Ricard Simó1, Iain J Nixon2, Aleix Rovira3, Vincent Vander Poorten4,5, Alvaro Sanabria6, Mark Zafereo7, Dana M Hartl8, Luiz P Kowalski9, Gregory W Randolph10, Dipti Kamani10, Ashok R Shaha11, Jatin Shah12, Jean-Paul Marie13, Alessandra Rinaldo, Alfio Ferlito14. 1. Department of Otorhinolaryngology Head and Neck Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, King's College London, London, United Kingdom. 2. Department of Otorhinolaryngology Head and Neck Surgery, Edinburgh Royal Infirmary, Edinburgh, United Kingdom. 3. Guy's and St Thomas' Hospital NHS Foundation Trust, St Thomas' Street, Guy's Hospital, SE1 9RT, United Kingdom. 4. Department of Otorhinolaryngology Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium. 5. Department of Oncology, Section Head and Neck Oncology, Leuven, Belgium. 6. Department of Surgery, Universidad de Antioquia, Hospital Universitario San Vicente Fundacion, CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello, Medellin, Colombia. 7. Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas, U.S.A. 8. Department of Otorhinolaryngology Head and Neck Surgery, Thyroid Surgery Unit, Institute Gustave Roussy, Paris, France. 9. Department of Otorhinolaryngology Head and Neck Surgery, A.C. Camargo Cancer Center, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil. 10. Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A. 11. Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, Cornell University Medical College, New York, New York, U.S.A. 12. Department of Surgery, Memorial Sloan-Kettering Cancer Center, Weil Medical College of Cornell University, New York, New York, U.S.A. 13. Experimental Surgery Laboratory, Institute of Biomedical Research, University Hospital Rouen, Rouen, France. 14. Department of Otorhinolaryngology Head and Neck Surgery, University of Udine School of Medicine, Udine, Italy.
Abstract
OBJECTIVES: Recurrent laryngeal nerve (RLN) injury is a recognized risk during thyroid and parathyroid surgery and can result in significant morbidity. The aim of this review paper is to consider the optimal approach to the immediate intraoperative repair of the RLN during thyroid surgery. METHODS: A PubMed literature search was performed from inception to June 2020 using the following search strategy: immediate repair or repair recurrent laryngeal nerve, repair or reinnervation recurrent laryngeal nerve and immediate neurorraphy or neurorraphy recurrent laryngeal nerve. RESULTS: Methods of immediate intraoperative repair of the RLN include direct end-to-end anastomosis, free nerve graft anastomosis, ansa cervicalis to RLN anastomosis, vagus to RLN anastomosis, and primary interposition graft. Techniques of nerve repair include micro-suturing, use of fibrin glue, and nerve grafting. Direct micro-suture is preferable when the defect can be repaired without tension. Fibrin glue has also been proposed for nerve repair but has been criticized for its toxicity, excessive slow reabsorption, and the risk of inflammatory reaction in the peripheral tissues. When the proximal stump of the RLN cannot be used, grafting could be done using transverse cervical nerve, supraclavicular nerve, vagus nerve, or ansa cervicalis. CONCLUSIONS: Current evidence is low-level; however, it suggests that when the RLN has been severed, avulsed, or sacrificed during thyroid surgery it should be repaired intraoperatively. The immediate repair has on balance more advantages than disadvantages and should be considered whenever possible. This should enable the maintenance of vocal cord tone, better and prompter voice recovery and avoidance of aspiration. Laryngoscope, 131:1429-1435, 2021.
OBJECTIVES: Recurrent laryngeal nerve (RLN) injury is a recognized risk during thyroid and parathyroid surgery and can result in significant morbidity. The aim of this review paper is to consider the optimal approach to the immediate intraoperative repair of the RLN during thyroid surgery. METHODS: A PubMed literature search was performed from inception to June 2020 using the following search strategy: immediate repair or repair recurrent laryngeal nerve, repair or reinnervation recurrent laryngeal nerve and immediate neurorraphy or neurorraphy recurrent laryngeal nerve. RESULTS: Methods of immediate intraoperative repair of the RLN include direct end-to-end anastomosis, free nerve graft anastomosis, ansa cervicalis to RLN anastomosis, vagus to RLN anastomosis, and primary interposition graft. Techniques of nerve repair include micro-suturing, use of fibrin glue, and nerve grafting. Direct micro-suture is preferable when the defect can be repaired without tension. Fibrin glue has also been proposed for nerve repair but has been criticized for its toxicity, excessive slow reabsorption, and the risk of inflammatory reaction in the peripheral tissues. When the proximal stump of the RLN cannot be used, grafting could be done using transverse cervical nerve, supraclavicular nerve, vagus nerve, or ansa cervicalis. CONCLUSIONS: Current evidence is low-level; however, it suggests that when the RLN has been severed, avulsed, or sacrificed during thyroid surgery it should be repaired intraoperatively. The immediate repair has on balance more advantages than disadvantages and should be considered whenever possible. This should enable the maintenance of vocal cord tone, better and prompter voice recovery and avoidance of aspiration. Laryngoscope, 131:1429-1435, 2021.
Authors: Cesare Piazza; Davide Lancini; Michele Tomasoni; Anil D'Cruz; Dana M Hartl; Luiz P Kowalski; Gregory W Randolph; Alessandra Rinaldo; Jatin P Shah; Ashok R Shaha; Ricard Simo; Vincent Vander Poorten; Mark Zafereo; Alfio Ferlito Journal: Front Endocrinol (Lausanne) Date: 2021-11-11 Impact factor: 5.555