World Journal of Surgery

, Volume 43, Issue 11, pp 2829–2841 | Cite as

Recurrent Laryngeal Nerve Morbidity: Lessons from Endoscopic via Bilateral Areola and Open Thyroidectomy Technique

  • Daqi Zhang
  • Jiao Zhang
  • Gianlorenzo Dionigi
  • Fang Li
  • Tie Wang
  • Hongbo Li
  • Nan LiangEmail author
  • Hui SunEmail author
Original Scientific Report with Video


Background and aim

Elucidating the mechanism of recurrent laryngeal nerve (RLN) injuries through intraoperative electromyographic (EMG) and laryngeal examination approaches may deepen our knowledge regarding its prevention strategies. To date, no studies have been reported on the mechanism of RLN injury caused by endoscopic thyroidectomy via bilateral areola approach (ETBAA).


Both intraoperative EMG profiles and postoperative laryngeal examination were used to investigate the mechanisms of RLN injury and compare the safety aspects between ETBAA and open thyroidectomy approach (OTA).


This study examined 1420 nerves at risk. The mean follow-up period was 17 ± 4 (range 6–48) months. The incidence of vocal cord paralysis was 4.1% (59/1420). The number of cases with decreased EMG signals and vocal cord palsy was higher in ETBAA group than in OTA group (P < 0.05). The left RLNs in ETBAA group were at higher risk compared to the right nerves.


The results of the current study indicate that ETBAA exhibits higher risk of RLN injury. The topic includes a video.


Author’s contributions

HS, NL and GD were involved in conception and design; HS, NL and GD contributed to administrative support; and DZ performed collection and assembly of data.


This study was funded by the National Nature Science Foundation of China (No. 81702651), China Postdoctoral Science Foundation (No. 2017M611313), Department of Science and Technology of Jilin Province (Nos. 20170520018JH, 20190201225JC).

Compliance with ethical standards

Conflict of interest

The authors Daqi Zhang, Jiao Zhang, Gianlorenzo Dionigi, Fang Li, Tie Wang, Hongbo Li, Nan Liang and Hui Sun declare no conflict of interest. The funders had no role in (1) the design of this study; (2) the collection, analysis and interpretation of data; (3) the writing of the manuscript; or (4) the decision to submit the manuscript for publication.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

Supplementary material 1 (WMV 114784 kb)


  1. 1.
    Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufflation for unilateral benign thyroid lesions. Surg Endosc 23(9):2053–2060. CrossRefPubMedGoogle Scholar
  2. 2.
    Bärlehner E, Benhidjeb T (2008) Cervical scarless endoscopic thyroidectomy: axillo-bilateral-breast approach (ABBA). Surg Endosc 22(1):154–157CrossRefGoogle Scholar
  3. 3.
    Strik MW, Anders S, Barth M, Bärlehner E, Benecke C, Benhidjeb T (2007) Total videoendoscopic thyroid resection by the axillobilateral breast approach. Operative method and first results. Chirurg 78(12):1139–1144CrossRefGoogle Scholar
  4. 4.
    Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK (2007) Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg 31(3):601–606. CrossRefPubMedGoogle Scholar
  5. 5.
    Yan H, Wang Y, Wang P, Xie Q, Zhao Q (2015) “Scarless” (in the neck) endoscopic thyroidectomy (SET) with ipsilateral levels II, III, and IV dissection via breast approach for papillary thyroid carcinoma: a preliminary report. Surg Endosc 29(8):2158–2163. CrossRefPubMedGoogle Scholar
  6. 6.
    Jeryong K, Jinsun L, Hyegyong K, Eilsung C, Jiyoung S, Insang S, Moonsang A, Jiyeon K, Jaeeun H (2008) Total endoscopic thyroidectomy with bilateral breast areola and ipsilateral axillary (BBIA) approach. World J Surg 32(11):2488–2493. CrossRefPubMedGoogle Scholar
  7. 7.
    Hur SM, Kim SH, Lee SK, Kim WW, Choe JH, Lee JE, Kim JH, Nam SJ, Yang JH, Kim JS (2011) New endoscopic thyroidectomy with the bilateral areolar approach: a comparison with the bilateral axillo-breast approach. Surg Laparosc Endosc Percutan Tech 21(5):e219–e224. CrossRefPubMedGoogle Scholar
  8. 8.
    Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T, Kitajima M (2000) Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech 10(1):1–4CrossRefGoogle Scholar
  9. 9.
    Shimazu K, Shiba E, Tamaki Y, Takiguchi S, Taniguchi E, Ohashi S, Noguchi S (2003) Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech 13(3):196–201CrossRefGoogle Scholar
  10. 10.
    Wang CC, Hu YZ, Lai ZW, Yang JG, Chen J, Pan YL, Xu P, Li JY (2009) Endoscopic thyroidectomy via the areola of breast approach. Zhonghua Wai Ke Za Zhi 47(14):1067–1069PubMedGoogle Scholar
  11. 11.
    Chantawibul S, Lokechareonlarp S, Pokawatana C (2003) Total video endoscopic thyroidectomy by an axillary approach. J Laparoendosc Adv Surg Tech A 13(5):295–299CrossRefGoogle Scholar
  12. 12.
    Huang XM, Sun W, Zeng L, Liu X, Lu X, Xu YD, Zhang ZG, Xu G (2011) Gasless endoscopic thyroidectomy via an anterior chest approach—a review of 219 cases with benign tumor. World J Surg 35(6):1281–1286. CrossRefPubMedGoogle Scholar
  13. 13.
    Li Z, Wang P, Wang Y, Xu S, Cao L, Que R, Zhou F (2011) Endoscopic lateral neck dissection via breast approach for papillary thyroid carcinoma: a preliminary report. Surg Endosc 25(3):890–896. CrossRefPubMedGoogle Scholar
  14. 14.
    Youben F, Bomin G, Bo W, Jie K, Fan Y, Wencai Q, Yuyao H, Qi Z (2011) Trans-areola single-incision endoscopic thyroidectomy. Surg Laparosc Endosc Percutan Tech 21(4):e192–e196. CrossRefPubMedGoogle Scholar
  15. 15.
    Wang C, Feng Z, Li J, Yang W, Zhai H, Choi N, Yang J, Hu Y, Pan Y, Cao G (2015) Endoscopic thyroidectomy via areola approach: summary of 1250 cases in a single institution. Surg Endosc 29(1):192–201. CrossRefPubMedGoogle Scholar
  16. 16.
    Bliss RD, Gauger PG, Delbridge LW (2000) Surgeon’s approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg 24(8):891–897. CrossRefPubMedGoogle Scholar
  17. 17.
    Zhang D, Li F, Wu CW, Liu X, Xin J, Chiang FY, Sun H (2017) Percutaneous probe stimulation for intraoperative neuromonitoring in total endoscopic thyroidectomy: a preliminary experience. Head Neck 39(5):1001–1007. CrossRefPubMedGoogle Scholar
  18. 18.
    Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccolli 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–S16CrossRefGoogle Scholar
  19. 19.
    Xin J, Liu X, Sun H, Li J, Zhang D, Fu Y (2014) A laryngoscopy-based classification system for perioperative abnormal vocal cord movement in thyroid surgery. J Int Med Res 42(4):1029–1037. CrossRefPubMedGoogle Scholar
  20. 20.
    Dionigi G, Alesina PF, Barczynski M, Boni L, Chiang FY, Kim HY, Materazzi G, Randolph GW, Terris DJ, Wu CW (2012) Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring. Surg Endosc 26(9):2601–2608. CrossRefPubMedGoogle Scholar
  21. 21.
    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. CrossRefPubMedGoogle Scholar
  22. 22.
    Shindo ML, Wu JC, Park EE (2005) Surgical anatomy of the recurrent laryngeal nerves revisited. Otolaryngol Head Neck Surg 133:514–519CrossRefGoogle Scholar
  23. 23.
    Haller JM, Iwanik M, Shen FH (2012) Clinically relevant anatomy of recurrent laryngeal nerve. Spine (Phila Pa 1976) 37:97–100CrossRefGoogle Scholar
  24. 24.
    Uen YH, Chen TH, Shyu JF et al (2006) Surgical anatomy of the recurrent laryngeal nerves and its clinical applications in Chinese adults. Surg Today 36:312–315CrossRefGoogle Scholar
  25. 25.
    Lee MS, Lee UY, Lee JH, Han SH (2009) Relative direction and position of recurrent laryngeal nerve for anatomical configuration. Surg Radiol Anat 31:649–655CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  1. 1.Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid CarcinomaChina-Japan Union Hospital of Jilin UniversityChangchun CityPeople’s Republic of China
  2. 2.Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ‘‘G. Barresi’’, University Hospital G. MartinoUniversity of MessinaMessinaItaly

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