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Identification of valid anatomical landmarks to locate and protect recurrent laryngeal nerve during thyroid surgery: a cadaveric study

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Abstract

Purpose

Recurrent laryngeal nerve (RLN) is the most critical structure in terms of intricacy. Anatomic variations of the nerve may further make thyroid surgery cumbersome. The present study was undertaken to provide comprehensive knowledge about the soundness of commonly used anatomical landmarks such as Berry’s ligament (BL), tracheo-esophageal groove (TEG), inferior thyroid artery (ITA), and the midpoint of the posterior border of the thyroid gland in the identification of the nerve intraoperatively.

Methods

Thirty adult cadavers were dissected to identify the RLN in the neck and to locate it in relation to the aforementioned anatomical landmarks.

Results

The RLN/BL relationship: RLN was most often located superficial to the BL (88.3%), followed by deep to the BL in 8.4%, and piercing the BL in 3.3% of cases, respectively. The RLN/TEG relationship: the RLN was located inside the TEG in most cases (71.7%), followed by RLN lying outside the TEG in 28.3%. Outside the groove, it was most commonly found lateral to the TEG (64.7%). RLN/ITA relationship: the nerve was passing deep to the artery in most of the cases (65%), followed by superficial (30%) and rarely (5%) in-between the branches. RLN/ midpoint posterior border of thyroid relationship: In 57 (95%) cases, RLN was coursing in the area posterior to the midpoint of the posterior border of the gland with an average distance of 4.95 ± 2.23 mm ranging between 2.21 and 12.1 mm.

Conclusions

Both the BL and TEG are potentially crucial for safeguarding RLN. Although in results, BL turns out to be more consistent than TEG, we propose the utilization of both these anatomical landmarks together for complication-free neck surgeries. Furthermore, the midpoint of the posterior border of the thyroid turns out to be the single most consistent landmark for identifying RLN during partial thyroidectomy.

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Data availability

All data are presented in the manuscript.

References

  1. Ardito G, Revelli L, D’Alatri L et al (2004) Revisited anatomy of the recurrent laryngeal nerves. Am J Surg 187:249–253. https://doi.org/10.1016/j.amjsurg.2003.11.001

    Article  Google Scholar 

  2. Armstrong WG (1951) Multiple divisions of the recurrent laryngeal nerve: an anatomic study. AMA Arch Surg 62:532. https://doi.org/10.1001/archsurg.1951.01250030540011

    Article  CAS  Google Scholar 

  3. Asgharpour E, Maranillo E, Sañudo J et al (2012) Recurrent laryngeal nerve landmarks revisited. Head Neck 34:1240–1246. https://doi.org/10.1002/hed.21882

    Article  Google Scholar 

  4. Berlin D, Lahey F (1929) Dissections of the recurrent and superior laryngeal nerves. Surg Gynecol Obst 49:102–104

    Google Scholar 

  5. Botelho JB, Vieira DM, de Carvalho DM et al (2012) Estudo das relações anatomocirúrgicas entre os nervos laríngeos recorrentes e o ligamento de Berry. Rev Col Bras Cir 39:364–367. https://doi.org/10.1590/S0100-69912012000500004

    Article  Google Scholar 

  6. Çakir BÖ, Ercan I, Şam B et al (2006) Reliable surgical landmarks for the identification of the recurrent laryngeal nerve. Otolaryngol Head Neck Surg 135:299–302. https://doi.org/10.1016/j.otohns.2006.03.026

    Article  Google Scholar 

  7. Chang S, Tang H-H, Wang C-C et al (2012) A standard approach to expose the recurrent laryngeal nerve during endoscopic thyroidectomy. J Laparoendosc Adv Surg Tech 22:259–263. https://doi.org/10.1089/lap.2011.0320

    Article  Google Scholar 

  8. Chen X, Xie L, Guo X (2002) The regional dissection and clinical application in pars cervicalis of recurrent laryngeal nerve. Sichuan J Anat 10:150–152

    Google Scholar 

  9. Cirocchi R, Arezzo A, D’Andrea V et al (2019) Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD012483.pub2

    Article  Google Scholar 

  10. Gauger G, Leigh W, Delbridge NP (2001) Incidence and importance of the tubercle of Zuckerkandl in thyroid surgery. Eur J Surg 167:249–254. https://doi.org/10.1080/110241501300091363

    Article  CAS  Google Scholar 

  11. Gremillion G, Fatakia A, Dornelles A et al (2012) Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: Is It Worth the Cost? Ochsner J 12:363–366

    Google Scholar 

  12. Gür E, Haciyanli M, Karaisli S et al (2019) Intraoperative nerve monitoring during thyroidectomy: evaluation of signal loss, prognostic value and surgical strategy. Ann R Coll Surg Eng 101:589–595. https://doi.org/10.1308/rcsann.2019.0087

    Article  Google Scholar 

  13. Henry BM, Sanna B, Graves MJ et al (2017) The reliability of the tracheoesophageal groove and the ligament of berry as landmarks for identifying the recurrent laryngeal nerve: a cadaveric study and meta-analysis. BioMed Res Int 2017:1–11. https://doi.org/10.1155/2017/4357591

    Article  Google Scholar 

  14. Henry BM, Sanna B, Vikse J et al (2017) Zuckerkandl’s tubercle and its relationship to the recurrent laryngeal nerve: a cadaveric dissection and meta-analysis. Auris Nasus Larynx 44:639–647. https://doi.org/10.1016/j.anl.2017.03.013

    Article  Google Scholar 

  15. Henry BM, Vikse J, Graves MJ et al (2016) Extralaryngeal branching of the recurrent laryngeal nerve: a meta-analysis of 28,387 nerves. Langenbecks Arch Surg 401:913–923. https://doi.org/10.1007/s00423-016-1455-7

    Article  Google Scholar 

  16. Hunt PS, Poole M, Reeve TS (2005) A reappraisal of the surgical anatomy of the thyroid and parathyroid glands. Br J Surg 55:63–66. https://doi.org/10.1002/bjs.1800550119

    Article  Google Scholar 

  17. Kaisha W, Wobenjo A, Saidi H (2011) Topography of the recurrent laryngeal nerve in relation to the thyroid artery, Zuckerkandl tubercle, and Berry ligament in Kenyans. Clin Anat 24:853–857. https://doi.org/10.1002/ca.21192

    Article  CAS  Google Scholar 

  18. Leow CK, Webb AJ (1998) The lateral thyroid ligament of Berry. Int Surg 83:75–78

    CAS  Google Scholar 

  19. Menck J, Grüber J, Lierse W (1990) Anterior approach to the cervical vertebrae and the location of the recurrent laryngeal nerve. Unfallchirurg 93:384–386

    CAS  Google Scholar 

  20. Ngo Nyeki AR, Njock LR, Miloundja J et al (2015) Recurrent laryngeal nerve landmarks during thyroidectomy. Eur Ann Otorhinolaryngol Head Neck Dis 132:265–269. https://doi.org/10.1016/j.anorl.2015.08.002

    Article  Google Scholar 

  21. Noussios G, Chatzis I, Konstantinidis S et al (2020) The anatomical relationship of inferior thyroid artery and recurrent laryngeal nerve: a review of the literature and its clinical importance. J Clin Med Res 12:640–646. https://doi.org/10.14740/jocmr4296

    Article  Google Scholar 

  22. Pelizzo MR, Toniato A, Gemo G (1998) Zuckerkandl’s tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg 187:333–336. https://doi.org/10.1016/S1072-7515(98)00160-4

    Article  CAS  Google Scholar 

  23. Pisanu A, Porceddu G, Podda M et al (2014) Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res 188:152–161. https://doi.org/10.1016/j.jss.2013.12.022

    Article  Google Scholar 

  24. Prabhu S, Mehra S (2021) Nothing unusual: bilateral recurrent laryngeal nerves have followed the rule. Surg Radiol Anat 43:613–613. https://doi.org/10.1007/s00276-020-02571-y

    Article  Google Scholar 

  25. Pradeep PV, Jayashree B, Harshita SS (2012) A closer look at laryngeal nerves during thyroid surgery: a descriptive study of 584 nerves. Anat Res Int 2012:490390

    CAS  Google Scholar 

  26. Prades JM, Lelonge Y, Dubois MD et al (2021) Dual laryngeal reinnervation in bilateral vocal fold paralysis: anatomical pitfalls. Surg Radiol Anat 43:1745–1751. https://doi.org/10.1007/s00276-021-02698-6

    Article  Google Scholar 

  27. Rajabian A, Walsh M, Quraishi NA (2017) Berry’s ligament and the inferior thyroid artery as reliable anatomical landmarks for the Recurrent Laryngeal Nerve (RLN): a fresh-cadaveric study of the cervical spine. The RLN relevant to spine. Spine J 17:S33–S39. https://doi.org/10.1016/j.spinee.2017.01.011

    Article  Google Scholar 

  28. Sasou S, Nakamura S, Kurihara H (1998) Suspensory ligament of Berry: Its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head Neck 20:695–698

    Article  CAS  Google Scholar 

  29. Serpell JW (2010) New operative surgical concept of two fascial layers enveloping the recurrent laryngeal nerve. Ann Surg Oncol 17:1628–1636. https://doi.org/10.1245/s10434-010-0928-0

    Article  Google Scholar 

  30. Skandalakis JE, Droulias C, Harlaftis N et al (1976) The recurrent laryngeal nerve. Am Surg 42:629–634

    CAS  Google Scholar 

  31. 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(4):312–315. https://doi.org/10.1007/s00595-005-3151-z

    Article  Google Scholar 

  32. Williams PL, Bannister LH (eds) (1995) Gray’s anatomy: the anatomical basis of medicine and surgery, 38th edn. Churchill Livingstone, New York, pp 564–567

    Google Scholar 

  33. Yalcin B, Develi S, Tubbs RS et al (2013) A detailed study of the relationship between the external laryngeal nerve and superior thyroid artery, including its glandular branches. Clin Anat 26:814–822

    Google Scholar 

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Acknowledgements

The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase mankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.

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Non-funded.

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Authors and Affiliations

  1. Department of Anatomy, All India Institute of Medical Sciences, Bathinda, India

    Apurba Patra & Priti Chaudhary

  2. Department of Anatomy, All India Institute of Medical Sciences, Patna, India

    Adil Asghar

  3. Department of Anatomy, All India Institute of Medical Sciences, Rishikesh, India

    Kumar Satish Ravi

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  1. Apurba Patra
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  2. Adil Asghar
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AP: project development, Data collection, Manuscript writing. AA: project development, Literature review, Manuscript writing. PC: manuscript writing, editing and critical revision KSR: manuscript writing, editing and critical revision; Approval of the final version of the manuscript: all authors.

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Correspondence to Kumar Satish Ravi.

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Patra, A., Asghar, A., Chaudhary, P. et al. Identification of valid anatomical landmarks to locate and protect recurrent laryngeal nerve during thyroid surgery: a cadaveric study. Surg Radiol Anat 45, 73–80 (2023). https://doi.org/10.1007/s00276-022-03054-y

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