be a feature of quality in this very frequently performed operation. Risk factors and prevention strategies are demonstrated and discussed with reference to the current literature. Exact knowledge of the anatomy and possible variants of the track of the recurrent laryngeal nerve as well as its visualization and careful dissection are the cornerstones for nerve preservation. The use of intraoperative neuromonitoring allows preservation of the anatomical structure and functional integrity of the nerve and lesions which are not visible can be detected. Preconditions for correct interpretation are a standardized application and preoperative and postoperative laryngoscopy.

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