Intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer

OBJECTIVE

This study evaluated the safety and efficacy of intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer.

METHODS

From April 2008 to April 2009, a total of 25 patients at high risk for left recurrent laryngeal nerve injury agreed to and underwent intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer in our hospital. Results and clinical records were reviewed.

RESULTS

All the patients' left recurrent laryngeal nerves were identified during operation by intraoperative recurrent laryngeal nerve monitoring. Twenty-four patients retained normal left recurrent laryngeal nerves after the operation. One patient, in whom part of the left recurrent laryngeal nerve was found to be invaded, underwent single-stage nerve anastomosis under recurrent laryngeal nerve monitoring after the invaded nerve was resected. There were no significant intraoperative or postoperative complications among the other patients.

CONCLUSIONS

Intraoperative recurrent laryngeal nerve monitoring during thoracotomy is a safe and effective way of identifying the nerve. It may help surgeons to avoid injuring the recurrent laryngeal nerve during some thoracic procedures.

[Intraoperative identification of the recurrent laryngeal nerves in thyroid surgery]

Accidental injury to the recurrent laryngeal nerve is a common complication of thyroid surgery. Different mechanisms of injury have been described, such as mechanical, electrical, or thermal. Retrosternal operations, secondary bleeding requiring wound revision, or neoplastic tumors are also frequent causes of this complication. Intraoperative direct stimulation of suspected nerve structures as well as vagal nerve stimulation have been proposed to avoid the injury. The effect of stimulation can be assessed by direct observation of the vocal cords (direct laryngoscopy or fiberoscopy via a laryngeal mask airway), or electromyography of the posterior cricoarytenoid muscle. All of these methods limit the use of muscle relaxants during anaesthesia. Details of anaesthetic management are presented.

Complications during and after surgery of the lower cervical spine by isolated anterior approach with CSLP implant

BACKGROUND

The merits of different operative approaches in the management of spinal injury is debated. The aim of this study was to assess, retrospectively, the outcome of treatment of injuries of the lower cervical spine by an anterior approach, in terms of fusion rate and complications.

MATERIALS AND METHODS

Between 1995 and 2004, 270 patients with an injury of the lower cervical spine were operated on by an anterior approach in our hospital. There were 67 females and 203 males. Using the Aebi and Nazarian classification, 22% of patients had a type A injury, 23% of patients had a type B injury and 55% of patients had a type C injury. All had an anterior approach with monocortical stabilisation using a cervical spine locking plate [Synthes].

RESULTS

Radiological evidence of fusion was found in all but one patient at 6 months. Complications occurred in a small proportion of the series. Recurrent laryngeal nerve injury was noted in seven patients, an abscess in the wound in one patient, a haematoma requiring re-operation for evacuation in two patients. The cervical locking plate broke in one patient and this patient went on to develop a pseudoarthrosis from failure to fuse. In another patient there was release of the plate osteosynthesis.

CONCLUSIONS

Treatment of the injured lower cervical spine by an anterior operation and plate fixation was successful in achieving bone fusion in almost every patient and was followed by a complication in only a small proportion of our series. Similar results in other reports indicate that this approach is a safe and effective procedure.

[Total videoendoscopic thyroid resection by the axillobilateral breast approach. Operative method and first results]

BACKGROUND

The axillobilateral breast approach (ABBA) is a procedure allowing thyroid resection without scarring at the neck. We operated on a series of 26 patients with this technique.

METHOD

Via incisions at the edge of the mamilla and axilla, trocars are placed subcutaneously under the platyma. Dissection is performed bluntly and with an ultrasonographic scalpel under videoscopic control. The procedure itself corresponds to conventional surgery. The specimen is removed through the axillary trocar.

RESULTS

Twenty-six female patients underwent thyroid resection using the ABBA technique. Subtotal resection was performed in 24. Mean operation times were 111 min (unilateral) and 187 min (bilateral). In none of these cases was conversion necessary. One transient recurrent laryngeal nerve palsy and one paresis of the arm plexus were found postoperatively.

CONCLUSION

In selected patients the ABBA technique is feasible and safe with the mandatory radicalness. The primary aim of this method is the cosmetic result.

[Safety of routine exposure of recurrent laryngeal nerve in thyroid surgery]

OBJECTIVE

To explore the safe approach to routine exposure of the recurrent laryngeal nerve in thyroid surgery.

METHODS

A total of 1974 sides of laryngeal nerves were exposed in 1458 thyroid surgeries, which included six right side non-recurrent laryngeal nerves. Ninety seven percent (1915 sides of the laryngeal nerves) were exposed through inferior thyroid artery way. The rest were exposed through nerve entrance way (38 sides, 1.9%) or isthmus-to-tracheoesophageal groove way (21 sides, 1.1%).

RESULTS

Permanent injury of recurrent laryngeal nerves occurred in seven cases, which comprised 0.5% of the total surgeries. Transient injury of recurrent laryngeal nerves occurred in 24 cases, which comprised 1.6% of the total surgeries.

CONCLUSION

Routine exposure of recurrent laryngeal nerve in thyroid surgery is safe. The exposure should be started from the inferior thyroid artery and be ended at the nerve entrance into laryngeal.

[Surgical anatomy of the external branch of the superior laryngeal nerve: clinical-anatomical investigation]

On the basis of an anatomical (60 observations) and clinical material (160 patients with different diseases of the thyroid gland) the authors specified topography of the external branch of the superior laryngeal nerve, proposed supplements to the classification of variants of its passage, estimated the risk of traumatizing this structure during operation, determined the zone of most probable injury. Anatomical substantiation is given to the places of most convenient ligation of the main branches of the superior thyroid vessels.

Lateral Mobilization of the Recurrent Laryngeal Nerve to Facilitate Tracheal Surgery in Patients with Thyroid Cancer Invading the Trachea Near Berry’s Ligament

BACKGROUND

Thyroid cancer often invades the trachea and the recurrent laryngeal nerve (RLN) at or near Berry's ligament, which fixes the thyroid gland to the trachea. In patients with thyroid cancer invading the trachea near the ligament, preservation of the RLN is very difficult. Regardless of whether the nerve is preserved or is resected and reconstructed, the presence of the nerve interferes with tracheal resection and repair. We proposed a new technique to solve this problem.

METHODS

Before tracheal surgery, the inferior pharyngeal constrictor muscle was divided along the lateral edge of the thyroid cartilage, and the RLN was mobilized and retracted laterally. We applied this technique in 11 patients with papillary thyroid carcinoma invading the trachea. Two patients demonstrated vocal cord paralysis preoperatively. The procedures used for tracheal surgery in this series were partial resection of the trachea with creation of a tracheocutaneostomy, that with direct suture, and shaving off the tumor in 7, 2, and 2 patients, respectively.

RESULTS

The RLN could be preserved and mobilized laterally in eight patients. While three patients demonstrated transient vocal cord paralysis, the remaining five had functioning cords postoperatively. In three patients the RLN was resected, and the remaining distal stump was mobilized and anastomosed with the ansa cervicalis. These patients recovered their voices and maximum phonation time increased to the normal level. The tracheocutaneous stoma was closed with local skin flap about four months later in all patients.

CONCLUSION

Lateral mobilization of the RLN facilitates the preservation of the nerve and the performance of tracheal surgery in patients with thyroid cancer invading the trachea at or near Berry's ligament.

Pre-existing left pulmonary artery stenosis and other anomalies associated with device occlusion of patent ductus arteriosus

A retrospective analysis was performed on 200 consecutive patients who underwent cardiac catheterization for occlusion of Patent Ductus Arteriosus (PDA) at a single center by a single operator. Four significant anomalies were observed: pre-existing Left Pulmonary Artery (LPA) stenosis, left recurrent laryngeal nerve (LRLN) injury, electrocardiogram (EKG) changes, and aorto-pulmonary (AP) collateral arteries. The observation of pre-existing LPA stenosis, marked EKG changes, and permanent LRLN injury have not been previously reported. Incidence, etiology, and clinical significance of these anomalies are discussed with specific new recommendations for the prevention of LRLN injury and occlusion of AP collaterals.

A new system for continuous recurrent laryngeal nerve monitoring

Existing nerve monitoring devices in thyroid surgery are - except for one - mainly intermittently working nerve identification tools. We present a new vagal electrode which allows true continuous monitoring of the recurrent laryngeal nerve (RLN). The electrode was designed as a tripolar hybrid cuff electrode consisting of polyimide, gold and platinum layers embedded in a flexible silicon cuff which can be opened at the long side for introducing the nerve. It is fully implantable and atraumatic. The evoked potentials are sensed by standard thyroid electrodes. Real-time signal analysis and audio feedback are achieved by specially designed software. Homogeneous and stable signals were recorded throughout the operations. Thus real-time computer-based signal analysis was possible. Evoked potentials reached 300-900 mV. Mean time to place the cuff electrode was 5.5 min. The nerve was stimulated a mean of 63 min (range 55-99 min). No RLN lesions were detected postoperatively. The new vagal electrode was easy to handle and led to stable and reproducible signals. The stimulation current could be kept extremely low due to the special geometry of the electrode. It offers the possibility for uninterrupted, continuous laryngeal nerve monitoring in thyroid surgery. In an ongoing clinical trial its compatibility as an add-on for existing nerve monitoring devices is being tested.

Does recurrent laryngeal nerve anatomy condition the choice of the side for approaching the anterior cervical spine?

AIM

The anterior cervical presternocleidomastoid approach is a safe and standardized procedure. Nevertheless, in all the largest series presented in literature, a certain risk of injury to the recurrent laryngeal nerves (RLNs) is reported and the choice of the side of the approach seems to influence such risk. Our aim was to study the surgical anatomy of the RLNs and to understand whether the side of the approach can be a risk factor for their surgical damage.

METHODS

We performed an anatomical dissection of 6 fresh cadavers, studying the origin and the course of both the RLNs, to assess their vulnerability in the anterior presternocleidomastoid approach to the cervical spine.

RESULTS

The origin of the right RLN was at C7 in 2 cases and at T1 in 4 cases. In all cases it arose where vagus nerve crossed the subclavian artery and it was directed superiorly and transversely to the esophagotracheal groove.

CONCLUSIONS

The right and left RLNs have different origin and course. Although the discussion about the best side for the anterior cervical approach is debated, in our opinion, both anatomical and surgical considerations, concerning RLNs, lead to the evidences that the left side approach, when possible, should be preferred below the level of C4.

The axillary access in unilateral thyroid resection

BACKGROUND AND STUDY AIMS

With this study, we intended to find out if it is possible to avoid the typical scar after thyroid resection by using a 20 mm axillary access and a 3.5 mm incision in the jugulum.

MATERIALS AND METHODS

We present the results of our proof-of-concept study with 12 patients. For this technique, a modified axilloscope and ultrasonic scissors were used, which permit a total resection of the unilateral thyroid.

RESULTS

The feasibility of this endoscopic technique was shown by the successful operation of these patients with unilateral pathological findings. Furthermore, we showed that this technique allows to resect tissue up to a whole lobe while at the same time finding and identifying the recurrent laryngeal nerve and subsequently verifying the findings by using the neuro-monitoring system.

CONCLUSIONS

This study shows that endoscopic thyroid surgery approximates the norms of endocrine neck surgery. The presented method is useful in thyroid surgery for patients with single nodules and a small thyroid gland.

[Applied anatomy of the superior laryngeal nerve and surgical prophylactics of its lesions]

The article gives a brief historical reference on the discovery and investigation of the superior laryngeal nerve, the anatomical and clinical exploration of its topography, physiology and pathophysiology, as well as main variants of the correlations of the external branch of the nerve and the superior thyroid artery. The importance of superior laryngeal nerve is shown in the voice-forming function of the larynx. The incidence and main methods of prevention of intraoperative lesions of the nerve are described. The authors consider the potentials of clinical and instrumental diagnostics, as well as the effectiveness of treatment of traumas of the exterior branch of the superior laryngeal nerve during surgery for diseases of the thyroid gland.

[Surgical prophylactics of injuries of the recurrent laryngeal nerves during operations for diseases of the thyroid gland]

The work presents an analysis of specific features of surgical anatomy of recurrent laryngeal nerves in 676 patients operated in the City Center of endocrine surgery and oncology of St. Petersburg for different diseases of the thyroid gland (TG) during the period from 01.01.2005 to 15.07.2006 mainly by one and the same surgeon. In the course of 696 operations 718 recurrent laryngeal nerves were detected, verified, separated in the neck from the subclavian area to the place of entering into the larynx, and photo-video documented. In 656 cases the disease of TG was primary, and in 40 cases--recurrent. The investigation performed allowed the development and use of reliable methods of prophylactics and treatment of recurrent laryngeal nerves injured in patients during operations for different diseases of TG, carcinoma of this organ included. The optimal places of detection and identification were determined as well as the ways of separation of these nerves from the surrounding tissues. The surgical anatomy of the recurrent laryngeal nerves in the neck was studied. The role, place and effectiveness of electrophysiological monitoring were established. The corrections introduced in the technique of thyroidectomies in 4110 patients resulted in lowered incidence of postoperative pareses of the laryngeal muscles from 0.91% to 0.56% during the period from 2001 to 2006.

[Intraoperative neuro-monitoring of the recurrent laryngeal nerve. Experience of 1000 consecutive patients]

Intraoperative neuro-monitoring was introduced in thyroid surgery several years ago resulting in a facilitated identification of the recurrent laryngeal nerve and less recurrent laryngeal nerve injuries. Between 1999 and 2005 data of all patients undergoing thyroid resection were recorded and analyzed yearly. The intraoperative identification of recurrent laryngeal nerve succeeded in 99.2% (1768 nerves at risk). The percentage of complete resecting surgical procedures raised from 17% to 84%. Minimal vocal cord dysfunction, associated with hematoma and edema in most cases, was diagnosed laryngoscopically in 2.9%. The permanent palsy rate of 0.8% in the first year decreased down to 0.32%. Routinely introduction of intraoperative neuro-monitoring in thyroid surgery is associated with a demonstrable decreased palsy rate. Anyway, the rate of minimal vocal cord movement disorders and transient recurrent laryngeal nerve palsies is not changed.

Intraoperatives Neuromonitoring des Nervus laryngeus recurrens - Ergebnisse und Lernkurve

Intraoperative neuromonitoring was introduced in thyroid surgery several years ago resulting in a facilitated identification of the recurrent laryngeal nerve and less recurrent laryngeal nerve injuries. Between 1999 and 2004 data of all patients (n=937) undergoing thyroid resection were recorded prospectively and analyzed yearly. The intraoperative identification of recurrent laryngeal nerve succeeded in 99.2% (1665 nerves at risk). The percentage of completely resecting surgical procedures raised from 17% to 56%. Minimal vocal cord dysfunction associated with hematoma and edema in most cases was diagnosed laryngosopically in 1.4-2.4%. Transient recurrent nerve palsies were seen in 2.3% without changes throughout the years. The permanent palsy rate of 0.8% in the first years decreased. No permanent palsies were diagnosed in the last 3 years. Routine introduction of intraoperative neuromonitoring in thyroid surgery is associated with a demonstrable learning curve lasting several years. Permanent palsy rate is decreased. The rate of minimal vocal cord movement disorders and transient recurrent laryngeal nerve palsies is not changed.

The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: A comparative study on 1000 nerves at risk

BACKGROUND

The role of intraoperative neuromonitoring of recurrent laryngeal nerve (RLN) during thyroidectomy has not been well established. The present study evaluates whether RLN injury can be reduced by the application of this technique during thyroidectomy in a single center.

METHODS

Of 1000 RLNs that were at risk of injury in 639 consecutive patients who underwent thyroidectomy, the outcome of 501 RLNs with the use of neuromonitoring was compared with that of 499 nerves that were operated by routine identification only. The incidences of RLN paralysis were compared between the 2 groups and the assigned risk subgroups.

RESULTS

Postoperative palsy was identified in 47 RLNs (4.7%), with complete recovery in 37 of 44 RLNs (84%) without documented injury. The overall incidence of postoperative RLN paralysis was significantly higher during thyroidectomy for malignancy (P = .025) and secondary thyroidectomy (P = .017). There was no significant difference in postoperative, transient, and permanent paralysis rates between the neuromonitoring and control groups. In subgroup analysis, the postoperative RLN palsy rate was higher during reoperative thyroidectomy (19% vs 4.6%; P = .019) in the control group but not in the neuromonitoring group (7.8% vs 3.8%; P > .05).

CONCLUSION

Neuromonitoring of the RLN during thyroid surgery could not be demonstrated to reduce RLN injury significantly, compared with the adoption of routine RLN identification. However, its application can be considered for selected high-risk thyroidectomies.

Recurrent Laryngeal Nerve Palsy after Anterior Cervical Spine Surgery

Background

Vocal fold immobility (paresis or paralysis) from recurrent laryngeal nerve injury remains an important cause of morbidity after anterior cervical spine surgery. A maneuver involving endotracheal tube (ETT) cuff manipulation has been proposed to reduce its incidence. This study is a randomized, prospective, double-blind investigation to test the hypothesis that ETT cuff manipulation reduces the incidence of postoperative vocal fold immobility after anterior cervical spine surgery.

Methods

One hundred patients scheduled to undergo anterior cervical spine surgery were randomly assigned to one of two groups. After inducing general endotracheal anesthesia, patients in the intervention group had their ETT cuff pressures maintained at 20 mmHg or less. After placement of self-retaining retractors, the ETT cuff was deflated for 5 s and then reinflated. Patients in the control group had no further manipulation of their ETT once the cuff was inflated after intubation. Cuff pressures in both groups were recorded before skin incision (baseline) and after placement of self-retaining retractors (peak). Patients' vocal fold motion was evaluated by indirect laryngoscopy performed preoperatively and postoperatively. The examination was videotaped and reviewed by a blinded otolaryngologist. Postoperative vocal fold motion was graded as normal, paretic, or paralyzed.

Results

Complete data were available in 94 patients. The incidence of vocal fold paralysis was 3.2% (95% confidence interval, 0.7-9.4%). Cuff manipulation decreased ETT cuff pressure but did not reduce the incidence of vocal fold immobility (15.4% vs. 14.5%).

Conclusion

Endotracheal tube cuff deflation/reinflation and pressure adjustment do not reduce the incidence of vocal fold immobility in anterior cervical spine surgery.

Complications of thyroid surgery

Thyroid surgery has a history of significant changes in the technique and the incidence of complications. Since then continuous developments in surgical techniques and better understanding of thyroid anatomy and pathology have increased the safety of thyroid surgery and reduced the incidence of complications. Nowadays, the rate of postoperative mortality is extremely low. Nevertheless, the incidence of postoperative complications varies in literature from 7.4% to 53% of the operations performed. The most common and potentially life-threatening complications in thyroid gland surgery are vocal cord palsy and hypocalcemia. Herein we discuss the common complications in thyroid gland surgery and their proper management.

Clinical Implementation of Endoscopic Thyroidectomy in Selected Patients

OBJECTIVES

Systematic investigation of minimal access thyroid compartment surgery combined with the advent of several key new technologies has culminated in the implementation of endoscopic thyroidectomy in specific clinical situations.

STUDY DESIGN

: The authors conducted a prospective, nonrandomized analysis of a consecutive cohort of surgical patients from the Medical College of Georgia Thyroid Center.

METHODS AND MATERIALS

A series of patients meeting specific criteria underwent thyroid surgery with the intention of performing endoscopic thyroidectomy. Demographic and clinical data were prospectively collected and included age, gender, indications for surgery, length of incision, need for conversion, and pathology.

RESULTS

Thirty-five patients successfully underwent 36 endoscopic thyroidectomies between February 2005 and March 2006 (representing 28.8% of the 125 thyroidectomies done during that period of time). There were 32 females and three males with a mean age of 45.3 +/- 13.9 years. There were five total thyroidectomies and 31 hemithyroidectomies. The mean incision length was 24.2 +/- 0.5 mm. There were no cases of permanent hypocalcemia or recurrent laryngeal nerve paralysis. Factors that increased the difficulty of endoscopic surgery included obesity, the presence of thyroiditis, and nodules >2.5 cm.

CONCLUSIONS

The combination of new technology and careful experimental investigation has spawned a new era of thyroidectomy in which definitive management of thyroid pathology may be accomplished through an incision of <1 inch. This approach is feasible in the hands of surgeons with high-volume thyroidectomy practices who are comfortable with endoscopic principles. The cosmetic advantages are self-evident.

The advantage of near-total thyroidectomy to avoid postoperative hypoparathyroidism in benign multinodular goiter

BACKGROUND

In recent years, total or near-total thyroidectomy has emerged as a surgical option to treat patients with multinodular goiter, especially in endemic iodine-deficient regions. The aim of this study was to compare the complication rates of total and near-total thyroidectomy in multinodular goiter and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups.

STUDY DESIGN

Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total thyroidectomy (group 1, n = 104) and near-total thyroidectomy leaving less than 2 g (group 2, n = 112).

RESULTS

There were no persistent complications. The incidence of transient hypoparathyroidism in group 1 (26%) was significantly higher than in group 2 (9.8%) (p < 0.001). The rate of asymptomatic hypocalcemia in group 2 (7.4%) was lower than in group 1 (27%) (p < 0.001). The incidence of papillary cancer was 9.6% in group 1 and 12.5% in group 2 (p > 0.05). None of the patients underwent completion thyroidectomy before ablative therapy. Ten patients were found to have the histological criteria for radioactive iodine ablation. Of these 10 patients, four were in group 1 and six were in group 2 (p > 0.05).

CONCLUSION

In conclusion, we recommend near-total thyroidectomy in multinodular goiter instead of total or subtotal thyroidectomy. While near-total thyroidectomy and total thyroidectomy obviate the need for completion thyroidectomy in incidentally found thyroid cancer, and while there is no difference in the rate of recurrent laryngeal nerve palsy between the two methods, near-total thyroidectomy causes a significantly lower rate of hypoparathyroidism compared to total thyroidectomy.

[Preventing recurrent laryngeal nerve lesions by anastomosing it during thyroid surgery]

OBJECTIVE

To study how to prevent recurrent laryngeal nerve (RLN) lesions by anastomosing it during thyroid surgery.

METHOD

In the present study 517 patients with thyroid diseases underwent thyroid surgery from January 1993 to May 2005, with RLNs of 163 cases (187 sides, A group) anatomized and RLNs of 354 cases (438 sides. B group) not anatomized. The RLN in B group were protected generally during thyroid surgery. RLNs of A group were anatomized partly or totally.

RESULT

(1) In A group RLNs of 123 cases were partly anatomized and 64 totally. None of all RLNs was injuried. (2) B group 3 sides of 3 cases of all RLNs was injuried. The rate of RLN's lesion is 0.7%, which is significantly higher in A group than in B group.

CONCLUSION

Anastomosing RLN during thyroid surgery may prevent its lesions. The length of anatomized RLN must vary with the area and position of thyroid pathological changes. The RLN needn't be anatomized in these patients with the benign thyroid pathological changes which is far away trachea-oesophagus channel.

[The importance of nonrecurrent laryngeal nerve in thyroid surgery]

OBJECTIVE

To investigate the anatomic variation of nonrecurrent laryngeal nerve (NRLN) and its surgical identification and prevention during thyroidectomy.

METHODS

The database of 5 NRLN cases was analyzed to investigate the difference of operative maneuvers and procedures.

RESULTS

All 5 NRLN were located in the right side. Two cases were found have vocal cord paralysis and 1 case recovered in 3 cases who have NRLN injures.

CONCLUSIONS

Any transverse bond should not be cut between vascular and laryngeal except middle thyroid vein. Recurrent laryngeal nerve (RLN) should be dissected during thyroid excision. Cervical pneumogastric nerve should be systematic dissected to detect whether RNLN is exist, if RLN is not exist in the same side.