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Velayutham P, Thiagarajan S, Dhar H, Chidambaranathan N, Vaidya A, Teja K. A Nationwide Survey to Assess the Practices and Patterns of Use of Intraoperative Nerve Monitoring During Thyroid Surgery Among Surgeons in India. Indian J Surg Oncol 2024; 15:18-24. [PMID: 38511027 PMCID: PMC10948657 DOI: 10.1007/s13193-023-01818-5] [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: 07/02/2023] [Accepted: 09/06/2023] [Indexed: 03/22/2024] Open
Abstract
There is still equipoise for the routine use of intraoperative nerve monitoring (IONM) for thyroid surgeries; however, some surgeons tend to use it for various reasons. In our study, we did a national survey to assess the patterns and practice of the use of IONM among surgeons during thyroid surgery in India. A questionnaire survey was sent to surgeons (head and neck surgical oncologists, general surgical oncologists, endocrine surgeons and otolaryngologists) in different zones in India via email, and their responses were analysed. One hundred and one responses were received. The majority of the respondents were head and neck surgical oncologists (n = 56, 55.4%). Forty-three (42.6%) respondents used IONM during thyroid surgeries in this survey. Surgeons with ≤ 15 years of experience performing thyroid surgeries (p = 0.02) and surgeons performing > 50 thyroid surgeries also tended to use IONM. Mostly IONM was used for surgeries on thyroid malignancies (p = 0.016). The respondents used IONM for more than one reason such as medicolegal purposes and surgeon comfort among others. IONM was most often used during redo surgeries (n = 46, 45.5%) and in patients with already one fixed cord (n = 39, 38.6%). The majority felt IONM was not cost-effective (n = 53, 52.5%). The use of IONM during thyroid surgery in our survey was nearly 43%. It was used mostly for surgery for thyroid malignancies, and it was found to be used for more than one reason and indications such as redo surgeries (most commonly). Supplementary Information The online version contains supplementary material available at 10.1007/s13193-023-01818-5.
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Affiliation(s)
- Parthiban Velayutham
- Department of Neurosurgery, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra India
| | - Shivakumar Thiagarajan
- Department of Head & Neck Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra 400012 India
| | - Harsh Dhar
- Medica Super Speciality Hospital, Kolkata, Mumbai, India
| | | | - Abhishek Vaidya
- National Cancer Institute, Nagpur, Maharashtra India
- NKPSIMS, Nagpur, Maharashtra India
| | - Kantamani Teja
- Department of Head & Neck Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra 400012 India
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Traba A, de Abreu A, Nevado C, Duran H, Gil A, Pérez Seoane M, Lopez-Gonzalez L, Ortega MA, Álvarez-Mon M, Martin P, San Roman J, Díaz-Pedrero R. Vagus Nerve Stimulation in the Carotid Triangle: An Effective Method for Monitoring the Recurrent Laryngeal Nerve in Thyroid and Parathyroid Surgery. J Clin Med 2023; 13:102. [PMID: 38202109 PMCID: PMC10780223 DOI: 10.3390/jcm13010102] [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: 11/07/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Our objective is the description of the technique of vagus nerve stimulation in carotid triangle in order to monitor the recurrent laryngeal nerve (RLN) during thyroid and parathyroid surgery. METHODS We stimulated the vagus nerve in the carotid triangle during 150 thyroid or parathyroid surgeries using a monopolar electromyography electrode inserted under the mastoid process towards the jugular foramen as a cathode, and using another subdermal electrode in the mastoid as an anode. Another complementary method of vagus stimulation was achieved with a pair of subdermal electrodes, placing the cathode at the mandibular angle and the anode at the mastoid. RESULTS In all patients, compound muscle action potential (CMAP) was recorded in the vocal cords with both stimulation techniques, allowing semi-continuous monitoring to be carried out. Intraoperative lesions were detected in 16 of the cases; 9 of them were transient with CMAP recovery achieved when modifying surgical maneuvers. CONCLUSIONS Vagus nerve stimulation in the carotid triangle is a reliable technique for monitoring the RLN in thyroid surgery. Vagus nerve stimulation in the carotid triangle is effective and safe for RLN monitoring, and it is a clear alternative to direct continuous stimulation of the nerve that by contrast requires its dissection in the carotid sheath.
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Affiliation(s)
- Alfredo Traba
- Neurology and Neurophysiology, Hospital Universitario HM Sanchinarro, C/de Oña 10, 28050 Madrid, Spain;
| | - Angela de Abreu
- Neurology and Neurophysiology, Hospital Universitario HM Sanchinarro, C/de Oña 10, 28050 Madrid, Spain;
| | - Clara Nevado
- Neurology and Neurophysiology, Hospital Fundación Alcorcón, C/Budapest 1, 28922 Madrid, Spain;
| | - Hipólito Duran
- General and Digestive Surgery Department, Hospital Universitario HM Sanchinarro, C/Oña 10, 28050 Madrid, Spain;
| | - Antonio Gil
- General and Digestive Surgery Department, Hospital Universitario HM Montepríncipe, Av. de Montepríncipe 25, 28660 Madrid, Spain; (A.G.); (M.P.S.); (P.M.)
| | - María Pérez Seoane
- General and Digestive Surgery Department, Hospital Universitario HM Montepríncipe, Av. de Montepríncipe 25, 28660 Madrid, Spain; (A.G.); (M.P.S.); (P.M.)
| | - Laura Lopez-Gonzalez
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (L.L.-G.); (M.A.O.); (R.D.-P.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
| | - Miguel A. Ortega
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (L.L.-G.); (M.A.O.); (R.D.-P.)
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Melchor Álvarez-Mon
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
- Immune System Diseases-Rheumatology and Internal Medicine Service, University Hospital Prince of Asturias, Networking Research Center on for Liver and Digestive Diseases (CIBEREHD), 28806 Alcalá de Henares, Spain
| | - Pedro Martin
- General and Digestive Surgery Department, Hospital Universitario HM Montepríncipe, Av. de Montepríncipe 25, 28660 Madrid, Spain; (A.G.); (M.P.S.); (P.M.)
| | - Juan San Roman
- General and Digestive Surgery Department, Hospital Universitario HM Torrelodones, Av. Castillo Olivares s/n, 28250 Madrid, Spain;
| | - Raul Díaz-Pedrero
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (L.L.-G.); (M.A.O.); (R.D.-P.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain;
- General and Digestive Surgery Department, Hospital Universitario HM Rivas Vaciamadrid, 28521 Madrid, Spain
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Rubin F, Laccourreye O. Bravo TIRO! Eur Ann Otorhinolaryngol Head Neck Dis 2022; 140:103. [DOI: 10.1016/j.anorl.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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How blue lining the recurrent laryngeal nerve can aid in re-operative surgery? Eur Ann Otorhinolaryngol Head Neck Dis 2021; 139:95-97. [PMID: 34052162 DOI: 10.1016/j.anorl.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The recurrent laryngeal nerve (RLN), is one of the main structures at risk of injury causing vocal cord paralysis during head and neck surgery, especially during thyroid or parathyroid surgery, central neck dissection and upper oesophageal sphincter surgery. We describe the systematic use of marking of the RLN using non-resorbable blue polypropylene suture after its localisation, just inside its penetration below the cricopharyngeal muscle, to help identify the nerve for cases of re-operative surgery in this area. This specific marking technique could facilitate subsequent preservation of the nerve and reduce nerve injury risk in cases of planned or unexpected future operations, as well as emergency surgery due to postoperative complications. We apply this technique simultaneously with intra-operative laryngeal neuromonitoring. This method is safe and easy to perform.
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Abdelhamid A, Aspinall S. Intraoperative nerve monitoring in thyroid surgery: analysis of United Kingdom registry of endocrine and thyroid surgery database. Br J Surg 2021; 108:182-187. [PMID: 33711146 DOI: 10.1093/bjs/znaa081] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/14/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Intraoperative nerve monitoring (IONM) is used increasingly in thyroid surgery to prevent recurrent laryngeal nerve (RLN) injury, despite lack of definitive evidence. This study analysed the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS) to investigate whether IONM reduced the incidence of RLN injury. METHODS UKRETS data were extracted on 28 July 2018. Factors related to risk of RLN palsy, such as age, sex, retrosternal goitre, reoperation, use of energy devices, extent of surgery, nodal dissection and IONM, were analysed. Data with missing entries for these risk factors were excluded. Outcomes of patients who had preoperative and postoperative laryngoscopy were analysed. RESULTS RLN palsy occurred in 4.9 per cent of thyroidectomies. The palsy was temporary in 64.6 per cent and persistent in 35.4 per cent of patients. In multivariable analysis, IONM reduced the risk of RLN palsy (odds ratio (OR) 0.63, 95 per cent confidence interval (CI) 0.54 to 0.74, P < 0.001) and persistent nerve palsy (OR 0.47, 0.37 to 0.61, P < 0.001). Outpatient laryngoscopy was also associated with a reduced incidence of RLN palsy (OR 0.50, 0.37 to 0.67, P < 0.001). Bilateral RLN palsy occurred in 0.3 per cent. Reoperation (OR 12.30, 2.90 to 52.10, P = 0.001) and total thyroidectomy (OR 6.52, 1.50 to 27.80; P = 0.010) were significantly associated with bilateral RLN palsy. CONCLUSION The use of IONM is associated with a decreased risk of RLN injury in thyroidectomy. These results based on analysis of UKRETS data support the routine use of RLN monitoring in thyroid surgery.
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Affiliation(s)
- A Abdelhamid
- Department of General Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - S Aspinall
- Department of General Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
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Shah SB, Dubey JK, Bhardwaj M, Mittal A. Clinical pearls in anaesthesia for electromyographic tube guided robotic thyroidectomy. Indian J Anaesth 2021; 65:S51-S53. [PMID: 33814592 PMCID: PMC7993034 DOI: 10.4103/ija.ija_402_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/11/2020] [Accepted: 09/27/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Shagun Bhatia Shah
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Jitendra Kumar Dubey
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Manoj Bhardwaj
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Amit Mittal
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
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Sinclair CF, Téllez MJ, Peláez-Cruz R, Díaz-Baamonde A, Ulkatan S. Continuous neuromonitoring during radiofrequency ablation of benign thyroid nodules provides objective evidence of laryngeal nerve safety. Am J Surg 2020; 222:354-360. [PMID: 33384152 DOI: 10.1016/j.amjsurg.2020.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The recurrent laryngeal nerves(RLN) run immediately posterior to the thyroid capsule and could be injured during thyroid radiofrequency ablation(RFA). This study assesses whether RLN functional integrity is altered during RFA using continuous intraoperative neuromonitoring(CIONM). METHODS Prospective case series of twenty nodules treated with RFA under general anesthesia utilizing the laryngeal adductor reflex(LAR) for CIONM. RESULTS Thirteen nodules abutted the posterior thyroid capsule and 'danger triangle' for RLN injury. The ablative field did not breach the posterior capsule; 40 W was the maximal power used adjacent to the capsule. No patient experienced significant LAR amplitude alterations. Pre and postoperative laryngoscopy and voice assessments were comparable. At 12 months' median follow-up, no patient displayed posterior nodule regrowth. CONCLUSIONS This prospective case series supports the premise that benign nodule RFA is safe with regards to RLN functional integrity provided the posterior capsule is not breached by the ablation zone and posterior power is ≤ 40 W.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, NY, USA.
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
| | - Roberto Peláez-Cruz
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
| | - Alba Díaz-Baamonde
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
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Simó R, Nixon IJ, Rovira A, Vander Poorten V, Sanabria A, Zafereo M, Hartl DM, Kowalski LP, Randolph GW, Kamani D, Shaha AR, Shah J, Marie JP, Rinaldo A, Ferlito A. Immediate Intraoperative Repair of the Recurrent Laryngeal Nerve in Thyroid Surgery. Laryngoscope 2020; 131:1429-1435. [PMID: 33118630 DOI: 10.1002/lary.29204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/02/2020] [Accepted: 09/30/2020] [Indexed: 11/07/2022]
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.
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Affiliation(s)
- Ricard Simó
- Department of Otorhinolaryngology Head and Neck Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, King's College London, London, United Kingdom
| | - Iain J Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
| | - Aleix Rovira
- Guy's and St Thomas' Hospital NHS Foundation Trust, St Thomas' Street, Guy's Hospital, SE1 9RT, United Kingdom
| | - Vincent Vander Poorten
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, Leuven, Belgium
| | - Alvaro Sanabria
- Department of Surgery, Universidad de Antioquia, Hospital Universitario San Vicente Fundacion, CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello, Medellin, Colombia
| | - Mark Zafereo
- Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Dana M Hartl
- Department of Otorhinolaryngology Head and Neck Surgery, Thyroid Surgery Unit, Institute Gustave Roussy, Paris, France
| | - Luiz P Kowalski
- Department of Otorhinolaryngology Head and Neck Surgery, A.C. Camargo Cancer Center, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Ashok R Shaha
- Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, Cornell University Medical College, New York, New York, U.S.A
| | - Jatin Shah
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, Weil Medical College of Cornell University, New York, New York, U.S.A
| | - Jean-Paul Marie
- Experimental Surgery Laboratory, Institute of Biomedical Research, University Hospital Rouen, Rouen, France
| | | | - Alfio Ferlito
- Department of Otorhinolaryngology Head and Neck Surgery, University of Udine School of Medicine, Udine, Italy
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Sun H, Carcoforo P, Dionigi G. Prerequisites for introducing neural monitoring in thyroid surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 137:91. [PMID: 31699621 DOI: 10.1016/j.anorl.2018.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/04/2018] [Accepted: 05/17/2018] [Indexed: 10/25/2022]
Affiliation(s)
- H Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun, Jilin, China
| | - P Carcoforo
- Department of Surgery, S. Anna University Hospital, Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - G Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy.
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