Use Of Intraoperative Nerve Monitoring Research Articles

Techniques of detecting recurrent laryngeal nerve palsy in patients undergoing thyroid surgery: Pearls and pitfalls

Abstract Though permanent vocal cord palsy consequent to recurrent laryngeal nerve (RLN) injury is rare following thyroidectomies, its consequences are grave enough for it to be the most feared complication postoperatively. Anesthesiologists and surgeons take various precautions to prevent its occurrence and employ various methods for its early detection. They include direct visualization of the nerve intraoperatively, use of intraoperative nerve monitoring, and post-extubation visualization of vocal cord mobility by use of direct or indirect methods. In the present narrative review, we aim to discuss the clinical evidence pertaining to the various methods adopted for the prevention and early detection of RLN palsy during thyroidectomy.

Nerve monitoring in endocrine surgery: Practice patterns differ among surgeons for parathyroidectomy and thyroidectomy

BackgroundIt is unknown whether intraoperative nerve monitoring is associated with reduced vocal cord dysfunction after parathyroidectomy. We aimed to investigate intraoperative nerve monitoring use among Collaborative Endocrine Surgery Quality Improvement Program surgeons and factors associated with vocal cord dysfunction after parathyroidectomy. MethodsPatients who underwent parathyroidectomy included in the Collaborative Endocrine Surgery Quality Improvement Program (2014–2022) were identified. The annual percent change in parathyroidectomies performed with intraoperative nerve monitoring was calculated using joinpoint regression. Multivariable logistic regression was used to compare outcomes between patients undergoing parathyroidectomy with/without intraoperative nerve monitoring. To compare surgeon-specific trends, Collaborative Endocrine Surgery Quality Improvement Program thyroidectomy and parathyroidectomy datasets (2014–2021) were combined. Parathyroidectomies performed by surgeons who used intraoperative nerve monitoring consistently in thyroidectomy were identified. Factors associated with intraoperative nerve monitoring were examined using multivariable logistic regression. ResultsA total of 9,813 patients underwent parathyroidectomy. Intraoperative nerve monitoring was used in 49% of cases (n = 4,818). There was an increase in parathyroidectomies with intraoperative nerve monitoring from 2014 to 2018 (annual percent change 22.2, P = .01), followed by a plateau (2018–2022 annual percent change −0.66, P = .85). Few patients (0.44%, n = 43) developed vocal cord dysfunction. Vocal cord dysfunction was not associated with intraoperative nerve monitoring (adjusted odds ratio 0.92, P = .75). Whereas 41% (n = 56/138) of surgeons used intraoperative nerve monitoring routinely in parathyroidectomy, 65% (n = 90/138) used it routinely in thyroidectomy. Among surgeons who used intraoperative nerve monitoring routinely in thyroidectomy, only 57% used it routinely in parathyroidectomy; factors associated with intraoperative nerve monitoring during parathyroidectomy included reoperation (adjusted odds ratio 2.51, P < .01), secondary/tertiary hyperparathyroidism (adjusted odds ratio 1.42, P = .02), multiglandular disease (adjusted odds ratio 1.76, P < .001), and non-localized disease (adjusted odds ratio 1.65, P < .001). ConclusionEndocrine surgeons use intraoperative nerve monitoring selectively. Surgeons who routinely use intraoperative nerve monitoring during thyroidectomy are more likely to use it during parathyroidectomy. Future studies should determine who may benefit most from intraoperative nerve monitoring in parathyroidectomy.

A Nationwide Survey to Assess the Practices and Patterns of Use of Intraoperative Nerve Monitoring During Thyroid Surgery Among Surgeons in India.

The online version contains supplementary material available at 10.1007/s13193-023-01818-5.

Intraoperative Nerve Monitoring Ought to be Used In Complementary Thyroidectomy

Background: Injuries to the recurrent inferior laryngeal nerve (RLN) remain one of the major post-operative complications after thyroid surgery. In studies, temporary RLN damage during thyroidectomy is %2-11, and the rate of permanent RLN damage is %0.6-1.6. Complementary thyroidectomies have a higher complication rate compared to the first surgical procedure. In the last two decades, intraoperative neural monitoring has become a powerful tool for risk minimization. In our study, we aimed to retrospectively examine the pa-tients who underwent complementary thyroidectomy and intraoperative nerve monitoring. Materials and Methods: Between January 2016 and February 2020, the files of 54 patients, who underwent complementary thyroidectomy and nerve monitoring in our clinic, were analyzed retrospectively.Patients who did not undergo nerve monitoring were not included in the study. The age, gender, pathology and indication, first surgery type, and the length of hospital stay of the patients, the reason for undergoing complementary thyroidectomy, and whether or not postoperative complications developed in the patients, were all recorded. Results: The mean age of the patients was 44.4 (16-82 years). The average length of hospital stay of the patients was 2.37 (1-5 days). According to the initial pathology results of the patients who underwent comp-lementary thyroidectomy, 34 had papillary thyroid cancer, 6 had follicular thyroid carcinoma or suspicion, 1 had medullary thyroid carcinoma, 1 patient had Anaplastic thyroid carcinoma suspicion and 12 patients had Multinodular Goiter recurrence. Conclusions: As a result, complementary thyroid surgery poses an important problem for surgeons. It has a high rate of complications due to the formation of scar and loss of normal tissue planes. Therefore, we think that the use of intraoperative nerve monitoring during complementary thyroidectomy surgery may be helpful in reducing the occurrence of permanent or temporary recurrent laryngeal nerve damage. Key Words: Intraoperative Nerve Monitoring Complementary Thyroidectomy, Complication

Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility.

The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy. This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups. Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy. The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.

Routine use of intraoperative nerve monitoring is associated with a reduced risk of vocal cord dysfunction after thyroid cancer surgery

BackgroundThe aim of this study was to investigate the associations between individual surgeon’s intraoperative nerve monitoring (IONM) practice and factors associated with vocal cord (VC) dysfunction in patients with thyroid cancer undergoing thyroidectomy.MethodsUsing Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) 2014-21 data, multivariable logistic regression analyses investigated variables associated with short- and long-term VC-dysfunction, associations of routine use of IONM with postoperative outcomes, and patient characteristics associated with IONM use.ResultsAmong 5,446 patients (76.7% female, mean age 49 years), 68.5% had surgery by surgeons using IONM in ≥ 90% of cases (63% of surgeons, n = 73). Post-operative VC-dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short-term and 2.7% in the long-term. When surgeons routinely used IONM, the incidence of VC-dysfunction was 2.4% in the short-term and 2.2% in the long-term, compared to 4.4% and 3.7%, respectively, when surgeons did not routinely use IONM (p < 0.01). After adjustment, routine use of IONM was independently associated with reduced risk of short- (OR 0.48, p < 0.01) and long-term (OR 0.52, p < 0.01) VC-dysfunction, a lower risk of postoperative hypoparathyroidism in the short- (OR 0.67, p < 0.01) and long-term (OR 0.54, p < 0.01), and higher likelihood of same-day discharge (OR 2.03, p < 0.01). Extrathyroidal tumor extension and N1-stage were factors associated with postoperative VC-dysfunction in the short- (OR 3.12, p < 0.01; OR 1.92, p = 0.01, respectively) and long-term (OR 3.11, p < 0.01; OR 2.32, p < 0.01, respectively).ConclusionRoutine use of IONM was independently associated with a lower risk of endocrine surgery-specific complications and greater likelihood of same-day discharge.

Effectiveness of the recurrent laryngeal nerve monitoring during endoscopic thyroid surgery: systematic review and meta-analysis.

Thyroid disease is a common endocrine disorder, and thyroid surgeries and postoperative complications have increased recently. This study aimed to explore the effectiveness of intraoperative nerve monitoring (IONM) in endoscopic thyroid surgery using subgroup analysis and determine confounding factors. Two researchers individually searched for relevant studies published till November 2022 in the PubMed, Embase, Web of Science and Cochrane Library databases. Eventually, eight studies met the inclusion criteria. Heterogeneity was assessed using the Cochran's Q test, and a funnel plot was implemented to evaluate publication bias. The odds ratio or risk difference were calculated using fixed-effects models. The weighted mean difference of continuous variables was calculated. Subgroup analysis was performed according to the disease type. Eight eligible papers included 915 patients and 1242 exposed nerves. The frequencies of transient, permanent and total recurrent laryngeal nerve (RLN) palsy were 2.64, 0.19 and 2.83%, respectively, in the IONM group and 6.15, 0.75 and 6.90%, respectively, in the conventional exposure group. In addition, analysis of the secondary outcome indicators for the average total length of surgery, localisation time of the RLN, recognition rate of the superior laryngeal nerve and length of incision revealed that IONM reduced the localisation time of the RLN and increased the identification rate of the superior laryngeal nerve. Subgroup analysis showed that IONM significantly reduced the incidence of RLN palsy in patients with malignancies. The use of IONM significantly reduced the incidence of transient RLN palsy during endoscopic thyroid surgery, but it did not significantly reduce the incidence of permanent RLN palsy. However, the reduction in the total RLN palsy was statistically significant. In addition, IONM can effectively reduce the location time of the RLN and increase the recognition rate of the superior laryngeal nerve. Therefore, the application of IONM for malignant tumours is recommended.

Tiroid cerrahisi eğitiminde intraoperatif nöromonitörizasyonun rolü

Aim: Intraoperative nerve monitoring (IONM) during thyroid surgery has been widely accepted as an additive improvement to the gold standard of visually identifying the RLN. This study aims to evaluate the role of IONM application in thyroid surgery education during general surgery residency. Materials and Methods: Patients who underwent total thyroidectomy between January 2012 and December 2019 were included in the study. The patients were divided into 2 groups according to the use of IONM (Group 1: With IONM, Group 2: Without IONM). These groups were also divided into subgroups as assistants and experts among themselves. Results: This study involved 256 patients. There were 116 patients in group 1, and 140 patients in group 2. Histologic analysis results revealed that IONM was used more frequently in patients with a malignancy (p=0.015). The median operative time was significantly longer when IONM was used, with an operative time of 130 minutes for group 1 and 120 minutes for group 2 (p=0.015). When Group 1B and Group 2B were compared among themselves, the median operation time in Group 1B was 130 minutes, and the median operation time in Group 2B was 125 minutes (p=0.026). In the comparison between Groups 1B and 2B, it was detected that the rate of use of IONM was higher in malignancies (p=0.025). Conclusion: According to our results, the use of IONM did not reduce the incidence of RLN paralysis in thyroidectomy performed by specialists and residents.

Pediatric thyroid surgery: Retrospective analysis on the first 25 pediatric thyroidectomies performed in a reference center for adult thyroid diseases.

Pediatric thyroid carcinoma represents about 4-5% of all pediatric carcinoma with an incidence of 0.5 cases/100,000, compared to 2-10/100000 cases in the adult population. The aim of this study is to present the experience of a reference adult endocrine surgery unit in charge of the treatment of pediatric thyroid diseases. From January 2019 to September 2022, 25 patients, aged 5-17, underwent thyroid surgery. We analysed indications for surgery, use of intraoperative nerve monitoring (IONM), definitive histological examination, postoperative outcomes and risk factors related. Surgical indication was performed for Graves' disease (27%) and for nodular pathology (73%): of these, four were malignant lesions (TIR4/TIR5), eight with indeterminate characteristics (TIR3A/TIR3B) and four characterized as benign (TIR1/TIR2). Total thyroidectomy (TT) was performed in 76% of cases, three of which were prophylactic for the activation of the RET gene mutation in MEN 2A. IONM was used in eight cases (32%), all patients aged 11 years or less. FNA's accuracy was 100% for lesions typified as benign and malignant (TIR1/TIR2 and TIR4/TIR5). The overall malignancy rate achieved was 40% and in the final histological examination 75% of the TIR 3B lesions were malignant. Six patients (24%) developed hypoparathyroidism in the first postoperative day, with normalization of calcium values within thirty days in 5 patients. Pediatric thyroid nodules are rare and distinguished from adult thyroid disease by a worse prognosis and higher malignancy rates. Our work reports a much higher malignancy rate among indeterminate TIR 3B lesions than observed in the adult population and the three patients who underwent prophylactic total thyroidectomy for activating RET gene mutation had all a definitive histological diagnosis of medullary carcinoma. Post-surgical hypoparathyroidism is a common finding in these patients: in most cases the condition is transient and it benefits from supportive therapy. Intraoperative finding of a thinner recurrent laryngeal nerve in younger patients makes nerve isolation more difficult than in adult surgery: IONM is recommended in patients under 12. Pediatric thyroid surgery is challenging, we sustain it requires referral thyroid Centers for thyroid disease with highly skilled general endocrine surgeons.

Functional outcome following intracapsular resection of head and neck peripheral nerve sheath tumors: a retrospective cohort

BackgroundIntracapsular resection of head and neck peripheral nerve sheath tumors (PNST) has emerged as a nerve-preserving technique compared to en bloc resection. The aim of this study was to evaluate and compare the functional outcome of both surgical techniques performed at a single tertiary referral center.MethodsThis is a retrospective cohort of patients with head and neck PNST undergoing surgical resection from 2011 to 2021 at the Tel Aviv Sourasky Medical Center. Demographic data, the nerve of origin and surgical technique, including the use of intraoperative nerve monitoring were recorded and analyzed in association with postoperative functional outcomes.ResultsOverall, 25 patients who had a cervical or parapharyngeal PNST resected were included. Nerve function was preserved in 11 of 18 patients (61%) who underwent intracapsular resection, while all those who underwent en bloc resections inevitably suffered from neurologic deficits (100%, N = 7). Sympathetic chain origin and an apparent neurologic deficit pre-operatively were associated with postoperative neural compromise.ConclusionImproved functional outcome can be anticipated following intracapsular resection of extracranial head and neck PNST compared to complete resection, particularly in asymptomatic patients.Graphical abstract

Usefulness of intraoperative nerve monitoring for giant type AB thymoma combined with an aberrant right subclavian artery: a case report

Abnormal tumor vascularization and escalating tumor size represent two major impediments that make cancer surgery impossible or complicated. Herein, we report the case of a giant thymoma (type AB) in a 58-year-old woman who presented with cough and yellow sputum. The thymoma grew extensively from the neck to the upper mediastinum. The patient exhibited an aberrant right subclavian artery and a non-recurrent inferior laryngeal nerve. Intraoperative nerve monitoring facilitated the identification and preservation of vital nerves spanning the neck and chest, including the non-recurrent inferior laryngeal nerve. Furthermore, the tumor was divided naturally along the constriction, and a good field of view was acquired to identify abnormal right subclavian arteries and nerves that ran deep in the tumor and surgical field. The tumor was safely removed without complications using intraoperative nerve monitoring, and the thymoma that grew extensively from the neck to the upper mediastinum and was associated with an aberrant right subclavian artery was resected. Intraoperative nerve monitoring was helpful in identifying the non-recurrent inferior laryngeal nerve and left recurrent laryngeal nerve.

Intraoperative Nerve Monitoring Is Associated with Less Postoperative Vocal Cord Dysfunction and Hypoparathyroidism in Patients Undergoing Thyroidectomy for Thyroid Cancer

INTRODUCTION: Intraoperative nerve monitoring (IONM) during thyroid operation for benign disease is associated with a lower risk of recurrent laryngeal nerve injury. This study aimed to investigate factors associated with short- and long-term vocal cord (VC) dysfunction in patients undergoing operation for thyroid cancer. METHODS: Patients ≥18 years of age undergoing thyroid operation for malignant disease from January 2014 to April 2021 in the Collaborative Endocrine Surgery Quality Improvement Program database were included. Multivariable logistic regression analyses investigated variables associated with short-term (≤30 days postoperative) and long-term (31 to 180 days) VC dysfunction and characteristics associated with IONM use. RESULTS: Among 5,446 patients, 76.7% were women, and the mean age was 49 years. Papillary thyroid cancer (PTC) was the most common type (84.6%). Few patients had nodal metastases or extrathyroidal extension (27.3% and 3.9%, respectively). Postoperative VC dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short term and in 2.7% in the long term. Patients with tumors who had extrathyroidal extension or nodal metastases were at higher risk for short-term (odds ratio [OR] 3.17, p < 0.001; OR 1.91, p = 0.005, respectively) and long-term (OR 3.1, p < 0.001; OR 2.34, p < 0,001, respectively) VC dysfunction. IONM was independently associated with a reduced risk of short-term (OR 0.61, p = 0.006) and long-term (OR 0.48, p < 0.001) VC dysfunction. IONM use was associated with outpatient surgery (OR 1.61, p < 0.001) and fewer postoperative hypoparathyroidism events in the short (OR 0.7, p < 0.001) and long term (OR 0.64, p = 0.002). CONCLUSION: IONM is independently associated with a lower rate of endocrine-specific complication and more outpatient surgery. Future studies are needed to identify barriers to broader IONM use.

172. THE MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY WITH A TRANS-BICERVICAL APPROACH USING INTRAOPERATIVE NERVE MONITORING (IOMN)

Abstract We developed ‘mediastinoscopic esophagectomy with lymph node dissection’ (MELD), performed under pneumomediastinum via a trans-bicervical and transhiatal approach using cadavers. A clinical trial on the feasibility and safety of MELD showed it to be useful for complete mediastinal lymph node dissection. We report the indications and novel aspects of MELD. MELD was indicated for patients of thoracic esophageal cancer without bulky primary lesions or lymph node metastases. MELD was performed in 16 patients. First, 101R and part of the 106recR lymph nodes were dissected in open surgery. After attaching an APS electrode for intraoperative nerve monitoring (IOMN) to the right vagus nerve, open surgery was changed to the pneumomediastinal method. The dorsal side of the esophagus was dissected along the visceral sheath. The 106tbL lymph nodes and the106recR lymph nodes were dissected using a right trans-cervical pneumomediastinal approach. The 106recL lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The median pneumomediastinal operation time was 320 minutes. The median amount of bleeding was 230 mL, and the median postoperative hospital stay was 16 days. Regarding complications, eight patients developed recurrent laryngeal nerve palsy (right, n = 3; left, n = 2; bilateral, n = 3), but no patients required conversion to thoracotomy, and no leakage, pneumonia, or operative deaths occurred. After incorporating the use of IOMN, the incidence of recurrent laryngeal nerve palsy was drastically reduced recurrent laryngeal nerve palsy was drastically decrease. Previous clinical trials shown that MELD can retrieve the mediastinal lymph nodes at the same level as thoracoscopic esophagectomy. The incidence of recurrent laryngeal nerve palsy was reduced by IONM; thus, MELD is considered a feasible procedure for radical esophagectomy.

Intraoperative Neuromonitoring: Evaluating the Role of Continuous IONM and IONM Techniques for Emerging Surgical and Percutaneous Procedures.

Intraoperative nerve monitoring (IONM) is a tool used during thyroid surgery to assist in the identification of the recurrent laryngeal nerve (RLN). Multiple IONM systems that exist for thyroidectomy require intubation with an endotracheal tube. Given that one of the advantages of thermal ablation procedures, such as radiofrequency ablation, is that they can be done safely without the use of general anesthesia, nerve monitoring systems that utilize cutaneous surface electrodes have been developed, though are not widely available in the United States. This article will review the use of IONM for RFA including the cutaneous surface electrode system.

Current research status on pelvic autonomic nerve monitoring in rectal cancer surgery

Rectal cancer is a common malignant tumor of the digestive tract, and surgery is the main treatment strategy. Disorders of bowel, anorectal and urogenital function remain common problems after total mesorectal resection (TME), which seriously decreases the quality of life of patients. Surgical nerve damage is one of the main causes of the complications, while TME with pelvic autonomic nerve preservation is an effective way to reduce the occurrence of adverse outcomes. Intraoperative nerve monitoring (IONM) is a promising method to assist the surgeon to identify and protect the pelvic autonomic nerves. Nevertheless, the monitoring methods and technical standards vary, and the clinical use of IONM is still limited. This review aims to summarize the researches on IONM in rectal and pelvic surgery. The electrical nerve stimulation technique and different methods of IONM in rectal cancer surgery are introduced. Also, the authors discuss the limitations of current researches, including methodological disunity and lack of equipment, then prospect the future direction in this field.

Association between intraoperative nerve monitoring and the duration of thyroid surgery: A tertiary care center experience

Background: Recurrent laryngeal nerve (RLN) injury is one of the serious complications of thyroid surgeries, which has been a topic of medicolegal concern. Although the course of the nerve can vary between patients, RLN visualization has been the gold standard method for identifying the nerve intraoperatively. However, over recent years, intraoperative nerve monitoring (IONM) has gained more acceptance and has been standardized and utilized, in addition to visual nerve identification, in many thyroids and parathyroid surgery centers. In this study, we aim to determine the association between the use of nerve integrity monitoring systems and the duration of thyroid surgery. Materials and Methods: This is a retrospective chart review, conducted at hospital in Jeddah, Saudi Arabia. We included all patients who underwent thyroid surgery during the period between 2014 and 2019, with no exclusion criteria. We studied variables including duration of surgery, preoperative assessment, diagnosis, surgical procedure, use of IONM, and comorbidities. Results: A total of 236 patients were included, of which 69 (29.2%) cases used IONM. The mean duration of all surgeries was 179.95 ± 96.9 min, whereas the mean duration of surgeries using IONM only was 214.39 min, compared to 165.72 min of surgeries without IONM, which reveals a statistically significant association between the use of nerve monitoring and an increase in the duration of surgery (P ≤0.002). Conclusion: IONM utilization in thyroid surgeries was associated with a longer duration of surgery. However, more studies are required to support this result.

The value of intraoperative nerve monitoring against recurrent laryngeal nerve injury in thyroid reoperations.

Reoperative thyroidectomy is challenging for surgeons because of the higher incidence of recurrent laryngeal nerve (RLN) palsy. RLN identification is the gold standard during thyroidectomy; however, it is sometimes difficult to perform thyroid reoperations. In recent years, intraoperative nerve monitoring (IONM) has gained increased acceptance, and the use of IONM can be a valuable adjunct to visual identification. The aim of this study was to evaluate the value of IONM during thyroid reoperation.A total of 109 patients who met our criteria at the Affiliated Hospital of Hangzhou Normal University from January 2010 to June 2020 were retrospectively analyzed and divided into the IONM group and the visualization-alone group (VA group) according to whether neuromonitoring was used during the operation. The patients’ characteristics, perioperative data, and intraoperative information including the RLN identification, time of RLNs confirmation, operative time, intraoperative blood loss, and the rate of RLN injury were collected.Sixty-five procedures (94 RLNs at risk) were performed in the IONM group, whereas 44 (65 RLNs at risk) were in the VA group. The rate of RLN identification was 96.8% in the IONM group and 75.4% in the VA group (P < .05). The incidence of RLN injury was 5.3% in the IONM group and 13.8% in the VA group (P > .05). The incidence of surgeon-related RLN injury rate was 0% in the IONM group compared to 7.7% in the VA group (P < .05), but the tumor-related or scar-related RLN injury rate between the 2 groups were not significantly different (4.3% vs 3.1%, 1.1% vs 3.1%, P > .05).IONM in thyroid reoperation was helpful in improving the RLN identification rate and reducing the surgeon-related RLN injury rate, but was ineffective in reducing the tumor-related and scar-related RLN injury rate. In the future, multicenter prospective studies with large sample sizes may be needed to further assess the role of IONM in thyroid reoperations.

Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy.

Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available. This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM. The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy. IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

Seeing Is Not Believing: Intraoperative Nerve Monitoring (IONM) in the Thyroid Surgery.

Ensuring the integrity of the recurrent laryngeal nerve (RLN), the external branch of superior laryngeal nerve (EBSLN) and preservation of normal voice are the prime 'functional' goals of thyroid surgery. More in-depth knowledge of neuronal mechanisms has revealed that anatomical integrity does not always translate into functional integrity. Despite meticulous dissection, neural injuries are not always predictable or visually evident. Intraoperative nerve monitoring (IONM) is designed to aid in nerve identification and early detection of functional impairment. With the evolution of technique, intermittent monitoring has given way to continuous-IONM. Over the years, IONM gathered both support and flak. Despite numerous randomised studies, systematic reviews, and meta-analyses, there still prevails a state of clinical equipoise concerning the utility of IONM and its cost-effectiveness. This article inspects the true usefulness of IONM, elaborates on the optimal way to practice it, and presents a critical literature review.

Intraoperative Nerve Monitoring Setup and Data Interpretation: How Do I Augment My IONM Experience?

The purpose of this article is to review the current intraoperative nerve monitoring technologies on the market and discuss the setup and interpretation of data to provide surgeons a guide by which to perform nerve monitoring during endocrine surgical cases. The associated risk minimization to the recurrent laryngeal nerve with the use of intraoperative nerve monitoring allows continued self-improvement by surgeons during dissection and offers some protection in litigious environments. This article emphasizes the published International Neural Monitoring Study Group guidelines on intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery. These guidelines have informed the algorithms by which intermittent and continuous nerve monitoring (IIONM and CIONM, respectively) is used. There have been multiple follow-up studies on rates of use, prognostication, and clinical outcomes using the technology. Established algorithms for intraoperative nerve monitoring allow the endocrine surgeon to easily gather and analyze data that are valuable in ultimately improving post-operative voice outcomes.