Clinical Application of Recurrent Laryngeal Nerve Protection and Monitoring During Thyroidectomy_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

SUN Hui ¹ , LIU Xiaoli ¹ , ZHANG Daqi ¹ , FU Yantao ¹ , FU Qingfeng ¹ , JIN Tian ¹ , ZHENG Zelin ²

1.Division of Thyroid Surgery, China Japan Union Hospital of Jilin University, Changchun 130033, China;;
2.Department of Gastrointestinal Surgery, China Japan Union Hospital of Jilin University, Changchun 130033, China;

Corresponding author：

Keywords：

Recurrent laryngeal nerve; Visual identification; Intraoperative neuromonitoring; Thyroidectomy

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Objective To investigate the clinical significance of visual identification and intraoperative neuromonitoring of recurrent laryngeal nerve (RLN) during thyroidectomy.
Methods Totally 1 664 patients underwent thyroidectomy with RLN protection from January 2009 to December 2009 were included in this study, in which 1 447 cases were protected by visual identification only, and 217 complex thyroidectomy cases were protected by visual identification and intraoperative monitoring.
Results By the “multisites, three steps” RLN exposure method, 1 417 cases （85.16%） were successfully recognized and the recognition time was (3.57±1.26) min. The recognition time in the rest 30 complex cases (2.07%) without intraoperative neuromonitoring was (17.02±5.48) min. By this method, the temporary RLN injury occurred in 23 cases (1.54%) and 15 cases (65.22%) recovered within 2 weeks. In patients undewent intraoperative neuromonitoring, the recognition rate was 100% (217/217) and recognition time was (2.18±0.67) min. The temporary RLN injury occurred in 4 cases (1.84%) and 3 cases (75.00%) recovered within 2 weeks. All temporary RLN injuries recovered within 1 month and no persistent RLN injury occurred. Conclusions Conventional visual identification can reduce the RLN injury, but not meet the needs of the RLN protection during complex thyroidectomy. The combination of visual identification and intraoperative neuromonitoring can further improve the recognition rate and shorten the recovery time of vocal cord dyskinesia.

Citation： SUN Hui ,LIU Xiaoli,ZHANG Daqi,FU Yantao,FU Qingfeng,JIN Tian,ZHENG Zelin. Clinical Application of Recurrent Laryngeal Nerve Protection and Monitoring During Thyroidectomy. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2010, 17(8): 768-771. doi: Copy

1.	刘晓莉, 孙辉, 郑泽霖, 等. 甲状腺术中喉返神经监测技术的应用与进展 [J]. 中国普通外科杂志, 2009; 18(11): 11871190.
2.	孙辉, 侯信明, 付言涛, 等. 甲状腺手术中喉返神经的显露保护技巧 [J]. 中国地方病防治杂志, 2009; 24(6): 469471.
3.	孙辉, 刘晓莉, 付言涛, 等. 术中神经监测技术在复杂甲状腺手术中的应用 [J]. 中国实用外科杂志, 2010; 30(1): 6668.
4.	Chiang FY, Lu IC, Kuo WR, et al. The mechanism of recurrent laryngeal nerve injury during thyroid surgerythe application of intraoperative neuromonitoring [J]. Surgery, 2008; 143(6): 743749.
5.	Chiang FY, Lee KW, Chen HC, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation [J]. World J Surg, 2010; (34): 223229.
6.	Brauckhoff M, Walls G, Brauckhoff K, et al. Identfication of the nonrecurrent inferior laryngeal nerve using intraoperative neurostimulation [J]. Langenbecks Arch Surg, 2002; 386(7): 482487.
7.	符活, 张国庆. 甲状腺切除术中喉返神经损伤的防治 [J]. 中国普外基础与临床杂志, 2009; 16(9): 762.
8.	王永福, 陈建超. 甲状腺手术中喉返神经损伤原因分析 [J]. 中国普外基础与临床杂志, 2008; 15(5): 229.
9.	刘春萍,　黄韬. 甲状腺手术喉返神经损伤的原因及处理探讨 [J]. 中国普外基础与临床杂志, 2008; 15(5): 314317.
10.	Chan WF, Lang BH, Lo CY. The role of intraoperative neuromonitoring recurrent laryngeal nerve during thyroidectomy: a comparative study on 1 000 nerves at risk [J]. Surgery, 2006； 140(6): 866873.
11.	Chiang FY, Wang LF, Huang YF, et al. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve [J]. Surgery, 2005; 137(3): 342347.
12.	Snyder SK, Hendricks JC. Intraoperative neurophysiology testing of the recurrent laryngeal nerve: plaudits and pitfalls [J]. Surgery, 2005; 138(6): 11831192.
13.	Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery [J]. Surgery, 2004; 136(6): 13101322.
14.	Yarbrough DE, Thompson GB, Kasperbauer JL, et al. Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery [J]. Surgery, 2004; 136(6): 11071115.
15.	Steurer M, Passler C, Denk DM, et al. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1 000 nerves at risk [J]. Laryngoscope, 2002; 112(1): 124133.
16.	Hermann M, Alk G, Roka R, et al. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of the nerve dissection and impact of individual surgeon in more than 27 000 nerves at risk [J]. Ann Surg, 2002; 235(2): 261268.
17.	Scott AR, Chong PS, Brigger MT, et al. Serial electromyography of the thyroarytenoid muscles using the NIMresponse system in a canine model of vocal fold paralysis [J]. Ann Otol Rhinol Laryngol, 2009; 118(1): 5666.
18.	Barczyński M, Konturek A, Cichoń S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy [J]. Br J Surg, 2009; 96(3): 240246.
19.	Tomoda C, Hirokawa Y, Uruno T. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation test for predicting vocal cord palsy after thyroid surgery [J]. World J Surg, 2006; 30(7): 12301233.
20.	Beldi G, Kinsbergen T, Schlumpf R. Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery [J]. World J Surg, 2004; 28(6): 589591.
21.	Toniato A, Mazzarotto R, Piotto A, et al. Identification of the nonrecurrent laryngeal nerve during thyroid surgery: 20year experience [J]. World J Surg, 2004; 28(7): 659661.
22.	Lahey FH. Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy [J]. Surg Gynecol Obstet, 1938; 66: 775777.
23.	Dralle H, Sekulla C, Lorenz K, et al. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery [J]. World J Surg, 2008; 32(7): 13581366.
24.	Xu W, Han D, Hou L, et al. Value of laryngeal electromyography in diagnosis of vocal fold immobility [J]. Ann Otol Rhinol Laryngol, 2007; 116(8): 576581.
25.	Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury [J]. Ann Surg, 2004; 240(1): 917.
26.	Thomusch O, Machens A, Sekulla C, et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany [J]. World J Surg, 2000; 24(11): 13351341.
27.	Johnson S, Goldenberg D. Intraoperative monitoring of the recurrent laryngeal nerve during revision thyroid surgery [J]. Otolaryngol Clin North Am, 2008; 41(6): 11471154, ix.
28.	Dionigi G, Boni L, Rovera F, et al. Neuromonitoring and videoassisted thyroidectomy: a prospective, randomized casecontrol evaluation [J]. Surg Endosc, 2009; 23(5): 9961003.

1. 刘晓莉, 孙辉, 郑泽霖, 等. 甲状腺术中喉返神经监测技术的应用与进展 [J]. 中国普通外科杂志, 2009; 18(11): 11871190.
2. 孙辉, 侯信明, 付言涛, 等. 甲状腺手术中喉返神经的显露保护技巧 [J]. 中国地方病防治杂志, 2009; 24(6): 469471.
3. 孙辉, 刘晓莉, 付言涛, 等. 术中神经监测技术在复杂甲状腺手术中的应用 [J]. 中国实用外科杂志, 2010; 30(1): 6668.
4. Chiang FY, Lu IC, Kuo WR, et al. The mechanism of recurrent laryngeal nerve injury during thyroid surgerythe application of intraoperative neuromonitoring [J]. Surgery, 2008; 143(6): 743749.
5. Chiang FY, Lee KW, Chen HC, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation [J]. World J Surg, 2010; (34): 223229.
6. Brauckhoff M, Walls G, Brauckhoff K, et al. Identfication of the nonrecurrent inferior laryngeal nerve using intraoperative neurostimulation [J]. Langenbecks Arch Surg, 2002; 386(7): 482487.
7. 符活, 张国庆. 甲状腺切除术中喉返神经损伤的防治 [J]. 中国普外基础与临床杂志, 2009; 16(9): 762.
8. 王永福, 陈建超. 甲状腺手术中喉返神经损伤原因分析 [J]. 中国普外基础与临床杂志, 2008; 15(5): 229.
9. 刘春萍,　黄韬. 甲状腺手术喉返神经损伤的原因及处理探讨 [J]. 中国普外基础与临床杂志, 2008; 15(5): 314317.
10. Chan WF, Lang BH, Lo CY. The role of intraoperative neuromonitoring recurrent laryngeal nerve during thyroidectomy: a comparative study on 1 000 nerves at risk [J]. Surgery, 2006； 140(6): 866873.
11. Chiang FY, Wang LF, Huang YF, et al. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve [J]. Surgery, 2005; 137(3): 342347.
12. Snyder SK, Hendricks JC. Intraoperative neurophysiology testing of the recurrent laryngeal nerve: plaudits and pitfalls [J]. Surgery, 2005; 138(6): 11831192.
13. Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery [J]. Surgery, 2004; 136(6): 13101322.
14. Yarbrough DE, Thompson GB, Kasperbauer JL, et al. Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery [J]. Surgery, 2004; 136(6): 11071115.
15. Steurer M, Passler C, Denk DM, et al. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1 000 nerves at risk [J]. Laryngoscope, 2002; 112(1): 124133.
16. Hermann M, Alk G, Roka R, et al. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of the nerve dissection and impact of individual surgeon in more than 27 000 nerves at risk [J]. Ann Surg, 2002; 235(2): 261268.
17. Scott AR, Chong PS, Brigger MT, et al. Serial electromyography of the thyroarytenoid muscles using the NIMresponse system in a canine model of vocal fold paralysis [J]. Ann Otol Rhinol Laryngol, 2009; 118(1): 5666.
18. Barczyński M, Konturek A, Cichoń S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy [J]. Br J Surg, 2009; 96(3): 240246.
19. Tomoda C, Hirokawa Y, Uruno T. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation test for predicting vocal cord palsy after thyroid surgery [J]. World J Surg, 2006; 30(7): 12301233.
20. Beldi G, Kinsbergen T, Schlumpf R. Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery [J]. World J Surg, 2004; 28(6): 589591.
21. Toniato A, Mazzarotto R, Piotto A, et al. Identification of the nonrecurrent laryngeal nerve during thyroid surgery: 20year experience [J]. World J Surg, 2004; 28(7): 659661.
22. Lahey FH. Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy [J]. Surg Gynecol Obstet, 1938; 66: 775777.
23. Dralle H, Sekulla C, Lorenz K, et al. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery [J]. World J Surg, 2008; 32(7): 13581366.
24. Xu W, Han D, Hou L, et al. Value of laryngeal electromyography in diagnosis of vocal fold immobility [J]. Ann Otol Rhinol Laryngol, 2007; 116(8): 576581.
25. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury [J]. Ann Surg, 2004; 240(1): 917.
26. Thomusch O, Machens A, Sekulla C, et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany [J]. World J Surg, 2000; 24(11): 13351341.
27. Johnson S, Goldenberg D. Intraoperative monitoring of the recurrent laryngeal nerve during revision thyroid surgery [J]. Otolaryngol Clin North Am, 2008; 41(6): 11471154, ix.
28. Dionigi G, Boni L, Rovera F, et al. Neuromonitoring and videoassisted thyroidectomy: a prospective, randomized casecontrol evaluation [J]. Surg Endosc, 2009; 23(5): 9961003.

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Clinical Application of Recurrent Laryngeal Nerve Protection and Monitoring During Thyroidectomy

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