1
|
Jin X, Yuan R. Non-recurrent right laryngeal nerve identified during endoscopic thyroidectomy via areolar approach: a case report. Front Surg 2023; 10:1272431. [PMID: 37869421 PMCID: PMC10587543 DOI: 10.3389/fsurg.2023.1272431] [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: 08/04/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023] Open
Abstract
Background Nonrecurrent laryngeal nerve (NRLN) is a rare but significant anatomical variation in thyroid surgery, and lack of awareness of NRLN may lead to intraoperative injury. Here, we report a clinical case of NRLN discovered during endoscopic thyroid surgery via total areola approach in a 23-year-old female patient. Case presentation A 23-year-old female patient presented with bilateral thyroid nodules for three years. She underwent bilateral thyroid nodule fine-needle aspiration biopsy and BRAF gene testing at our hospital, with results indicating bilateral papillary thyroid carcinoma and positive BRAF gene V600E mutation. Neck-enhanced CT revealed bilateral thyroid nodules and the right subclavian artery branching from the aortic arch on the distal side of the left subclavian artery. The patient underwent endoscopic thyroidectomy via total areola approach for radical resection of bilateral thyroid cancer. Intraoperatively, NRLN was found on the right side and RLN on the left side. The surgery was successful, and no postoperative complications were observed. Postoperative pathology confirmed bilateral papillary thyroid carcinoma. Conclusions Although NRLN is a rare occurrence, clinicians should not overlook its presence to prevent serious complications. Preoperative imaging confirmation of the presence or absence of an abnormal subclavian artery course is crucial in preventing the sudden discovery of NRLN during surgery. Endoscopic thyroid surgery via total areola approach is a safe and effective technique but requires a high level of professional skills and an understanding of anatomical variations to prevent nerve injury.
Collapse
Affiliation(s)
| | - Ronghua Yuan
- Department of Thyroid and Breast Surgery, Nantong City No 1 People’s Hospital and Second Affiliated Hospital of Nantong University, Nantong, China
| |
Collapse
|
2
|
Zheng V, Rajeev R, Pinto D, de Jong MC, Sreenivasan DK, Parameswaran R. Variant anatomy of non-recurrent laryngeal nerve: when and how should it be taught in surgical residency? Langenbecks Arch Surg 2023; 408:185. [PMID: 37160507 DOI: 10.1007/s00423-023-02928-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION While the performance of a thyroidectomy is generally associated with a low risk of injury to the recurrent laryngeal nerve (RLN), the presence of a non-recurrent nerve (NRLN) increases the risk of this complication. Generally, the intraoperative detection via visual appreciation of variant anatomy of the RLN has been regarded as poor, possibly due to a lack of knowledge of both the normal and aberrant anatomy of the RLN. MATERIALS AND METHODS Articles for the review were searched through PubMed using the search terms and their combinations: "non-recurrent laryngeal nerve," "thyroidectomy," "injury," "palsy," "variant anatomy," and "residency," from January 1, 2000, to December 2022. Papers considered for the review were the articles published in English, with additional classic and articles of surgical importance retrieved from the reference list of papers. Only papers relevant to the scope of the review were considered for this review. FINDINGS The NRLN has been found to be associated with concurrent vascular abnormalities, such as the presence of an aberrant right subclavian artery (ARSA) or an arteria lusoria originating from the aortic arch. However, it seems that both the normal as well as aberrant anatomy of the RLN is currently not emphasized enough during postgraduate surgical training. With the increased use of intraoperative neuromonitoring (IONM), detection of NRLN has become possible through appropriate neural mapping during thyroid surgery, besides other pointers such as visualization during surgery, computerised tomography, and duplex ultrasound scans to visualize the variant vascular anatomy. There is also a possible role for cadaveric courses, either during medical school or in a post-graduate setting-adapted to the student's level to teach the variant anatomy. With the development of newer techniques such as artificial intelligence, there are potential new options for teaching and training anatomy in the near future. CONCLUSIONS AND RELEVANCE Adequate knowledge of the normal and aberrant anatomy of the RLN remains essential for the best outcomes in thyroid surgery, even in the era of the IONM. Moving forward, the knowledge of (aberrant) anatomy should be made an integral part of the core competencies of both medical students and surgical trainees. It is imperative that leaders of the different field work closely together to combine their knowledge towards providing their trainees with the best possible training options.
Collapse
Affiliation(s)
- Victoria Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Reshma Rajeev
- University of Buckingham Medical School, Buckingham, UK
| | - Diluka Pinto
- Division of Endocrine Surgery, National University Hospital, Lower Kent Ridge Road, Buckingham, Singapore
| | | | - Dinesh Kumar Sreenivasan
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, National University Hospital, Lower Kent Ridge Road, Buckingham, Singapore.
- Department of Surgery, Yong Loo Lin School of Medicine, Medical Drive, Singapore, Singapore.
| |
Collapse
|
3
|
Zhang D, Fu Y, Zhou L, Wang T, Liang N, Zhong Y, Dionigi G, Kim HY, Sun H. Prevention of non-recurrent laryngeal nerve injury in robotic thyroidectomy: imaging and technique. Surg Endosc 2021; 35:4865-4872. [PMID: 33721091 DOI: 10.1007/s00464-021-08421-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The aim of this report was to summarize observations, evaluate the feasibility, provide detailed information concerning proper techniques, and address limitations for non-recurrent laryngeal nerve (NRLN) dissection and release during the robotic bilateral axillo-breast approach (BABA) for thyroidectomy. MATERIALS AND METHODS The BABA approach was used in two cases of thyroidectomy in the setting of NRLN. Preoperative CT imaging findings suggesting the aberrant anatomy are reviewed and technical planning, inclusive of intraoperative nerve monitoring, was employed. Intraoperative videos with narrative discussion of technique for safe dissection are provided, along with supplementary video of additional technical guidance. RESULTS In both cases, the NRLNs were identified, dissected, and preserved. We dissected the proximal segment of each NRLN to its origin. We determined that the use of only the NRLN proximal to distal robotic dissection jeopardized the nerve. The BABA approach with the Type I NRLN is similar to the dissection of the recurrent laryngeal nerve (RLN) in transoral thyroidectomy. Due to interference with endoscopic viewing caused by the thyroid cartilage, the Type I NRLN is more challenging to manage both at the laryngeal entry point and its origin from the vagus nerve (VN). For the Type II NRLN, it is essential to identify its point of origin and the reflection of the nerve from the VN. Therefore, modification of nerve dissection to mirror open surgery with bidirectional nerve dissection assisted in avoidance of traction injury to the nerve. CONCLUSIONS We presented a video, a detailed description of methods, and discussed limits for NRLN management in robotic BABA. This report included (i) a description of the aberrant anatomy and CT scans to inform surgeons of the possible NRLN locations, (ii) a description of a technique for using the nerve monitor in the robotic surgeries, and (iii) a description of the techniques used to isolate and protect the NRLN during the robotic surgery. In robotic BABA, our NRLN-sparing technique and degree included mainly a multi-directional nerve dissection (i.e., medial-grade, later-grade approach together with proximal to/from distal) using athermal technique. The NRLN-sparing technique is predominantly carried out in an anterior dissection plane.
Collapse
Affiliation(s)
- Daqi Zhang
- 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, Changchun, 130000, People's Republic of China
| | - Yantao Fu
- 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, Changchun, 130000, People's Republic of China
| | - Le Zhou
- 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, Changchun, 130000, People's Republic of China
| | - Tie Wang
- 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, Changchun, 130000, People's Republic of China
| | - Nan Liang
- 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, Changchun, 130000, People's Republic of China
| | - Yifan Zhong
- 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, Changchun, 130000, People's Republic of China
| | - Gianlorenzo Dionigi
- Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital "G. Martino", University of Messina, Messina, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hui Sun
- 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, Changchun, 130000, People's Republic of China.
| |
Collapse
|
4
|
Liang RX, Wang B, Zhao WX, Xue ES, Ye Q, Chen ZY, Chen ZK, Lin XY, Lin ZH, Lin YJ. Predictive value of ultrasound diagnosis of aberrant right subclavian artery with non-recurrent laryngeal nerve. Arch Med Sci 2020; 20:719-725. [PMID: 39050178 PMCID: PMC11264091 DOI: 10.5114/aoms.2020.98971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/28/2019] [Indexed: 07/27/2024] Open
Abstract
Introduction This study aims to evaluate the predictive value of color Doppler ultrasound for the diagnosis of aberrant right subclavian artery (ARSA) with a co-occurring non-recurrent right laryngeal nerve (NRLN). Material and methods In the present study, 58 patients with ARSA (ARSA group) and 1,280 patients without ARSA (controls) were diagnosed by ultrasonography. In addition, 32 patients with ARSA (ARSA operation group) and controls underwent thyroidectomy with surgical exploration with or without NRLN. Then, the incidence of NRLN was analyzed. The right common carotid artery (RCCA) and right subclavian artery (RSA) trends were observed by ultrasound, and classified into two types: RCCA and RSA originating from the innominate artery (IA) (type I), and IA could not be detected (type II). Results A total of 32 cases of NRLN were found in the ARSA operation group, but no case was found in controls, and the difference was statistically significant (p = 0.0006). The difference in the constituent ratio of type I and type II was statistically significant between the ARSA group and controls (p = 0.0002). That is, the IA could not be detected in the ARSA group, which was accompanied by the RCCA that originated from the aortic arch, while the IA was detected in most patients in the control group at the level of the sternoclavicular joints. Conclusions Aberrant right subclavian artery can be rapidly detected by ultrasonography. Aberrant right subclavian artery occurs when the RCCA originates from the aortic arch during detection. Patients with ARSA sometimes have co-occurring NRLN. Hence, vigilance in protecting the NRLN is needed during an operation.
Collapse
Affiliation(s)
- Rong-Xi Liang
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Bo Wang
- Department of Vessels and Thyroid Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wen-Xin Zhao
- Department of Vessels and Thyroid Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - En-Sheng Xue
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Qin Ye
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Zhi-Yong Chen
- Department of Radiology, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Zhi-Kui Chen
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Xue-Ying Lin
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Zhen-Hu Lin
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - You-Jia Lin
- Department of Ultrasound, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| |
Collapse
|
5
|
Anatomical variation in the right non-recurrent laryngeal nerve reported from studies using pre-operative arterial imaging. Surg Radiol Anat 2019; 41:943-949. [PMID: 31087139 DOI: 10.1007/s00276-019-02252-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
The right non-recurrent (inferior) laryngeal nerve (NRLN) is a rare anatomical variant associated with an arterial anomaly, the aberrant right subclavian artery (ARSA), that is detectable by pre-operative imaging (POI) using computed tomography and/or ultrasound. Most surgical studies have utilized two major types, NRLNs arising near the upper pole of the thyroid gland (type 1), vs. at a lower level (type 2) but with two subtypes defined by relationships to the inferior thyroid artery (ITA). This review found 8 English language surgical studies using POI that reported at least 1 NRLN and had anatomical information; of the 88 right NRLNs, 69.3% were classified as type 2 and 30.7% as type 1. Meta-analysis yielded a weighted proportion of 74.0% for type 2, but with substantial heterogeneity. For a subgroup of 5 POI studies with information on subtypes, 22 (59.5%) of 37 type 2 nerves were type 2a (i.e., running at or above the ITA). Similarly, a separate review of large surgical series without POI found that 60.4% of all 91 type 2 NRLNs were type 2a. The study findings should be relevant to the increasing numbers of anterior neck surgeries including bilateral thyroidectomies. A need was identified for studies on inter-observer reliability (agreement) among surgeons on NRLN types, and on injury rates (and related symptoms) by the type of NRLN.
Collapse
|
6
|
Le VQ, Ngo QD, Ngo XQ. Nonrecurrent laryngeal nerve in thyroid surgery: Frequency, anatomical variations according to a new classification and surgery consideration. Head Neck 2019; 41:2969-2975. [PMID: 30993837 DOI: 10.1002/hed.25771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/19/2019] [Accepted: 04/02/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The nonrecurrent laryngeal nerve (NRLN) is a rare embryologically derived variant of the RLN. We aimed to identify the proportion of NRLN (during thyroidectomy), classify clinical NRLN types, and recommend some surgical considerations. METHOD In this prospective study, from May 2017 to September 2018, our hospital carried out 2158 thyroid operations. We reported the NRLN rate and distinguished NRLN into four types. RESULTS Overall, NRLN had an incidence rate of 0.74% (16 out of 2158 total thyroid surgeries). We did not detect any patient with left-sided NRLN. The traveling patterns of the nerves could be classified as descending (12.5%), vertical (25%), ascending (37.5%), or V-shaped (25%). CONCLUSION The NRLN is a rare variation of the RLN. From our experience, we recommend the guidelines will help surgeons to avoid NRLN injury.
Collapse
Affiliation(s)
- Van Quang Le
- Department of Oncology, Hanoi Medical University, Dong Da District, Hanoi, Vietnam.,Department of Head and Neck Surgery, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - Quoc Duy Ngo
- Department of Head and Neck Surgery, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - Xuan Quy Ngo
- Department of Head and Neck Surgery, Vietnam National Cancer Hospital, Hanoi, Vietnam
| |
Collapse
|