Advertisement

Surgical Endoscopy

, Volume 23, Issue 5, pp 996–1003 | Cite as

Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluation

  • Gianlorenzo Dionigi
  • Luigi Boni
  • Francesca Rovera
  • Alessandro Bacuzzi
  • Renzo Dionigi
Article

Abstract

Introduction

This study evaluates the role of intraoperative neuromonitoring (IONM) in video-assisted thyroidectomy (VAT) with emphasis given to the identification of recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve (EBSLN).

Methods

The study was based on a prospectively randomized series comprising 72 standard VAT gasless approaches. In the control group (N = 36), the laryngeal nerves were identified by 30° 5-mm endoscope magnification solely. The standard technique of the IONM group (N = 36) consisted of localizing and monitoring EBSLN, both vagus and RLNs, before and after thyroid resection to prove nerve integrity. Surgical outcomes were mean operative time, nerve representation, incision length, and morbidity.

Results

All procedures were performed successfully. There were no instances of equipment malfunction or interference. No permanent complications occurred in either group. The incidences of temporary RLN injury were 2.7% (1 patient) and 8.3% (3 patients) in the IONM and control group, respectively. The EBSLN was identified better in the IONM group: 83.6% versus 42% (p < 0.05). In the IONM group, a negative electromyography (EMG) response indicated an altered function of RLN and stage thyroidectomy was scheduled.

Conclusions

This is the first VAT series with a standardized IONM technique. The technical feasibility and safety of IONM in selected patients seem acceptable. Neuromonitoring during VAT is effective in providing identification and function of laryngeal nerves. IONM enables surgeons to feel more comfortable with their approach to VAT. A reduction of rates for postoperative complications could not be demonstrated in the present study. Larger series are needed for further evaluation.

Keywords

Video-assisted thyroidectomy Morbidity Neuromonitoring Recurrent laryngeal nerve External branch of the superior laryngeal nerve Stage thyroidectomy 

Notes

Acknowledgements

Written consent from the patients was obtained for publication of this report. Supported in part by grants from the Italian Ministry of Education, University and Research (FAR, Project 2007 “Il sistema di monitoraggio del nervo laringeo ricorrente e della branca sterna del nervo laringeo superior durante interventi di tiroidectomia mininvasiva”). The authors are grateful to Professors H. Dralle, G.W. Randolph, and L. Bartalena for general support, excellent technical assistance, and helpful discussion.

Authors’ contributions

GD: acquisition of data; FR, LB: study conception and design; GD: analysis and interpretation of data; LB, BA: drafting of manuscript; RD: Critical revision and supervision.

References

  1. 1.
    Yalcxin B (2006) Anatomic configurations of the recurrent laryngeal nerve and inferior thyroid artery. Surgery 139(2):181–187CrossRefGoogle Scholar
  2. 2.
    Brok HA, Copper MP, Stroeve RJ, Ongerboer de Visser BW, Venker-van Haagen AJ, Schouwenburg PF (1999) Evidence for recurrent laryngeal nerve contribution in motor innervation of the human cricopharyngeal muscle. Laryngoscope 109(5):705–708PubMedCrossRefGoogle Scholar
  3. 3.
    Cernea CR, Ferraz AR, Nishio S, Dutra A Jr, Hojaij FC, dos Santos LR (1992) Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck 14(5):380–383PubMedCrossRefGoogle Scholar
  4. 4.
    Kark AE, Kissin MW, Auerbach R, Meikle M (1984) Voice changes after thyroidectomy: role of the external laryngeal nerve. Br Med J (Clin Res Ed) 289(6456):1412–1415CrossRefGoogle Scholar
  5. 5.
    Jatzko GR, Lisborg PH, Müller MG, Wette VM (1994) Recurrent nerve palsy after thyroid operations–principal nerve identification and a literature review. Surgery 115(2):139–144PubMedGoogle Scholar
  6. 6.
    Loré JM Jr, Kokocharov SI, Kaufman S, Richmond A, Sundquist N (1998) Thirty-eight-year evaluation of a surgical technique to protect the external branch of the superior laryngeal nerve during thyroidectomy. Ann Otol Rhinol Laryngol 107(12):1015–1022PubMedGoogle Scholar
  7. 7.
    Jansson S, Tisell LE, Hagne I, Sanner E, Stenborg R, Svensson P (1988) Partial superior laryngeal nerve (SLN) lesions before and after thyroid surgery. World J Surg 12(4):522–527PubMedCrossRefGoogle Scholar
  8. 8.
    Timmermann W, Hamelmann WH, Thomusch O, Sekulla C, Grond S, Neumann HJ, Kruse E, Mühlig HP, Richter C, Voss J, Dralle H (2004) Effectiveness and results of intraoperative neuromonitoring in thyroid surgery. Statement of the Interdisciplinary Study Group on Intraoperative Neuromonitoring of Thyroid Surgery. Chirurg 75(9):916–922Google Scholar
  9. 9.
    Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, Dralle H (2000) Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg 24(11):1335–1341PubMedCrossRefGoogle Scholar
  10. 10.
    Thomusch O, Sekulla C, Machens A, Neumann HJ, Timmermann W, Dralle H (2004) Validity of intra-operative neuromonitoring signals in thyroid surgery. Langenbecks Arch Surg 389(6):499–503PubMedCrossRefGoogle Scholar
  11. 11.
    Miccoli P, Bellantone R, Mourad M, Walz M, Raffaelli M, Berti P (2002) Minimally invasive video-assisted thyroidectomy: multiinstitutional experience. World J Surg 26(8):972–975PubMedCrossRefGoogle Scholar
  12. 12.
    Pacini F, Schlumberger M, Dralle H, Elisei R, Smit JW, Wiersinga W, the European Thyroid Cancer Taskforce (2006) European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur J Endocrinol 154:787–803PubMedCrossRefGoogle Scholar
  13. 13.
    Cohen SM, Jacobson BH, Garrett CG, Noordzij JP, Stewart MG, Attia A, Ossoff RH, Cleveland TF (2007) Creation and validation of the Singing Voice Handicap Index. Ann Otol Rhinol Laryngol 116(6):402–406PubMedGoogle Scholar
  14. 14.
    Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A, the German IONM Study Group (2008) Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg [ahead of print]Google Scholar
  15. 15.
    Moosman DA, DeWeese MS (1968) The external laryngeal nerve as related to thyroidectomy. Surg Gynecol Obstet 127(5):1011–1016PubMedGoogle Scholar
  16. 16.
    Dionigi G, Rovera F, Boni L, Castano P, Dionigi R (2006) Surgical site infections after thyroidectomy. Surg Infect (Larchmt) 7:S117–S120Google Scholar
  17. 17.
    Miccoli P, Minuto MN, Ugolini C, Pisano R, Fosso A, Berti P (2008) Minimally invasive video-assisted thyroidectomy for benign thyroid disease: an evidence-based review. World J Surg [ahead of print]Google Scholar
  18. 18.
    Alvarado R, McMullen T, Sidhu SB, Delbridge LW, Sywak MS (2008) Minimally invasive thyroid surgery for single nodules: an evidence-based review of the lateral mini-incision technique. World J Surg [ahead of print]Google Scholar
  19. 19.
    Ujiki MB, Sturgeon C, Denham D, Yip L, Angelos P (2006) Minimally invasive video-assisted thyroidectomy for follicular neoplasm: is there an advantage over conventional thyroidectomy? Ann Surg Oncol 13(2):182–186PubMedCrossRefGoogle Scholar
  20. 20.
    Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G (2001) Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery 130(6):1039–1043PubMedCrossRefGoogle Scholar
  21. 21.
    Chatenever D (2006) Minimally invasive surgical visualization: experience in transition. Surg Endosc 20(S2):S412–S418PubMedCrossRefGoogle Scholar
  22. 22.
    Hagiike M, Phillips EH, Berci G (2007) Performance differences in laparoscopic surgical skills between true high-definition and three-chip CCD video systems. Surg Endosc 21(10):1849–1854PubMedCrossRefGoogle Scholar
  23. 23.
    Berti P, Materazzi G, Conte M, Galleri D, Miccoli P (2002) Visualization of the external branch of the superior laryngeal nerve during video-assisted thyroidectomy. J Am Coll Surg 195(4):573–574PubMedCrossRefGoogle Scholar
  24. 24.
    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):1254–1257PubMedCrossRefGoogle Scholar
  25. 25.
    Bärlehner E, Benhidjeb T (2008) Cervical scarless endoscopic thyroidectomy: axillo-bilateral-breast approach (ABBA). Surg Endosc 22(1):154–157PubMedCrossRefGoogle Scholar
  26. 26.
    Sasaki A, Nakajima J, Ikeda K, Otsuka K, Koeda K, Wakabayashi G (2008) Endoscopic thyroidectomy by the breast approach: a single institution’s 9-year experience. World J Surg 32(3):381–385PubMedCrossRefGoogle Scholar
  27. 27.
    Duh QY (2003) Minimally invasive endocrine surgery: standard of treatment or hype? Surgery 134(6):849–857PubMedCrossRefGoogle Scholar
  28. 28.
    Miccoli P, Materazzi G, Berti P (2008) Minimally invasive video-assisted lateral lymphadenectomy: a proposal. Surg Endosc 22(4):1131–1134PubMedCrossRefGoogle Scholar
  29. 29.
    Miccoli P, Elisei R, Donatini G, Materazzi G, Berti P (2007) Video-assisted central compartment lymphadenectomy in a patient with a positive RET oncogene: initial experience. Surg Endosc 21(1):120–123PubMedCrossRefGoogle Scholar
  30. 30.
    Berti P (2004) Materazzi G, Galleri D, Donatini G, Minuto M, Miccoli P (2004) Video-assisted thyroidectomy for Graves’ disease: report of a preliminary experience. Surg Endosc 18(8):1208–1210PubMedCrossRefGoogle Scholar
  31. 31.
    Caldarelli DD, Holinger LD (1980) Complications and sequelae of thyroid surgery. Otolaryngol Clin North Am 13(1):85–97PubMedGoogle Scholar
  32. 32.
    Patlow C, Norton J, Brennan M (1986) Vocal cord paralysis and reoperative parathyroidectomy. Ann Surg 203:282–285CrossRefGoogle Scholar
  33. 33.
    Beldi G, Kinsbergen T, Schlumpf R (2004) Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery. World J Surg 28(6):589–591PubMedCrossRefGoogle Scholar
  34. 34.
    Loch-Wilkinson TJ, Stalberg PL, Sidhu SB, Sywak MS, Wilkinson JF, Delbridge LW (2007) Nerve stimulation in thyroid surgery: is it really useful? ANZ J Surg 77(5):377–380PubMedCrossRefGoogle Scholar
  35. 35.
    Hermann M, Hellebart C, Freissmuth M (2004) Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg 240(1):9–17PubMedCrossRefGoogle Scholar
  36. 36.
    Eisele DW (1996) Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 106(4):443–449PubMedCrossRefGoogle Scholar
  37. 37.
    Aina EN, Hisham AN (2001) External laryngeal nerve in thyroid surgery—recognition and surgical implications. ANZ J Surg 71:212–214PubMedCrossRefGoogle Scholar
  38. 38.
    Kern KA (1993) Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease. Surgery 114(6):1167–1173PubMedGoogle Scholar
  39. 39.
    Dralle H (2006) Impact of modern technologies on quality of thyroid surgery. Langenbecks Arch Surg 391(1):1–3PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Gianlorenzo Dionigi
    • 1
  • Luigi Boni
    • 1
  • Francesca Rovera
    • 1
  • Alessandro Bacuzzi
    • 1
  • Renzo Dionigi
    • 1
  1. 1.Department of Surgical SciencesEndocrine Surgery Research Center, University of InsubriaVareseItaly

Personalised recommendations