The Recurrent Laryngeal Nerves and the Thoracic Surgeon

Abstract

Many thoracic surgeons are terrified to come anywhere near the recurrent laryngeal nerve (RLN), especially on the left side. The reason for this fear is the dreaded complication of damaging the nerve and causing loss of voice, among other serious complications. RLN palsy ranks among the leading reasons for medicolegal litigation of surgeons because of its attendant reduction in quality of life. It is not surprising, therefore, that thoracic surgeons can be timid and self-assuring in their reasoning that ‘the best way of avoiding injury to the RLN is not to look for it’. Unfortunately this adage has gained credit through long use and the lack of clear descriptive anatomy in the medical literature targeting the needs of the thoracic surgeon. It is the purpose of this publication to dissipate all the myth around the anatomy of RLN, and encourage its deliberate exposure as a first step towards safety. In the author’s unit, this approach has virtually eliminated the risk of injuring the nerves during mediastinal nodal dissection. It has to be said that the use of bipolar diathermy devices in video assisted thoracoscopic surgery (VATS) played a major role in safe dissection around the RLN.The course of the right RLN is short, and the thoracic surgeon is unlikely to damage it. The left RLN anatomy is more complex and requires in-depth understanding. The thoracic surgeon is encouraged to expose the nerve early in nodal dissection to avoid damaging it. Absolute knowledge of the RLN anatomy is mandatory to thoracic surgical practice, and the author strongly believes that the best way to avoid injuring the RLN is to expose it and monitor its motor branch.