Recurrent Nerve Dissection Research Articles

Rocuronium with sugammadex as a rescue reversal agent to solve conflicting recommendations for thyroid or parathyroid surgery. A prospective study

IntroductionFor thyroid or parathyroid surgery, there is a challenge to select a muscle relaxant agent allowing a good quality for tracheal intubation without any residual effect at the time of intraoperative neural monitoring. Patients and methodsIn this monocentric study, non-morbidly obese adult patients without risk factors for difficult tracheal intubation who underwent thyroid or parathyroid surgery with intraoperative neural monitoring were prospectively included. After rocuronium injection (0.5 mg.kg−1) during propofol-sufentanil induction, intubation conditions were evaluated using the Copenhagen score. The surgeon positioned the electrodes NIM® and tested the vagal nerve before recurrent nerve dissection. The signal was considered positive when the wave amplitude exceeded 100 μV. If not, sugammadex (2 mg.kg−1) was administered. The dissection began when the signal was positive. ResultsFrom January 2022 to June 2022, 48 out of 50 patients, 39 (81%) female, met inclusion criteria and were prospectively recruited in the study (two patients had predictable difficult intubation criteria). Intubation conditions were clinically acceptable for 46/48 (96%) of patients. The time delay from rocuronium injection to vagal stimulation was 43 min (mean) +/− 11 (SD). The vagal stimulation was positive in 45 patients (94%). In the 3 remaining patients, sugammadex successfully reversed residual curarization and allowed positive vagal stimulation. DiscussionThis prospective study shows that the use of 0.5 mg.kg−1 rocuronium with sugammadex as a rescue reversal agent allows good quality and safety for intubation conditions and intraoperative neural monitoring in patients scheduled for thyroid or parathyroid surgery.

Incidental cervical metastases from thyroid carcinoma during neck dissection

ObjectivesTo quantify and discuss the prevalence of unsuspected thyroid lymph node metastases discovered in specimens from neck dissection for head and neck squamous cell carcinoma (HNSCC) and discuss the impact on patient management. Study designRetrospective study between May 2004 and January 2007. SettingUniversity hospital. MethodsPathological analysis of cervical lymph node dissection performed during surgery for HNSCC in a total of 349 neck dissections in 266 consecutive patients. ResultsTwenty-one patients showed metastatic lymph nodes from thyroid cancer (prevalence 7.9%): 13 cases were metastatic from a papillary thyroid carcinoma and 8 cases from a follicular carcinoma. In 5 of the 21 patients, classical dissection was associated to recurrent nerve dissection and unilateral lobectomy; no thyroid carcinoma was found. Thirteen patients received radiotherapy for HNSCC.Follow-up comprised annual ultrasonographic examination of the neck and thyroid in these 21 patients. Total thyroidectomy was decided on in 5, with discovery of 3 micro-papillary thyroid carcinomas, in a single patient (complementary 131I treatment). No thyroid carcinomas were found for the other 4 patients. No patients died from thyroid carcinoma during follow-up (mean: 41 months). ConclusionThe prevalence of lymph node metastasis from thyroid carcinoma in cervical lymph node dissection during treatment of HNSCC seems higher (7.9%) than rates reported in the literature (0.3 to 1.6%). This may be due to the histopathological methods employed. Management of patients should be discussed in the light of thyroid ultrasonography and prognosis of HNSCC.

Minilaparoscopy-Assisted Hemithyroidectomy and Central Neck Dissection (Level VI) Using Bilateral Breast Approach

Introduction: Minilaparoscopy-assisted thyroidectomy using the bilateral breast approach is a technique for thyroidectomy in patients with thyroid disease. This technique can promote the effect of cosmetology in thyroid surgery. In this video, we outline the instrument, operating room setup, and trocar position, present a minilaparoscopy-assisted hemithyroidectomy and central neck dissection (level VI), and demonstrate recurrent laryngeal nerve and two parathyroids in operation. Materials and Methods: In August 2014, we operated on a 35-year-old female patient. The patient underwent fine-needle aspiration cytology, diagnosed as left papillary thyroid carcinoma. After CT scan and ultrasonic inspection preoperation, the clinical staging is cT1aN0M0 staging I. According to the Chinese thyroid nodule and thyroid cancer guideline,1 we decided to perform left hemithyroidectomy and central neck dissection (level VI) using a bilateral areolar approach. 0.2 mL carbon nanoparticle suspension was injected to the thyroid gland with ultrasonic guidance 2 weeks before operation. The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the superior pole vessels are divided. The superior pole is then mobilized laterally and the recurrent laryngeal nerve is searched for at the inferior pole. The dissection continues between the nerve and the posterior part of the thyroid progressively, from bottom to top. After the recurrent nerve dissection, the gland can usually be extracted without difficulty, dividing the last vessels in berry ligament holding the gland. While in central neck dissection, first, we confirmed the lateral boundaries of central compartment and identified the recurrent laryngeal nerve. Then completed the central neck dissection. Finally, we present the superior thyroid artery, recurrent laryngeal nerve, and parathyroids after dissection, cleaning up, and closure. Results: The patient who was operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Carbon nanoparticle suspension is an ideal lymphatic tracer for endoscopic thyroidectomy and central neck dissection, although there is some leakage of carbon nanoparticle suspension in this patient. It does not affect the identification and preservation of recurrent laryngeal nerve and parathyroids. Conclusions: We prefer to operate cN0 thyroid cancer using this technique because it allows us to better identify and preserve the recurrent laryngeal nerve and parathyroids and same boundaries in central neck dissection. Moreover, it brings better cosmetic results for young patients. No competing financial interests exist. Runtime of video: 9 mins 57 secs

Retrosternal Thyroid Goiter: Recurrent Laryngeal Nerve Dissection According to the Charles Proye's Toboggan Technique

Introduction: We present a case report supported by a video of a case of recurrent retrosternal thyroid goiter with superior identification of the recurrent laryngeal nerve (also called the Charles Proye's toboggan technique).1 Materials and Methods: In November 2012, we operated a 71-year-old patient for a recurrent unilateral retrosternal thyroid goiter. The patient underwent a subtotal thyroidectomy 20 years earlier; she showed symptoms of airway and esophageal compression. After a CT scan and a laryngoscopy, the patient underwent a right thyroid lobectomy. The surgery of retrosternal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion.2 Charles Proye described a surgical technique to avoid this lesion. To have a better exposition, a section of the prethyroid muscles can be considered, particularly if it is a voluminous and/or recurrent goiter.3–4 The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the middle thyroid vein is divided and the superior pole vessels are divided. The superior pole is then mobilized laterally, and the recurrent laryngeal nerve is searched for at its entry point into the larynx. The nerve function can be verified by the neuromonitoring, which also helps to find it in this vessel-rich area. The dissection continues between the nerve and the posterior part of the thyroid, progressively from top to bottom, descending as on a toboggan. After the recurrent nerve dissection, the goiter can usually be extracted without difficulty, dividing the last vessels holding the goiter inside.1–4 Results: With the toboggan technique, it is often possible to do the thyroidectomy for mediastinal goiter without sternotomy and recurrent nerve damage.1 Using this technique, the recurrent nerve is never put under tension. The patient operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Conclusions: Whenever possible, we prefer to operate intrathoracic goiters using this technique because it allows us to better recognize and preserve the recurrent nerve without putting it under tension. The Source of Work or Study: In 1981, Charles Proye described a new surgical technique to operate intrathoracic goiters without sternotomy and with preservation of recurrent nerve; the surgery of mediastinal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion. We utilize in our clinic this technique for intrathoracic goiters. This video describes the details of the Charles Proye's technique. The authors have not received any payment or support. The article is based on a videocommunication during the congress of the IAES in Helsinki, August 2013. Running time of video: 4 mins, 53 secs

Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk.

To evaluate the effect of recurrent nerve dissection on the incidence of recurrent laryngeal nerve injury (RLNI) and to analyze the performance of individual surgeons. Dissection of the recurrent nerve is mandatory in total thyroidectomy, but its relative merit in less extensive resections is not clear. The reported rates of RLNI differ widely; this may reflect a variation in the performance of individual surgeons. The authors studied the incidence of RLNI in primary surgery for benign thyroid disease during three periods in a single center. In period 1 (1979-1990; 9,385 consecutive patients, 15,865 nerves at risk), the recurrent nerve was not exposed. In period 2 (1991-1998; 6,128 patients, 10,548 nerves at risk), dissection of the recurrent nerve was the standard procedure. Global outcome and individual performance in these two periods were compared and presented to the surgeons. The effect of this quality control procedure was tested in 1999 (period 3; 930 patients, 1,561 nerves at risk). Exposure of the recurrent nerve significantly reduced the global rate of postoperative and permanent RLNI. Some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent RLNI rates ranged from 0% to 1.1%). The documented significant differences in individual performances did not affect the outcome in period 3. The extent of nerve dissection was a source of variability; the rate of permanent RLNI averaged 0.9%, 0.3%, and 0.1% for surgeons who only localized, partially exposed, and completely dissected the recurrent nerve, respectively. Recurrent nerve dissection significantly reduces the risk of RLNI. Extensive dissection facilitates visual control of nerve integrity during resection and is therefore superior to a more limited exposure of the nerve. Quality control can improve the global outcome and identify the variability in individual performance. This cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes.

TWO CASES OF THYROID PAPPILLARY CARCINOMA WITH A GIANT GROWTH

Two cases of giant thyroid papillary carcinoma were experienced. Case 1 was an 81-year-old woman having a mass which measured 12×10cm in size and contained about 300ml of blood. The left internal jugular vein, left recurrent nurve, anterior cervical muscles and left sternocleidomastoid muscle were involved in the tumor (JT4, N1, EX2, M0, stage III). Left thyroidectomy with lymph node, left internal jugular vein and left recurrent nerve dissection was performed (R0). Case 2 was a 62-year-old women having a mass measuring 15×15cm in size. Right internal jugular vein was pressed, and right recurrent nerve and anterior cervical muscle were involved in the tumor (JT4, N3, EX2, M0 stage III). Total thyroidectomy with lymph node dissection was performed (R1). It is rare to follow a thyroid tumor for a long duration without any treatment until the tumor becomes huge in size, because the tumor grows gradually. An appropriate operative procedure should be selected considering age and quality of life of the patient and stage of the cancer.