Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery.
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ABSTRACT:
SUBMITTER: Cirocchi R
PROVIDER: S-EPMC6353246 | biostudies-literature | 2019 Jan
REPOSITORIES: biostudies-literature
Publications
Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery.
Cirocchi Roberto R Arezzo Alberto A D'Andrea Vito V Abraha Iosief I Popivanov Georgi I GI Avenia Nicola N Gerardi Chiara C Henry Brandon Michael BM Randolph Justus J Barczyñski Marcin M
The Cochrane database of systematic reviews 20190119
<h4>Background</h4>Injuries to the recurrent inferior laryngeal nerve (RILN) remain one of the major post-operative complications after thyroid and parathyroid surgery. Damage to this nerve can result in a temporary or permanent palsy, which is associated with vocal cord paresis or paralysis. Visual identification of the RILN is a common procedure to prevent nerve injury during thyroid and parathyroid surgery. Recently, intraoperative neuromonitoring (IONM) has been introduced in order to facili ...[more]
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Project description:BackgroundThe recurrent laryngeal nerve (RLN), especially on the left side, is particularly vulnerable during lung operations. Therefore, continuous intraoperative neuromonitoring (cIONM) would be desirable. With the use of a double-lumen tube (DLT) for single-lung ventilation, there is some uncertainty where the recording electrode should be positioned. The aim of this study was to assess the feasibility of this technique and to predict the ideal position of a single recording electrode.MethodsPatients scheduled to undergo left thoracotomy due to pulmonary pathologies, two adhesive electrodes were affixed consecutively above the proximal cuff of the DLT prior to intubation for a precise location of the recording from the vocal cords. Following thoracotomy, the vagus nerve alongside the aortic arch was exposed. A continuous stimulation probe (Saxophone® electrode, Dr. Langer Medical, Waldkirch, Germany) was placed around the nerve. The signals of the respective electrode were recorded and analyzed with regard to previously defined limits of positive signaling.ResultsStrong signals with an amplitude of at least 165 µV were recorded in 18 of 20 patients. In these patients 100% of the signals were recorded via the distally located electrode. An additional signal was recorded via the proximal electrode in four patients. cIONM was found to be a safe and reproducible technique.ConclusionsThe described technique enables the use of cIONM of the RLN throughout the entire course of the surgical procedure.
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Project description:AimTo evaluate the efficacy of intraoperative neuromonitoring in identifying recurrent laryngeal nerves and decreasing the incidence of nerve injury in minimally invasive esophagectomies for esophageal cancers.MethodsA total of 167 minimally invasive esophagectomy patients were retrospectively reviewed. They were divided into intraoperative neuromonitoring (n = 84) and no intraoperative neuromonitoring (n = 83) groups, based on whether or not intraoperative neuromonitoring was used during surgery. We compared short-term surgical outcomes and incidence of recurrent laryngeal nerve palsy between the two groups before and after propensity score matching. The association between the loss of signal and recurrent laryngeal nerve palsy was also evaluated.ResultsThe incidence of recurrent laryngeal nerve palsy (grade 2 and higher) was lower in the intraoperative neuromonitoring group than in the no intraoperative neuromonitoring group (6.0% vs 21.2%, P = 0.02). The rate of recurrent laryngeal nerve palsy recovery within 6 months was also significantly higher in the intraoperative neuromonitoring group (87.5% vs 20.0%, P < 0.01). The positive and negative predictive values of intraoperative neuromonitoring for recurrent laryngeal nerve palsy were 60% (9/15) and 86.9% (60/69), respectively. The duration from paralysis to recovery was shorter in recurrent laryngeal nerve palsy cases with negative loss of signal results than in cases with positive loss of signal results (median: 43 days vs 95 days).ConclusionIntraoperative neuromonitoring is useful in identifying recurrent laryngeal nerves and may aid in reducing the incidence of recurrent laryngeal nerve injury during esophageal surgery.
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Project description:BackgroundContinuous intraoperative neuromonitoring has successfully demonstrated to predict impending damage to the recurrent laryngeal nerve, by detecting changes in electromyographic recordings. Despite the apparent benefits associated with continuous intraoperative neuromonitoring, its safety is still a debate. The aim of this study was to investigate the electrophysiological impact of continuous intraoperative neuromonitoring on the vagus nerve.MethodsIn this prospective study, the amplitude of the electromyographic wave of the vagus nerve-recurrent laryngeal nerve axis was measured both proximally and distally to the stimulation electrode placed upon the vagus nerve. Electromyographic signal amplitudes were collected at three distinct events during the operation: during the dissection of the vagus nerve, before application of the continuous stimulation electrode onto the vagus nerve and after its removal.ResultsIn total, 169 vagus nerves were analysed, among 108 included patients undergoing continuous intraoperative neuromonitoring-enhanced endocrine neck surgeries. Electrode application resulted in a significant overall decrease in measured proximo-distal amplitudes of -10.94 µV (95 per cent c.i. -17.06 to -4.82 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -1.4(5.4) per cent. Before the removal of the electrode, the measured proximo-distal difference in amplitudes was -18.58 µV (95 per cent c.i. -28.31 to -8.86 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -2.50(9.59) per cent. Seven nerves suffered a loss of amplitude greater than 20 per cent of the baseline measurement.ConclusionIn addition to supporting claims that continuous intraoperative neuromonitoring exposes the vagus nerve to injury, this study shows a mild electrophysiological impact of continuous intraoperative neuromonitoring electrode placement on the vagus nerve-recurrent laryngeal nerve axis. However, the small observed differences are negligible and were not associated with a clinically relevant outcome, making continuous intraoperative neuromonitoring a safe adjunct in selected thyroid surgeries.
| S-EPMC10249491 | biostudies-literature
Project description:Intraoperative neuromonitoring (IONM) facilitates recurrent laryngeal nerve (RLN) protection in thyroid and parathyroid surgeries. This study aimed to investigate a novel transcutaneous electromyography (EMG) recording method for IONM of the RLN during minimally invasive parathyroidectomy (MIP). Twenty patients with primary hyperparathyroidism undergoing MIP were enrolled. Two paired needle electrodes were percutaneously inserted into the bilateral laminas of thyroid cartilage for monitoring the vagus nerve and RLN. A standardized IONM procedure (V1-R1-R2-V2 signals) was strictly followed, and the RLN was routinely located and mapped. Pre- and postoperative laryngofiberoscopy was performed to confirm vocal cord function. The proposed technique was successfully used in all patients, and typical EMG signals were effectively detected. No significant change in EMG signals before and after tumor resection was noted, and a normal vocal cord movement was ensured in all patients with postoperative laryngofiberoscopy. IONM helped localize the position of the RLN and facilitated the safe resection of the parathyroid tumor during MIP. The novel transcutaneous EMG recording method proposed in this study was feasible, convenient, reliable, and inexpensive.
| S-EPMC7203296 | biostudies-literature
Project description:We applied continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic surgery (VATS) lobectomy for left lung cancer and evaluated its safety and usefulness. An electrode was attached to a double-lumen tube, and placed at vocal cord level to detect the EMG signal evoked by vocal cord movement. Before 4?L lymph node dissection, an automatic periodic stimulation device was applied to the vagus nerve to stimulate vagus nerve continuously. Surgery was suspended if the amplitude decreased lower than the threshold and was resumed when the amplitude recovered. Ten patients (6 male, 4 female) were enrolled. CIONM was successfully performed in all patients without technical failure, and there was no hemodynamic instability. Amplitude decreased below the threshold in four patients. One patient did not recover amplitude and experienced transient vocal cord palsy. In the three other patients, the amplitude recovered above the threshold and no vocal cord palsy occurred. The six patients who did not exhibit amplitude decrease experienced no vocal cord palsy. Our results suggest that CIONM may be applied safely for VATS left lobectomy and may be used to predict postoperative vocal cord function. This approach may be helpful to prevent RLN injury during VATS left lobectomy.
| S-EPMC7069963 | biostudies-literature
Project description:Reoperative thyroid surgery is rare and has a high complication rate. This retrospective cohort study was performed to determine the recurrent laryngeal nerve injury and hypoparathyroidism rates after reoperative thyroid surgery in two university hospitals in Benghazi, Libya.All consecutive patients who underwent reoperative thyroid surgery between January 2002 and July 2014 were included retrospectively. The cohort was divided according to whether the reoperation was in the previously operated lobe or both lobes (ipsilateral group), or only in the previously non-operated lobe (contralateral group).Of the 73 patients, 66 were female and seven were male. The median age was 37 (19-80) years. Nine (12.3%), five (6.8%), and one (1.4%) patient developed postoperative transient hypocalcemia, transient recurrent laryngeal nerve palsy, and permanent recurrent laryngeal nerve injury, respectively. None of the patients developed permanent hypocalcemia. The ipsilateral group had a higher rate of permanent recurrent laryngeal nerve injury after reoperation than the contralateral group (3.1% vs. 0%). It also had higher rates of transient recurrent laryngeal nerve injury (12.5% vs. 2.4%) and transient hypocalcemia (28.1% vs. 0%), but the two groups did not differ in terms of permanent hypocalcemia rates (both 0%).Reoperative thyroid surgery is technically challenging with a high incidence of complications. The ipsilateral group had more complications after reoperative thyroid surgery than the contralateral group. Hemi- or total thyroidectomy at the primary surgery is recommended to reduce the frequency of reoperative thyroid surgery.
| S-EPMC5448565 | biostudies-other
Project description:Objective:Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator. Methods:Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point. Results:Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500??V. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279??V, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217??V, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99??V, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2. Conclusion:The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.
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Project description: Not available
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Project description:We adopted a vision-based tracking system for augmented reality (AR), and evaluated whether it helped surgeons to localize the recurrent laryngeal nerve (RLN) during robotic thyroid surgery. We constructed an AR image of the trachea, common carotid artery, and RLN using CT images. During surgery, an AR image of the trachea and common carotid artery were overlaid on the physical structures after they were exposed. The vision-based tracking system was activated so that the AR image of the RLN followed the camera movement. After identifying the RLN, the distance between the AR image of the RLN and the actual RLN was measured. Eleven RLNs (9 right, 4 left) were tested. The mean distance between the RLN AR image and the actual RLN was 1.9?±?1.5?mm (range 0.5 to 3.7). RLN localization using AR and vision-based tracking system was successfully applied during robotic thyroidectomy. There were no cases of RLN palsy. This technique may allow surgeons to identify hidden anatomical structures during robotic surgery.
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