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Influence of Intraoperative Neuromonitoring on Surgeons’ Technique During Thyroidectomy

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When assessing the value of intraoperative nerve monitoring (IONM) during routine thyroidectomy, it is necessary to consider its influence on the surgeon’s dissection technique. We investigated the effect of IONM on individual surgeon performance by determining the learning curve associated with this tool.


A one-year prospective study was conducted between May 2008 and April 2009 within a team of three experienced endocrine surgeons. The measure of surgical performance was based on the detection of immediate postoperative recurrent laryngeal nerve palsy by laryngoscopy. Individual learning curves associated with IONM acquisition were drawn with the cumulative sum (CUSUM) chart. Each surgeon was questioned about possible changes he had experienced in his own surgical technique after the introduction of IONM.


A total of 475 consecutive patients who underwent thyroid surgery with IONM were included. The pattern of learning curves varied among surgeons and ranged from 35 to 304 procedures required for complete IONM acquisition. The surgeon with the longest learning curve also described a drastic modification of his technique related to nerve dissection.


Intraoperative nerve monitoring can induce changes in surgical practice. The different learning curve patterns among surgeons may reflect the variable degree to which surgeons will modify their own dissection technique. Such an effect on learning must be considered when assessing the impact of using IONM on patient safety.

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  1. Kern KA (1993) Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease. Surgery 114:1167–1173

    PubMed  CAS  Google Scholar 

  2. Shaw GY, Pierce E (2009) Malpractice litigation involving iatrogenic surgical vocal fold paralysis: a closed-claims review with recommendations for prevention and management. Ann Otol Rhinol Laryngol 118:6–12

    PubMed  Google Scholar 

  3. Munch S, de Kryger L (2001) A piece of my mind. Moral wounds: complicated complications. JAMA 285:1131–1132

    Article  PubMed  CAS  Google Scholar 

  4. Lahey FH, Hoover WB (1938) Injuries to the recurrent laryngeal nerve in thyroid operations: their management and avoidance. Ann Surg 108:545–562

    Article  PubMed  CAS  Google Scholar 

  5. Jatzko GR, Lisborg PH, Müller MG et al (1994) Recurrent nerve palsy after thyroid operations—principal nerve identification and a literature review. Surgery 115:139–144

    PubMed  CAS  Google Scholar 

  6. Hermann M, Alk G, Roka R et al (2002) Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27, 000 nerves at risk. Ann Surg 235:261–268

    Article  PubMed  Google Scholar 

  7. Jeannon JP, Orabi AA, Bruch GA et al (2009) Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract 63:624–629

    Article  PubMed  Google Scholar 

  8. Shedd DP, Burget GC (1966) Identification of the recurrent laryngeal nerve. Arch Surg 92:861–864

    PubMed  CAS  Google Scholar 

  9. Sturgeon C, Sturgeon T, Angelos P (2009) Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons. World J Surg 33:417–425

    Article  PubMed  Google Scholar 

  10. Dralle H, Sekulla C, Lorenz K et al (2008) Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg 32:1358–1366

    Article  PubMed  CAS  Google Scholar 

  11. Haynes B (1999) Can it work? Does it work? Is it worth it? The testing of healthcare interventions is evolving. BMJ 319(7211):652–653

    PubMed  CAS  Google Scholar 

  12. Connolly TM, Watters DA (2010) Monitoring performance in thyroidectomy: cumulative sum analysis of outcomes. Thyroid 20:407–412

    Article  PubMed  Google Scholar 

  13. Duclos A, Touzet S, Soardo P et al (2009) Quality monitoring in thyroid surgery using the Shewhart control chart. Br J Surg 96:171–174

    Article  PubMed  CAS  Google Scholar 

  14. Rogers CA, Reeves BC, Caputo M et al (2004) Control chart for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg 128:811–819

    Article  PubMed  Google Scholar 

  15. Biau DJ, Williams SM, Schlup MM et al (2008) Quantitative and individualized assessment of the learning curve using LC-CUSUM. Br J Surg 95:925–929

    Article  PubMed  CAS  Google Scholar 

  16. Duclos A, Voirin N, Touzet S et al (2010) Crude versus case-mix-adjusted control charts for safety monitoring in thyroid surgery. Qual Saf Health Care 19:e17

    Article  PubMed  Google Scholar 

  17. Dralle H, Sekulla C, Haerting J et al (2004) Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 136:1310–1322

    Article  PubMed  Google Scholar 

  18. Thomusch O, Machens A, Sekulla C et al (2000) Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg 24:1335–1341

    Article  PubMed  CAS  Google Scholar 

  19. Dionigi G, Bacuzzi A, Boni L et al (2008) What is the learning curve for intraoperative neuromonitoring in thyroid surgery? Int J Surg 6(Suppl 1):S7–S12

    Article  PubMed  Google Scholar 

  20. Jonas J, Bähr R (2006) Intraoperative neuromonitoring of the recurrent laryngeal nerve—results and learning curve. Zentralbl Chir 131:443–448

    Article  PubMed  CAS  Google Scholar 

  21. Lamadé W, Renz K, Willeke F et al (1999) Effect of training on the incidence of nerve damage in thyroid surgery. Br J Surg 86:388–391

    Article  PubMed  Google Scholar 

  22. Reznick RK, MacRae H (2006) Teaching surgical skills—changes in the wind. N Engl J Med 355:2664–2669

    Article  PubMed  CAS  Google Scholar 

  23. Vincent C, Moorthy K, Sarker SK et al (2004) Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg 239:475–482

    Article  PubMed  Google Scholar 

  24. Lilford R, Braunholtz D, Harris J et al (2004) Trials in surgery. Br J Surg 91:6–16

    Article  PubMed  CAS  Google Scholar 

  25. Barczyński M, Konturek A, Cichoń S (2009) Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 96:240–246

    Article  PubMed  Google Scholar 

  26. Paradis C (2008) Bias in surgical research. Ann Surg 248:180–188

    Article  PubMed  Google Scholar 

  27. Ramsay CR, Grant AM, Wallace SA et al (2001) Statistical assessment of the learning curves of health technologies. Health Technol Assess 5:1–79

    PubMed  CAS  Google Scholar 

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The authors are grateful to David J. Biau (Service de Chirurgie Orthopédique et Traumatologique, Hôpital Cochin, Paris, France) for helpful contributions in designing the LC-CUSUM chart (Fig. 2). The authors are also grateful to Philippe Messy for extracting the study data from the hospital information system, and Sandrine Touzet for participating in the critical revision of the manuscript (Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, France).

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Correspondence to Antoine Duclos.

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Duclos, A., Lifante, JC., Ducarroz, S. et al. Influence of Intraoperative Neuromonitoring on Surgeons’ Technique During Thyroidectomy. World J Surg 35, 773–778 (2011).

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