Intermittent neural monitoring of the recurrent laryngeal nerve in surgery for recurrent goiter

Abstract

Reoperative thyroid surgery is still challenging even for skilled surgeons, and is associated with a higher incidence of complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) palsy. Displacement of the RLN, scar tissue from previous neck surgery and difficulty in maintaining good hemostasis are risk factors in reoperations. The prevalence of RLN injury in reoperative thyroid surgery ranges as high as 12.5% for transient injury and up to 3.8% for permanent injury. Bilateral paresis can also occur during reoperations, and is a dangerous complication influencing the quality of life, sometimes requiring tracheostomy. RLN identification is the gold standard during thyroidectomy, and the use of intraoperative neuromonitoring (IONM) can be a valuable adjunct to visual identification. This technique can be used to identify the RLN and the external branch of the superior laryngeal nerve (EBSLN), both of which are standardized procedures. The aim of this review was to evaluate the use of intermittent neural monitoring of the RLN in surgery for recurrent goiter, and to assess the prevalence of RLN injury while using IONM reported in the current literature.

Complication Risk in Secondary Thyroid Surgery

“…Literatürde ikincil girişimlerde yaklaşık %12.5 geçici, %3.8 kalıcı VKP bildirilmektedir. [27] Thomusch ve ark. selim guatr cerrahisi ile ilgili çalışmalarında, nüks guatr için ikincil girişimi geçici ve kalıcı VKP için bağımsız risk faktörü olarak belirlemişlerdir.…”

“…Veri gücü açısından çalışmalardaki hasta sayıları sınırlı ve hastalar heterojendir. [27] İkincil tiroid cerrahisi ile ilgili İONM kullanımının RLS paralizisi üzerine etkisi, 9 çalışma ve 2436 risk altındaki RLS'yi içeren son metaanalizde değerlendirilmiştir. Çalışmacılar örnek sayısının sınırlı ve çalışmalar arasında heterojenite olmasına rağmen, İONM kullanılmasının toplam VKP oranını (göreceli risk=0.434) ve kalıcı VKP oranını (göreceli risk=0.426) anlamlı olarak azalması ile ilgili olduğunu bildirmişledir.…”

“…Bu sonuç örnek sayısının azlığı ile ilgiliydi, çünkü kalıcı VKP oranları arasında anlamlı fark çıkabilmesi için grupların her birinde en az 952 hastaya gereksinim olduğu hesaplandı. [32] Çalışmamızda [27] Tiroid lojuna lateralden en az skatris dokusunun olduğu alandan ulaşarak, sinirin inferiorda öncelikle İONM probu ile bulunup haritalanmasının sinirin korunmasına önemli katkı sağladığı düşüncesindeyiz. Bu yöntemle, tüm RLS'leri belirleyerek gözle görebildik.…”

New techniques and technologies for the treatment of surgical endocrine diseases

“…Owing to the close international collaboration we are presenting in this issue 12 reports from leading experts in the field focused on selected hot topics in endocrine surgery: intraoperative neural monitoring (IONM) in thyroid surgery (1,2), safety of energy based devices (EBD) for hemostasis in thyroid surgery (3), utility of BRAF V600E mutation for prognostication of papillary thyroid cancer (PTC) recurrence (4), rare cases of PTC associated with thyroid Langerhans cell histiocytosis (5), management of thyroid cancer with tracheal invasion (6), utility of indocyanine green-enhanced fluorescence to assess parathyroid perfusion during thyroidectomy (7), value of iPTH assay for early prognostication of postoperative hypocalcemia (8), risk factors for perioperative hemodynamic instability in patients undergoing laparoscopic adrenalectomy for pheochromocytoma (9), utility of laparoscopic sleeve gastrectomy (LSG) for the treatment of diabetes mellitus type 2 (10), innovative solutions in bariatric surgery (11), including new endoscopic procedures for diabetes mellitus type 2 and obesity treatment (12).…”

“…Reoperative thyroid surgery remains most challenging even for skilled surgeons, and is associated with a higher incidence of complications, such as hypoparathyroidism and RLN palsy (2). Despite lacking hard evidence that IONM can diminish prevalence of permanent vocal fold's palsy as many as 95.7% of the respondents of the most recent International Survey on the Identification and Neural Monitoring of the EBSLN During Thyroidectomy expressed their confidence in IONM and listed reoperative thyroid cases as the top indication far ahead all other clinical situations for utilization of this technique during thyroid surgery (13).…”