The Reliability of the Tracheoesophageal Groove and the Ligament of Berry as Landmarks for Identifying the Recurrent Laryngeal Nerve: A Cadaveric Study and Meta-Analysis.

Brandon Michael Henry,R Shane Tubbs,Silvia Sanna,Beatrice Sanna,Krzysztof A Tomaszewski,Iwona M Tomaszewska,Jens Vikse,Matthew J Graves

doi:10.1155/2017/4357591

Abstract

Purpose. The aim of this meta-analysis was to provide a comprehensive evidence-based assessment, supplemented by cadaveric dissections, of the value of using the Ligament of Berry and Tracheoesophageal Groove as anatomical landmarks for identifying the Recurrent Laryngeal Nerve. Methods. Seven major databases were searched to identify studies for inclusion. Eligibility was judged by two reviewers. Suitable studies were identified and extracted. MetaXL was used for analysis. All pooled prevalence rates were calculated using a random effects model. Heterogeneity among included studies was assessed using the Chi2 test and the I2 statistic. Results. Sixteen studies (n = 2,470 nerves), including original cadaveric data, were analyzed for the BL/RLN relationship. The RLN was most often located superficial to the BL with a pooled prevalence estimate of 78.2% of nerves, followed by deep to the BL in 14.8%. Twenty-three studies (n = 5,970 nerves) examined the RLN/TEG relationship. The RLN was located inside the TEG in 63.7% (95% CI: 55.3–77.7) of sides. Conclusions. Both the BL and TEG are landmarks that can help surgeons provide patients with complication-free procedures. Our analysis showed that the BL is a more consistent anatomical landmark than the TEG, but it is necessary to use both to prevent iatrogenic RLN injuries during thyroidectomies.

Highlights

Surgeons use various techniques to identify the Recurrent Laryngeal Nerve (RLN) during operative procedures on the neck. These range in palpation, direct inspection, intraoperative nerve monitoring, and anatomical landmarks such as the suspensory ligament of the thyroid gland (Ligament of Berry, BL) and the Tracheoesophageal Groove (TEG)
When the RLN was located outside the groove, it was most commonly found lateral to the TEG (17 nerves, 73.9%) (Table 2)
There was a 90.3% prevalence of the RLN coursing superficially to the BL. This coincides with the prevalence rates noted in studies such as those by Asgharpour et al (2012) and Ngo Nyeki et al (2015) [1, 3] and with the most common (78.2%) superficial RLN/BL relationship identified in the meta-analysis

Summary

Introduction

Surgeons use various techniques to identify the Recurrent Laryngeal Nerve (RLN) during operative procedures on the neck. These range in palpation, direct inspection, intraoperative nerve monitoring, and anatomical landmarks such as the suspensory ligament of the thyroid gland (Ligament of Berry, BL) and the Tracheoesophageal Groove (TEG). It can help to identify the RLN during surgical procedures, but this has yet to be widely accepted and implemented as standard practice [3]. The TEG, the sulcus formed by the abutment of the trachea anteriorly and esophagus posteriorly, is useful for identifying the RLN [4]. The RLN is the structure most at risk for iatrogenic injury during procedures on the anterior neck, thyroidectomy [5]. The location of the RLN with respect to the BL has varied widely in previous reports, ranging from a piercing pattern in 0% of BioMed Research International

Methods

Results

Discussion

Conclusion