Daqi Zhang1, Hui Sun2, Ralph Tufano3, Ettore Caruso4, Gianlorenzo Dionigi5, Hoon Yub Kim6. 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 Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China. Electronic address: daqizhang@yeah.net. 2. 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 Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China. Electronic address: thyroidjl@168.com. 3. Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA. Electronic address: rtufano1@jhmi.edu. 4. Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Child-hood "G. Barresi", University Hospital G. Martino, University of Messina, Italy. Electronic address: ettore_caruso@hotmail.it. 5. Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Child-hood "G. Barresi", University Hospital G. Martino, University of Messina, Italy. Electronic address: gdionigi@unime.it. 6. Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Republic of Korea. Electronic address: hoonyubkim@korea.ac.kr.
Abstract
INTRODUCTION: The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA). METHODS: The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued. RESULTS: Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times. CONCLUSIONS: The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.
INTRODUCTION: The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA). METHODS: The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued. RESULTS: Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times. CONCLUSIONS: The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.
Authors: Salman Alsafran; Danah Quttaineh; Dalia Albloushi; Sarah Al Safi; Abdullah Alfawaz; Khalifah Alyatama; Ali Ismail Journal: Ann Med Surg (Lond) Date: 2021-11-23