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Lee J, Kim SH, Hong H. Comparison of Various Thyroidectomy Approaches: A Retrospective Cross-sectional Study. Surg Laparosc Endosc Percutan Tech 2023; 33:632-639. [PMID: 37934829 DOI: 10.1097/sle.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/19/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND To avoid anterior neck scarring, numerous remote-access techniques to approach the thyroid gland (Remote access approach) have been described, including the transaxillary approach (TA), bilateral axillo-breast approach (BABA), and transoral robotic thyroidectomy (TORT). Popular worldwide, Remote access approachs have unique characteristics, advantages, and disadvantages. Herein, we investigated the characteristics of these distinct thyroidectomy approaches to aid surgeons in selecting the most appropriate method for patients. PATIENTS AND METHODS In total, 2351 cases of patients who underwent thyroidectomy between 2019 and 2021 were reviewed, including 1973, 281, 66, and 31 patients who underwent the conventional transcervical approach (TCA), TA, BABA, and TORT, respectively. Demographic characteristics, outcomes, and complications associated with these procedures were compared. The data were analyzed using the Student t test and the χ 2 test. Kruskal-Wallis and Mann-Whitney U tests were used if normality was not found. RESULTS Central lymph nodes (LNs) were retrieved mostly in patients who underwent lobectomy through TORT (mean: 9.4, P < 0.001). Metastatic central LNs were found more frequently (mean: 1.9 in lobectomy, 3.7 in total thyroidectomy) in patients who underwent lobectomy through TCA and TORT than in those who underwent lobectomy through other approaches (mean: 1.4 and 2.4, respectively, P < 0.05). BABA group patients had significantly fewer central LNs retrieved than those in other groups in lobectomy and total thyroidectomy (mean: 4.8 and 6.2, respectively, P < 0.05). Stimulated thyroglobulin levels did not differ among the 4 groups. The incidence of transient vocal cord palsy was statistically higher in the BABA group (5 cases, 7.5%) than in the other groups; however, all patients recovered. No difference was found in permanent vocal cord palsy (0.4% in TCA) or hypoparathyroidism (1.3% to 3.1%) among the 4 groups. The tumor size was significantly larger in the BABA group than in the other groups, with 10.6% of the patients having tumors larger than 4 cm. Total thyroidectomy was performed more frequently in the BABA group (51.8%) than in the other groups ( P = 0.005). The path of the external branch of the superior laryngeal nerve was more evident in TA, and the Cernea type was confirmed and preserved in 90.6% of TA cases. CONCLUSIONS Owing to the differences in working space and direction of the surgical field, TA was advantageous for preserving the external branch of the superior laryngeal nerve, whereas BABA was effective for total thyroidectomy and excision of large goiters. TORT was beneficial for central compartment neck dissection. These characteristics should be considered when choosing the best approach to improving cosmesis, function, and recurrence.
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Affiliation(s)
- Jeonghun Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Torky RA, Abdel-Tawab M, Hussein MM. Short term Outcomes of Routine Exposure Versus non Exposure of the Recurrent Laryngeal Nerve During Thyroidectomy for Benign Thyroid Diseases. Indian J Otolaryngol Head Neck Surg 2023; 75:1974-1980. [PMID: 37636666 PMCID: PMC10447871 DOI: 10.1007/s12070-023-03763-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/30/2023] [Indexed: 08/29/2023] Open
Abstract
Aims To evaluate the outcomes of the exposure versus non-exposure of the RLN during thyroidectomy for benign thyroid diseases. Materials and methods A prospective study for patients who underwent thyroidectomy for benign diseases. They were classified into two groups, group 1 (the exposed group) and group 2 (the non-exposed group) of the RLN. History, examination, laboratory and radiological investigations as well as intra and post-operative details were recorded. Results 97 patients were included in the study, group 1 (63 patients) while group 2 (34 patients). The median age of both groups was 40 (for group 1) and 42 (for group 2) respectively. There was no significant difference regarding the gender of the patients (P = 0.089) and the type of surgery (P = 0.234). The duration of surgery as well as the amount of intraoperative blood loss were equal with no significant difference (P = 0.791) (P = 0.225). Hematoma was detected in three patients in the exposed group while RLN injury was detected in 5 patients in total (2 in group 1 and 3 in group 2) without any significant difference. There was significant hypocalcemia in favor of the non-exposed group (P = 0.001). Regarding the postoperative hospital stay, there was no significant difference between both groups (P = 0.720). Conclusions Exposure versus non-exposure of the RLN is still considered a matter of debate but precautions during dissection are a very useful maneuver. Meanwhile, it is better to expose the nerve with meticulous dissection and preservation of the parathyroid gland vascularity.
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Affiliation(s)
- Radwan Abdelsabour Torky
- Department of Surgery, main hospital, Assiut Faculty of medicine, Assiut University, Assiut, Egypt
| | - Mohamed Abdel-Tawab
- Department of diagnostic and interventional radiology, main hospital, Assiut Faculty of medicine, Assiut University, Assiut, Egypt
| | - Mohammed M. Hussein
- Department of Surgery, main hospital, Assiut Faculty of medicine, Assiut University, Assiut, Egypt
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Papagoras D, Tzikos G, Douridas G, Arseniou P, Panagiotou D, Kanara M, Papavramidis T. Visualization of the recurrent laryngeal nerve alone versus intraoperative nerve monitoring in primary thyroidectomy: a framework approach to a missing typology. Front Surg 2023; 10:1176511. [PMID: 37560316 PMCID: PMC10406577 DOI: 10.3389/fsurg.2023.1176511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Surgical studies evaluating a device or technology in comparison to an established surgical technique should accurately report all the important components of the surgical technique in order to reduce the risk of intervention bias. In the debate of visualization of the recurrent laryngeal nerve alone (VONA) versus intraoperative nerve monitoring (IONM) during thyroidectomy, surgical technique plays a key role in both strategies. Our aim was to investigate whether the surgical technique was considered as a risk of intervention bias by relevant meta-analyses and reviews and if steps of surgical intervention were described in their included studies. METHODS We searched PUBMED, CENTRAL-Cochrane library, PROSPERO and GOOGLE for reviews and meta-analyses focusing on the comparison of IONM to VONA in primary open thyroidectomy. Τhen, primary studies were extracted from their reference lists. We developed a typology for surgical technique applied in primary studies and a framework approach for the evaluation of this typology by the meta-analyses and reviews. RESULTS Twelve meta-analyses, one review (388,252 nerves at risk), and 84 primary studies (128,720 patients) were included. Five meta-analyses considered the absence of typology regarding the surgical technique as a source of intervention bias; 48 primary studies (57.14%) provided information about at least one item of the typology components and only 1 for all of them. DISCUSSION Surgical technique of thyroidectomy in terms of a typology is underreported in studies and undervalued by meta-analyses comparing VONA to IONM. This missing typology should be reconsidered in the comparative evaluation of these two strategies.
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Affiliation(s)
| | - Georgios Tzikos
- 1st Propedeutic Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Gerasimos Douridas
- Department of Surgery, Thriassio General Hospital of Elefsina, Elefsina, Greece
| | | | | | - Maria Kanara
- Department of Surgery, General Hospital of Trikala, Trikala, Greece
| | - Theodosios Papavramidis
- 1st Propedeutic Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Bhattacharjee A, Rathor A, Uddin S. Comparative Study of Parathyroid Identification Techniques Using Zuckerkandl's Tubercle Versus Parathyroid Arterial Supply as Intra-Operative Markers. Indian J Otolaryngol Head Neck Surg 2022; 74:483-489. [PMID: 36514436 PMCID: PMC9741674 DOI: 10.1007/s12070-021-02884-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/18/2021] [Indexed: 12/15/2022] Open
Abstract
Thyroid surgeons should be able to identify factors that prevent parathyroid damage. The aim of the study was (i) to compare the effectiveness of using Zuckerkandl's Tubercle (ZT) versus superior thyroid artery (STA) and inferior parathyroid artery (ITA) as markers for identification of superior and inferior parathyroid glands and (ii) to demonstrate a series of detailed, logical and orderly operative steps to identify ZT during thyroidectomy operation. This 1-year prospective observational study was carried out in the Department of Otolaryngology in a tertiary medical institute. Out of 36 cases of thyroidectomy, parathyroid identification in Group A was based on STA and ITA and in Group B was based on ZT. The surgical steps, parathyroid location, preservation and its anatomical relations were noted. The mean age in Group A and Group B was 38.8 years and 44.9 years respectively with 77.4 and 62.5% SPT identified above the intersection of RLN and ITA respectively. On left side 62.5% SPT were located at 2 o'clock position and 50% at 10 o'clock location in right side. In Group A, 60.7% of IPT glands were related close to ITA while in Group B it was 44.4%. Group B reported a higher rate of successful identification and preservation (93.75%). ZT greatly improved the reliability for localising and preserving the parathyroid glands during thyroidectomy. SPT is usually found to lie cranial to ZT, above the intersection of RLN & ITA and behind RLN whereas IPT is variable and lies below the intersection.
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Affiliation(s)
| | - Aakanksha Rathor
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - Shams Uddin
- Depatment of ENT, Silchar Medical College, Assam, 788014 India
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Iscan Y, Aygun N, Sormaz IC, Tunca F, Uludag M, Senyurek YG. Is craniocaudal dissection of recurrent laryngeal nerve safer than lateral approach: a prospective randomized study comparing both techniques by using continuous intraoperative nerve monitoring. Ann Surg Treat Res 2022; 103:205-216. [PMID: 36304193 PMCID: PMC9582614 DOI: 10.4174/astr.2022.103.4.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to compare the real-time electromyographic (EMG) changes and the rate of recurrent laryngeal nerve (RLN) injury in craniocaudal and lateral approaches for RLN during thyroidectomy. Methods One hundred twelve and 86 patients were prospectively randomized to receive lateral (group 1) or craniocaudal (group 2) approach to RLN, respectively, under continuous intraoperative nerve monitoring. Results Loss of signal (LOS) occurred in 7 (2.0%) of 356 nerves at risk (NAR). LOS was significantly associated with repeated adverse EMG changes and presence of RLN entrapment at the ligament of Berry (LOB), which was accompanied by other clinicopathological or anatomical features, such as tubercle of Zuckerkandl (TZ), extralaryngeal branching, hyperthyroidism, autoimmune thyroid disease (ATD), or thyroid lobe volume of >29 cm3 (P = 0.001 and P = 0.030, respectively). The rate of repeated adverse EMG changes and LOS in the NARs with LOB entrapment accompanied by other clinicopathological and anatomical features was higher in group 1 vs. group 2 (11.1% vs. 2.2%, respectively and 9.7% vs. 0%, respectively; P = 0.070). The total rate of vocal cord palsy (VCP) was significantly higher in group 1 than in group 2 (P = 0.005). The rate of permanent VCP showed no significant difference between the 2 groups. Conclusion The craniocaudal approach to the RLN is safer than the lateral approach in the RLNs with entrapment at the LOB accompanied by other features, such as TZ, extralaryngeal branching, hyperthyroidism, ATD, or high thyroid lobe volume.
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Affiliation(s)
- Yalin Iscan
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurcihan Aygun
- Division of Endocrine Surgery, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Ismail Cem Sormaz
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Tunca
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Uludag
- Division of Endocrine Surgery, Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey
| | - Yasemin Giles Senyurek
- Division of Endocrine Surgery, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Melikyan A, Menkov A. Postoperative Hypoparathyroidism: Prognosis, Prevention, and Treatment (Review). Sovrem Tekhnologii Med 2020; 12:101-108. [PMID: 34513060 PMCID: PMC8353683 DOI: 10.17691/stm2020.12.2.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 12/19/2022] Open
Abstract
This review summarizes the results of studies concerning the problem of post-surgical hypoparathyroidism, a common complication of thyroid gland surgery, decreasing the quality of life in patients and, in some cases, leading to disability. A search for publications was carried out in electronic databases Web of Science, Scopus, Academic Search Complete (EBSCO), eLIBRARY, using keywords. The search depth was 7-10 years. Prevalence of post-surgical hypoparathyroidism was evaluated, the pathogenetic causes of the disease development, its clinical forms, methods of diagnosis and treatment were studied. It has been found that there is no single algorithm for analyzing the prognostic factors for the development of this pathological condition. It is emphasized that drug therapy of post-surgical hypoparathyroidism has a number of adverse effects. Therefore, the issues of prevention and surgical correction are of particular relevance. However, controversial opinions of contemporary authors about their clinical effectiveness determine the scientific and practical significance of further research on these issues.
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Affiliation(s)
- A.A. Melikyan
- Surgeon, Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko, 190 Rodionova St., Nizhny Novgorod, 603126, Russia
| | - A.V. Menkov
- Professor, Department of General, Operative Surgery and Topographic Anatomy named after A.I. Kozhevnikov, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
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Ertaş B, Veyseller B, Karataş A, Özdilek A, Doğan R, Ozturan O. Hypoparathyroidism in Total Thyroidectomy due to Benign Thyroid Diseases. Clin Ther 2019; 40:762-767. [PMID: 29685599 DOI: 10.1016/j.clinthera.2018.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/08/2018] [Accepted: 04/02/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE Our aim was to compare the effects of exposing the recurrent laryngeal nerve throughout its entire course with exposing the nerve only at its entry to the larynx in patients undergoing total thyroidectomy due to benign thyroid diseases, and to evaluate the effects of these methods on the risk for hypoparathyroidism. METHODS The medical records of 437 patients who had undergone total thyroidectomy at the ear, nose, and throat clinic between 2001 and 2015 for benign thyroid diseases were evaluated retrospectively. Mean patient age was 46.7 years (range 18-79 years). Eighty-six patients were male and 351 were female. Patients were divided into 2 groups according to recurrent laryngeal nerve exposure during surgery. In the first group, the nerve was observed as it entered the larynx, and its course was not completely exposed. In the second group, the nerve was identified in the tracheoesophageal groove, and its course was fully exposed. Group 1 consisted of 256 patients (47 male and 209 female) and group 2 consisted of 181 patients (39 male and 142 female). There were no statistically significant differences between the groups in terms of age and gender, and the groups were homogeneously distributed. FINDINGS Transient hypoparathyroidism was observed in 15 (5.8%) patients and permanent hypoparathyroidism was observed in 3 (1.1%) patients in group 1, and transient hypoparathyroidism was observed in 23 (12.7%) patients and permanent hypoparathyroidism was observed in 7 (3.8%) patients in group 2. The rates of both transient and permanent hypoparathyroidism were higher in the patients in group 2, and the difference was statistically significant (P < 0.001). Transient recurrent nerve palsy was seen in 1 patient in each group. Permanent recurrent nerve palsy occurred in 1 patient in group 2, although the difference between groups was not statistically significant (P = 0.28). IMPLICATIONS Transient and permanent hypoparathyroidism were less common in thyroidectomies that involved detection of the recurrent laryngeal nerve at the site of entry to the larynx and keeping its dissection minimal; this technique was also more reliable.
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Affiliation(s)
- Burak Ertaş
- Acıbadem Maslak Hospital, Department of Otorhinolaryngology, Istanbul, Turkey
| | - Bayram Veyseller
- Acıbadem Maslak Hospital, Department of Otorhinolaryngology, Istanbul, Turkey
| | - Abdullah Karataş
- Haseki Training and Research Hospital, Department of Otorhinolaryngology, Istanbul, Turkey
| | - Alper Özdilek
- Acıbadem Maslak Hospital, Department of Otorhinolaryngology, Istanbul, Turkey
| | - Remzi Doğan
- Bezmialem Vakif University, Faculty of Medicine, Department of Otorhinolaryngology, Istanbul, Turkey.
| | - Orhan Ozturan
- Bezmialem Vakif University, Faculty of Medicine, Department of Otorhinolaryngology, Istanbul, Turkey
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MP S, S A, Jose J. Inferior Approach: a Safe Method for Identification of Recurrent Laryngeal Nerve During Thyroidectomy. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1848-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Butskiy O, Chang BA, Luu K, McKenzie RM, Anderson DW. A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction. J Otolaryngol Head Neck Surg 2018; 47:57. [PMID: 30223884 PMCID: PMC6142389 DOI: 10.1186/s40463-018-0306-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 09/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach). Methods All thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included. Results Surgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery. Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8–20%) and 3% (95% CI: 1–8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6–12%) and 0.3% (95%CI: 0.01–2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33–47 min), 48 min (IQR: 40–60 min), and 40 min (IQR: 35–51 min) respectively. 1% of cases required conversion to an alternative surgical approach. Conclusion In a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.
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Affiliation(s)
- Oleksandr Butskiy
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada. .,Gordon & Leslie Diamond Health Care Centre, 4th. Fl. 4299B-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Brent A Chang
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Kimberly Luu
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Robert M McKenzie
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Donald W Anderson
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada
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Sukumaran V, Teli B, Avula S, Pavuluru J. Effect of Dissection of the Recurrent Laryngeal Nerves on Parathyroid Insufficiency during Total Thyroidectomy for Multinodular Goitre. J Clin Diagn Res 2016; 10:PC01-3. [PMID: 27042514 DOI: 10.7860/jcdr/2016/16892.7196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Total thyroidectomy is the accepted standard treatment for benign goitrous enlargements. The surgical skill and technique is one of the most important factor which affect the outcome in thyroid surgery. Hypocalcaemia due to parathyroid insufficiency remains a significant postoperative morbidity after total thyroidectomy. The primary cause is unintentional damage to, or devascularization of, one or more parathyroid glands during surgery. AIM To study the risk of hypocalcaemia due to recurrent laryngeal nerves (RLNs) dissection during total thyroidectomy for benign multinodular goitre (MNG). MATERIALS AND METHODS The study is a non-randomized control trial, where 100 patients with benign MNG were divided into two groups (group A and group B) each consisting of 50 patients. All 100 patients underwent total thyroidectomy by a subcapsular dissection. In patients of group A, both RLNs were clearly dissected for a minimum length of 2cm down from its entry into the larynx before total thyroidectomy was performed. In group B, each patient had total thyroidectomy without making any deliberate attempt to dissect and demonstrate the RLNs. The patients in the two groups were followed up for the incidence of clinically significant hypocalcaemia in the postoperative period. RESULTS A total of 30% of patients in group A developed clinical and biochemical manifestations of hypocalcaemia but the incidence of hypocalcaemia was only 6% in the group B. Three (6%) patients out of those who developed hypocalcaemia in group A had a prolonged hypocalcaemia for upto six months. p-value is 0.003 and odds ratio is 6.59. CONCLUSION Routine dissection to identify the RLNs could predispose to a higher incidence of postop hypocalcaemia. Subcapsular dissection of the thyroid safely preserves the parathyroid glands.
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Affiliation(s)
- Vengayil Sukumaran
- Associate Professor, Department of Surgery, DMWIMS , Wayanad, Kerala, India
| | - Bhavuray Teli
- Assistant Professor, Department of Surgery, DMWIMS , Wayanad, Kerala, India
| | - Sreekant Avula
- Assistant Professor, Department of Surgery, DMWIMS , Wayanad, Kerala, India
| | - Jagadeesh Pavuluru
- Assistant Professor, Department of Surgery, DMWIMS , Wayanad, Kerala, India
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Abstract
Postoperative hypoparathyroidism after bilateral thyroid gland surgery or after interventions for recurrence is defined as intact parathyroid hormone levels (iPTH) < 15 pg/ml with simultaneous normal, below normal and markedly decreased serum calcium levels. After bilateral thyroid surgery and after reoperations a single iPTH measurement performed 12-24 h postoperatively can be used to predict parathyroid metabolism. Patients with an iPTH level ≥ 15 pg/ml may be discharged safely, patients with an iPTH < 10 pg/ml must be substituted with calcium and vitamin D and patients with an iPTH between 10 and 15 pg/ml (grey zone) may be discharged if a second measurement 48 h after surgery documents an iPTH ≥ 15 pg/ml. This procedure increases the length of hospital stay. Patients in the (grey zone) must be substituted. The iPTH level and its course determine the necessity, dose and length of calcium and vitamin D substitution.
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12
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Liu SC, Chou YF, Su WF. A Rapid and Accurate Technique for the Identification of the Recurrent Laryngeal Nerve. Ann Otol Rhinol Laryngol 2014; 123:805-10. [PMID: 24944276 DOI: 10.1177/0003489414538765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: We studied the anatomic relationship between the recurrent laryngeal nerve (RLN) and the third tracheal ring, which was very important for rapid identification of RLN in our hands. Methods: This study was initially performed using 8 fresh cadavers (4 female and 4 male). The transverse nerve location from the third trachea and the depth from its anterior surface were measured. We further observed the topography of RLN in relation to the trachea in 60 patients, between November 2008 and January 2011, at the Tri-Service General Hospital and Buddhist Tzu Chi General Hospital, Taipei Branch, Taiwan, with 46 lobo-isthmectomies and 14 total thyroidectomies. The time spent in identifying the RLN was also recorded. Results: Among cadaver groups, the transverse distance (width) and the vertical distance (depth) averaged 3.3 and 17.6 mm, respectively. Among the clinical cases, the width and depth averaged 4.4 and 14.6 mm, respectively. The depth measured in males was significantly deeper than that in females (22.3 vs 13.2 mm) ( P < .05). The time spent in identifying the RLN after starting dissection in the RLN triangle was not statistically significantly different between the cadaver group and the clinical group (10.6 ± 5.7 seconds and 15.5 ± 17.7 seconds, respectively; P > .05). The median time was 9 and 10 seconds, respectively. There was no statistically significant side-to-side difference in terms of the time spent in searching for the RLN. Conclusion: Using the third ring as guidance, our inferior-superior technique offers an extra benefit in identifying the RLN safely and quickly, as compared to the conventional inferior approach.
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Affiliation(s)
- Shao-Cheng Liu
- Department of Otolaryngology–Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yi-Fan Chou
- Department of Otolaryngology–Head and Neck Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, Taiwan, Republic of China
- Department of Otolaryngology–Head and Neck Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, Republic of China
| | - Wan-Fu Su
- Department of Otolaryngology–Head and Neck Surgery, Buddhist Tzu Chi General Hospital, Taipei Branch, Taiwan, Republic of China
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China
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Sykes RF, Moorthy R, Olaleye O, Black IM. Identification of the recurrent laryngeal nerve at the cricothyroid joint: Our experience of 181 thyroid procedures. Clin Otolaryngol 2014; 39:174-7. [PMID: 24801664 DOI: 10.1111/coa.12254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2014] [Indexed: 11/28/2022]
Affiliation(s)
- R F Sykes
- ENT Department, William Harvey Hospital, Kent, UK
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More Y, Shnayder Y, Girod DA, Sykes KJ, Carlisle MP, Chalmers B, Kraemer C, Tsue TT. Factors influencing morbidity after surgical management of malignant thyroid disease. Ann Otol Rhinol Laryngol 2013; 122:398-403. [PMID: 23837393 DOI: 10.1177/000348941312200609] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We performed a retrospective study of cases from 2005 to 2010 at an academic tertiary care center to analyze the factors that influence morbidity in surgical management of thyroid malignancy. METHODS The rates of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism (HPT) were analyzed in the entire cohort. The comparison groups were 1) primary surgery versus revision; 2) total thyroidectomy versus total thyroidectomy combined with neck node dissection; and 3) two groups defined by surgical technique according to the RLN approach: group 1, in which the RLN was identified inferiorly in the tracheoesophageal groove, and group 2, in which the RLN was identified near the cricothyroid joint point of entry. RESULTS We reviewed 308 patients who underwent surgery for thyroid cancer. Thirty-six (11.7%) had temporary HPT, and 8 (2.6%) had permanent HPT. Of a total of 586 RLNs at risk, 16 (2.7%) had temporary damage and 2 (0.3%) had permanent damage. The incidences of temporary RLN injury significantly differed between the primary-surgery and revision-surgery groups (2.5% versus 15.6%; p = 0.001), and also between the groups with total thyroidectomy and thyroidectomy with neck dissection (1.2% versus 7.8%; p = 0.027). The incidences of temporary HPT were significantly different between the groups with primary surgery and revision surgery (6.6% versus 31.3%; p = 0.001), between the groups with total thyroidectomy and total thyroidectomy with neck dissection (4.7% versus 15.6%; p = 0.009), and between group 1 and group 2 (surgical technique in terms of RLN approach; 8.2% versus 17.9%; p = 0.011). Permanent HPT and permanent RLN injury both occurred rarely in this cohort, with no significant differences among comparison groups. CONCLUSIONS Our study shows a higher incidence of temporary RLN injury and teniporary HPT in revision surgery cases and in total thyroidectomy with neck dissection. Temporary HPT was significantly more common when the RLN was identified near the cricothyroid joint.
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Affiliation(s)
- Yogesh More
- Department of Otolaryngology, Kansas University Medical Center, Kansas City, Kansas, USA
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Terris DJ, Singer MC. Qualitative and quantitative differences between 2 robotic thyroidectomy techniques. Otolaryngol Head Neck Surg 2012; 147:20-5. [PMID: 22371342 DOI: 10.1177/0194599812439283] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Two distinct remote access robotic thyroidectomy techniques were implemented in a high-volume endocrine surgery practice. Important technical and clinical differences were observed and are described. STUDY DESIGN Cross-sectional study with planned data collection. SETTING Thyroid center. SUBJECTS AND METHODS A panel of demographic and clinical parameters was captured in a series of patients undergoing 1 of 2 robotic thyroidectomy techniques (robotic axillary thyroidectomy [RAT] or robotic facelift thyroidectomy [RFT]). Particular attention was paid to time of surgery, ease of dissection, complications, use of drains, and length of stay. RESULTS Fifteen robotic hemithyroidectomies were accomplished by either RAT (n = 5) or RFT (n = 10). The duration of surgery for RAT averaged 196 ± 38.1 minutes, with no clear downward trend observed. The mean time of surgery for RFT was 156.9 ± 16.3 minutes, with a steady trend toward shorter surgical times. All 5 RAT patients were managed with drains and as inpatients (length of stay = 1.0 days); 9 of 10 RFT patients were managed without drains and on an outpatient basis (the first patient had a drain and was observed for 1 night in the hospital; P < .001). Ease of surgery, familiarity with anatomic dissection planes, and surgeon comfort level all favored RFT. CONCLUSIONS In an early experience of a small series of patients, a more rapid learning curve reflected by shorter operative times was observed with robotic facelift thyroidectomy compared with robotic axillary thyroidectomy. Furthermore, the vast majority of patients could be managed as outpatients, which represents one of several apparent advantages.
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Affiliation(s)
- David J Terris
- Department of Otolaryngology-Head and Neck Surgery, Georgia Health Sciences University, Augusta, Georgia 30912-4060, USA.
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