Abu Dhabi Neural Mapping (ADNM) during Minimally Invasive Thyroidectomy Enables the Early Identification of Non-Recurrent Laryngeal Nerve and Prevents Voice Dysfunction

Abstract

The aim of this study was to evaluate the diagnostic accuracy of a neuromonitoring protocol—the Abu Dhabi Neural Mapping protocol (ADNM)—using a new device, Nim-Vital™, during minimally invasive thyroidectomy in the early identification of non-recurrent laryngeal nerve (n-RLN) problems and the preservation of its function. Method: Patients with thyroid disorders that required thyroid resection, who were admitted to the Department of Surgery at Burjeel Hospital, Abu Dhabi, between January and July 2022, were included in the study. The data were extracted from a prospective database and were analyzed retrospectively. All nerves at risk were identified and exposed at seven precisely defined anatomical points, with strict adherence to the intraoperative technical steps of neuromonitoring. These were sequentially applied to the vagal nerve (VN), the superior laryngeal nerve (SLN), and the recurrent laryngeal nerve (RLN). In the next step after the creation of the skin-platysma flap, the strap muscle’s lateral border was moved from the medial limb of the sternocleidomastoid without using any electrical device and without any manipulation of the thyroid gland. The VN was exposed in the carotid sheath and then stimulated using a monopolar probe at a precisely defined point above the clavicle, using anatomical landmarks. Results: In total, 136 women with a mean age of 40 years (range 18–74) and 36 men with a mean age of 42 (range 21–66), demonstrating 270 nerves at risk, were included in the analysis. Indications for surgery were malignancy in 70 cases, toxic goiter/Graves in 23 cases, retrosternal goiter in 21, and symptomatic multinodular goiter in 64 cases. Of these, 100 patients received a total thyroidectomy, 46 received a right lobectomy, and 24 received a left lobectomy only. For a total thyroidectomy, the median skin-to-skin surgery duration was 52 min (range 24–104 min) and the median hospital stay was 2 days (range 1–4 days). In 4 cases (4/146; 2.74%) the pre-dissection stimulation of the vagal nerve (VN1) at the ADNM’s precisely defined point did not create any signal or proper EMG-curve that indicated the existence of the non-RLN. Proximal dissection of the right VN at a precisely defined point by the ADNM’s level of incisura of the larynx created a positive signal. The separation point of the right non-RLN from the VN was discovered in all four patients. The postoperative video-laryngoscopy confirmed bilateral mobile vocal cords in all cases. Conclusions: Following the ADNM protocol during thyroid surgery minimizes the risk of a non-laryngeal nerve injury and prevents voice dysfunction.

Papillary Thyroid Cancer Trends in the Wake of the COVID-19 Pandemic: Is There a Shift toward a More Aggressive Entity?

“…These patients may have experienced severe levels of anxiety and worry. Some studies and recommendations have suggested that waiting three months from diagnosis for thyroid cancer treatment is acceptable [ 19 , 20 , 21 , 22 ]. However, this suggestion should be treated with caution.…”

“…If treatment for diseases such as melanoma, non-small-cell lung cancer, or acute myeloid leukemia is delayed, the patient’s prognosis worsens significantly [ 10 , 23 ]. In contrast, patients with indolent tumors, such as most prostate cancers or differentiated thyroid carcinomas, may be able to wait for a while before experiencing any signs of malignancy [ 21 , 24 ]. Current clinical research has primarily addressed the dismal prognosis for high-risk tumors, but data for low-risk tumors are scarce.…”

“…Patients with other types of thyroid malignancies were not included in the study. Standard operating room (OR) procedures for thyroid surgery at our institution, including patient placement on the OR table, selection of anesthesia, equipment setup, and intraoperative neuromonitoring, were previously described [ 21 ].…”

Clinico-pathological initial outcome of a newly adopted novel surgical technique for nodal metastatic thyroid cancer at a large-volume centre in a high-income developing country

“…In our series, the rate of the well-known surgical complications (such as bleeding, reoperation, paresis of the vocal cords, hypoparathyroidism and readmission) is comparable to, and even lower than, the rate of those complications following a total thyroidectomy alone ( 34 ). The ADNM strategy for intraoperative neuromonitoring ( 20 ) has been shown to decrease RLN injury during thyroidectomy. Hypocalcaemia and hypoparathyroidism, which can be caused by damaging the blood supply to the parathyroid glands, can be avoided with the help of an endocrine loupe and careful dissection ( 31 ).…”

“…Patients with thyroid lymphoma, distant metastases or cervical lymph node metastases that could not be cleared were not included in the study. Standard operating room (OR) procedures for thyroid surgery at our institution, including patient placement on the OR table, the selection of anaesthesia, equipment setup and intraoperative neuromonitoring, have been previously described in detail ( 20 ). In addition to standard patient characteristics, laboratory results and imaging studies, this prospective database compiles pre-, intra- and postoperative clinicopathological parameters that are particularly relevant to the development of surgical morbidity in patients with thyroid cancer.…”