C\l=e'\sarGavil\l=a'\n,MD, Javier Gavil\l=a'\n,MD \s=b\Two hundred forty-two patients with a diagnosis of epidermoid carcinoma of the larynx were studied. All of them underwent surgery. One hundred sixty-one patients underwent functional neck dissection, with a total of 206 performed. Thirty-three patients underwent classic radical neck dissection, with a total of 35 performed. The overall 5-year neck tumor recurrence rate in the necks with functional neck dissection was 3.4%. Recurrences developed in 5.7% of fields protected by radical neck dissection. The overall recurrence rate in the surgically unprotected necks was 6.2%. Our results confirm that functional neck dissection is the procedure of choice in cases with NO disease and in cases with mobile nodes. From the oncologic viewpoint, functional neck dissection is a safe technique to treat the cervical spread from cancer of the larynx as long as its indications and technical characteristics are carefully observed.
\n,MD, C\l=e'\sarGavil\l=a'\n,MD \s=b\ Intraoperative identification of the recurrent laryngeal nerve (RLN) is mandatory in surgery of the thyroid and parathyroid glands to avoid surgical damage. Several methods have been proposed for identifying and localizing the RLN based on vocal cord motion produced by electrical stimulation of the nerve. Most of them require complex instrumentation, while others are in contradiction with anatomical basis. We present a safe and simple method for identifying the RLN during thyroid and parathyroid gland surgery, which requires no additional surgical instruments and can be performed as a routine procedure. Nonetheless, thorough knowledge of cervical anatomy still remains the most important point in this surgery.In 1933, Prioleau1 stated that in thy¬ roid surgery, a recurrent nerve seen is injured. Eleven years later, Lahey2 opened a new era in thyroid surgery by advocating the systematic intraoperative identification of the recurrent laryngeal nerve (RLN) in thyroidectomy. Nowadays, most au¬ thors agree with the principles proposed by Lahey in 1944, and the inci¬ dence of permanent surgical damage to the RLN in primary operations of the thyroid and parathyroid glands can be as low as 0.1 %.3 In 1956, Riddell" reported a decrease in surgical injury to the RLN, from 6% for un¬ identified nerves to 2% for 1056 iden¬ tified nerves. The incidence of RLN damage increases in reoperative pro¬ cedures.5·6The RLN runs upward, more or less in the groove between the trachea and the esophagus, and is closely related to the inferior thyroid artery and the posterior aspect of the thyroid gland. The right nerve is more commonly anterior (26% to 33%) or passes between the branches of the artery (47% to 50% ), while the left RLN is more commonly posterior (50% to 55% ) to the inferior thyroid artery.7 It is usual for the RLN to divide before entering the larynx,810 but the branches to the laryngeal muscles leave the RLN inside the larynx.11 The intrinsic muscles of the larynx are innervated by the RLN and the supe¬ rior laryngeal nerve. The cricothyroid is the only muscle innervated by the external branch of the superior laryn¬ geal nerve, while the other intrinsic muscles are innervated by the RLN.12 Apparently, the RLN sometimes may also help to supply the cricothyroid muscle,12 but this must be considered an exception rather than the rule.We present a method for intraoper¬ ative identification of the RLN, based on direct electrical stimulation of the nerve with a disposable nerve stimu¬ lator and palpation of the response of the posterior cricoarytenoid muscle (posticus). MATERIALS AND METHODSAfter division of the middle thyroid vein(s), the posterolateral surface of the thyroid gland is exposed, and the inferior thyroid artery is identified and used as a landmark. The suspected location of the RLN caudal to the artery is carefully explored using blunt dissection and an extremely meticulous surgical technique to obtain a bloodless field. Once the structure supposed to be the RLN is located,...
Identifying the parathyroid glands is of fundamental importance in thyroid and parathyroid surgery. We found that intravenous infusion of methylene blue was beneficial in intraoperative identification of the parathyroid glands in patients undergoing surgery for hyperparathyroidism as well as total and bilateral subtotal thyroidectomy. The technique is safe and easy to use, and it clearly reduces the operative time. We suggest that it be used routinely in thyroid and parathyroid surgery.
Functional neck dissection (FND) is a neck-functional, tumor-radical approach for the management of the neck in patients with head and neck cancer. Based on the anatomic knowledge of the lymphatic compartments of the neck, FND is a different surgical technique rather than a modification of the classic procedure described by Crile. From an oncologic viewpoint, FND is a relatively safe operation to treat the cervical spread from head and neck cancer as long as the indications and technical details are carefully followed. In this report, based on our experience with more than 1,000 FNDs, we analyze the history and the philosophy of the operation.
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