Abstract
Introduction
The objective of the study was to assess the mechanism of recurrent laryngeal nerve (RLN) injury during video-assisted thyroidectomy (VAT).
Methods
The study examined 201 nerves at risk (NAR). VAT with laryngeal neuromonitoring (LNM) was outlined according to this scheme: (a) preparation of the operative space; (b) vagal nerve stimulation (V1); (c) ligature of the superior thyroid vessels; (d) visualization, stimulation (R1), and dissection of the RLN; (e) extraction of the lobe; (f) resection of the thyroid lobe; (g) final hemostasis; (h) verification of the electrical integrity of the RLN (V2, R2). The site, cause, and circumstance of nerve injury were elucidated with the application of LNM. Laryngeal nerve injuries were classified into type 1 injury (segmental) and 2 (diffuse).
Results
Fourteen nerves (6.9 %) experienced loss of R2 and V2 signals. 80 percent of lesions occurred in the distal 1 cm of the course of the RLN. The incidence of type 1 and 2 injuries was 71 and 29 % respectively. The mechanisms of injury were traction (70 %) and thermal (30 %). Traction lesions were created during the extraction of the lobe from the mini-incision [point (e)]. Thermal injury occurred during energy-based device use in (f) and (g) circumstances.
Conclusions
RLN palsy still occurs with routine endoscopic identification of the nerve, even combined with LNM. LNM has the advantage of elucidating the mechanism of RLN injury. Traction and thermal RLN injuries are the most frequent lesions in VAT.
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References
Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C (1999) Minimally invasive surgery for small thyroid nodules: preliminary report. J Endocrinol Invest 22:849–851
Miccoli P, Bellantone R, Mourad M, Walz M, Raffaelli M, Berti P (2002) Minimally invasive video-assisted thyroidectomy: multi-institutional experience. World J Surg 26(8):972–975
Terris DJ, Angelos P, Steward DL, Simental AA (2008) Minimally invasive video-assisted thyroidectomy: a multi-institutional North American experience. Arch Otolaryngol Head Neck Surg 134(1):81–84
Dionigi G (2009) Evidence-based review series on endoscopic thyroidectomy: real progress and future trends. World J Surg 33(2):365–366
Dionigi G, Boni L, Rovera F, Rausei S, Dionigi R (2011) Wound morbidity in mini-invasive thyroidectomy. Surg Endosc 25(1):62–67
Duh QY (2003) Presidential address: minimally invasive endocrine surgery—standard of treatment or hype? Surgery 134(6):849–857
Alesina PF, Rolfs T, Rühland K, Brunkhorst V, Groeben H, Walz MK (2010) Evaluation of postoperative pain after minimally invasive video-assisted and conventional thyroidectomy: results of a prospective study. ESES Vienna presentation. Langenbecks Arch Surg 395(7):845–849
Dionigi G, Boni L, Rovera F, Annoni M, Villa F, Dionigi R (2008) Defining the learning curve for video-assisted thyroidectomy. Int J Surg 6(Suppl 1):S1–S3
Duh QY (2011) Robot-assisted endoscopic thyroidectomy: has the time come to abandon neck incisions? Ann Surg 253(6):1067–1068
Dionigi G, Duran-Poveda M (2011) New approaches in thyroid surgery: is there an increased risk of nerve injury? Ann Surg Oncol 18(Suppl 3):S252–S253
Dionigi G, Boni L, Rovera F, Bacuzzi A, Dionigi R (2009) Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluation. Surg Endosc 23(5):996–1003
Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, Hsieh MC, Wu CW (2010) Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg 34(2):223–229
Dionigi G, Chiang FY, Rausei S, Wu CW, Boni L, Lee KW, Rovera F, Cantone G, Bacuzzi A (2010) Surgical anatomy and neurophysiology of the vagus nerve (VN) for standardised intraoperative neuromonitoring (IONM) of the inferior laryngeal nerve (ILN) during thyroidectomy. Langenbecks Arch Surg 395(7):893–899
Randolph GW, Dralle H; International Intraoperative Monitoring Study Group, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccoli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Sloan T, Van Slycke S, Snyder S, Takami H, Volpi E, Woodson G (2011) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 121(Suppl 1):S1–S16
Dionigi G, Boni L, Rovera F, Rausei S, Castelnuovo P, Dionigi R (2010) Postoperative laryngoscopy in thyroid surgery: proper timing to detect recurrent laryngeal nerve injury. Langenbecks Arch Surg 395(4):327–331
Alesina PF, Singaporewalla RM, Eckstein A, Lahner H, Walz MK (2011) Is minimally invasive, video-assisted thyroidectomy feasible in Graves’ disease? Surgery 149(4):556–560
Snyder SK, Lairmore TC, Hendricks JC, Roberts JW (2008) Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg 206(1):123–130
Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW (2008) The mechanism of recurrent laryngeal nerve injury during thyroid surgery—the application of intraoperative neuromonitoring. Surgery 143(6):743–749
Reeve T, Thompson NW (2000) Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg 24:971–975
Brunaud L, Zarnegar R, Wada N, Ituarte P, Clark OH, Duh QY (2003) Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive? Arch Surg 138(10):1140–1143
Bergenfelz A, Jansson S, Kristoffersson A, Mårtensson H, Reihnér E, Wallin G, Lausen I (2008) Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg 393(5):667–673
Dionigi G (2009) Energy-based devices and recurrent laryngeal nerve injury: the need for safer instruments. Langenbecks Arch Surg 394(3):579–580
Barczyński M, Konturek A, Cichoń S (2008) Minimally invasive video-assisted thyroidectomy (MIVAT) with and without use of harmonic scalpel—a randomized study. Langenbecks Arch Surg 393(5):647–654
Terris DJ, Anderson SK, Watts TL, Chin E (2007) Laryngeal nerve monitoring and minimally invasive thyroid surgery: complementary technologies. Arch Otolaryngol Head Neck Surg 133(12):1254–1257
Disclosure
G. Dionigi, P.F. Alesina, M. Barczynski, L. Boni, F.Y. Chiang, H.Y. Kim, G. Materazzi, G.W. Randolph, D.J. Terris, and C.W. Wu have no conflicts of interest or financial ties to disclose.
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Dionigi, G., Alesina, P.F., Barczynski, M. et al. Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring. Surg Endosc 26, 2601–2608 (2012). https://doi.org/10.1007/s00464-012-2239-y
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DOI: https://doi.org/10.1007/s00464-012-2239-y