Success rate and learning curve of intraoperative neural monitoring of the external branch of the superior laryngeal nerve in thyroidectomy

Choi, Hae Won; Ji, Yong Bae; Kim, Eugene; Kim, Kyu Nam; Tae, Kyung

doi:10.1002/hed.26895

Cited by 3 publications

(4 citation statements)

References 35 publications

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“…In literature the LC required for correct use of IONM is mutable and has been reported to be around 45-50 procedures. 14,15 In detail, it was seen that the variability is partly due to the experience of the surgeons, being longer for the more experienced, probably due to the difficulty in integrating a new skill into an already consolidated technique. Few authors have investigated how and to what extent the use of this tool influences the technique during thyroidectomy.…”

Section: Discussionmentioning

confidence: 99%

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery

Fassari,

Micalizzi,

Lelli

et al. 2024

Surg Innov

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Introduction Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy. Methods Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate. Results As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported. Conclusions The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.

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Section: Discussionmentioning

confidence: 99%

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery

Fassari,

Micalizzi,

Lelli

et al. 2024

Surg Innov

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“…In this study, the V1 signal of the contralateral RLN was measured in all patients, and there was no statistical difference compared with the signal value of the affected side (P>0.05) (Table 2). Because it is impossible to distinguish the RLN and VN based on their anatomical positions when monitoring the signals of the contralateral nerves, we can distinguish them based on the latency of the signal value of nerve monitoring (18)(19)(20)(21). The latency of the ipsilateral VN is slightly longer than that of the RLN, so the monitored nerve can be better identified intuitively.…”

Section: Discussionmentioning

confidence: 99%

“…Although some believe that experienced surgeons benefit less from IONM and that simple avoidance of the EBSLN is equally effective in protecting nerve function, detection of the EBSLN may be useful, especially in the above cases. The reported visual detection rate of EBSLN during thyroidectomy is 21.2–98.3%, but has significantly increased with the help of IONM ( 18 ). By separating the space of the SCM branches (between the sternal and clavicular heads), SMIA thyroidectomy pulls the sternal thyroid muscle upward and medially away from the surface of the gland, allowing the extreme surgical field to be fully exposed without cutting off the sternal thyroid muscle and increasing collateral damage.…”

Section: Discussionmentioning

confidence: 99%

The feasibility of laryngeal nerve protection during thyroidectomy using sternocleidomastoid intermuscular approach with intraoperative neuromonitoring: a case series and step-by-step description of surgical procedure

Fu¹,

Zhao²,

Sun³

et al. 2022

Gland Surg

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Background: Thyroid surgery is increasingly demanding in terms of cosmetic neck outcomes and protection of anterior neck function, so we have adopted an alternative sternocleidomastoid intermuscular approach (SMIA) for open/conventional thyroidectomy. The protection of recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve (EBSLN) is the key and difficult point in thyroid surgery.The aim of this study was to testify the feasibility of RLN and EBSLN functional protection during SMIA thyroidectomy with the intraoperative neuromonitoring.Methods: A total of 39 patients and 39 RLN and EBSLNs who underwent monitored SMIA thyroidectomy were included. Thyroid gland is revealed and excised anterior to the cervical sheath between the sternal and clavicular heads of the sternocleidomastoid muscle. Standardized intraoperative neuromonitoring (IONM) procedures and postoperative laryngeal examination were performed to audit the SMIA. Following the fourstep method, V1, R1, R2, and V2 were monitored and the signal values were recorded. Statistical analysis was used to evaluate the change of IONM amplitude of RLN, combined with the results of laryngoscopy before and after operation to determine the status of RLN. EBSLN injuries were identified from changes in cricothyroid muscle (CTM) twitch and EMG. SMIA video vignette is detailed.Results: All RLN and EBSLNs [17 on the left and 22 on the right] were monitored in 39 patients [5 men, 34 women; mean age 34.1±8.7 years; mean body mass index 22.5 (±3.0, 17.0-30.8)] undergoing SMIA. For RLN of the affected side, we compared the V2 and V1 (1,236±672 vs. 1,240±428, P=0.973) , R2 and R1(1,676±778 vs. 1,656±765, P=0.849) signals separately, and the results were not statistically different (P>0.05).Comparing the V1(1,240±428 vs. 1,309±395, P=0.601) signals of the bilateral recurrent laryngeal nerve, there was no statistical difference (P>0.05). CTM twitch and EMG were preserved. Conclusions:The SMIA technique appears feasible. RLN and EBSLN are easier to be exposed during thyroid surgery of SMIA, which is beneficial to the neuroprotection during the operation. At the same time, ^ ORCID: 0000-0003-4951-9703. it can protect the anterior cervical function and improve the cosmetic effect after operation.

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“…Since then, the use of this technique has become increasingly widespread and the number of centers performing operations with IONM continues to grow ( 74 , 75 ). Numerous publications show a high rate of RLN identification with IONM and several studies investigate the LC for IONM ( 76 - 82 ). However, no study focuses on how much the IONM use affects the surgeon’s LC.…”

Section: Methodsmentioning

confidence: 99%

Definition of learning curve for thyroidectomy: systematic review on the different approaches

Fassari¹,

Gurrado²,

Iossa³

et al. 2023

Gland Surg

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Background Thyroidectomy is one of the most common surgical procedures carried out worldwide and it has evolved in recent years with alternative approaches. With the advent of minimally invasive techniques, the learning curve (LC) concept has become a fundamental “dogma”. Methods A literature search, according to the PRISMA guidelines, was performed via PubMed (MEDLINE), Scopus, Cochrane Library, EMBASE, and Web of Science. Only studies assessing the learning process to thyroidectomy (including hemi- and total thyroidectomy), reporting a minimum of 30 procedures and describing clearly the minimum number of performances required to achieve proficiency and the main evaluation items used to establish it, were included. Conventional, endoscopic and robotic approaches were separately analyzed. Only English-language studies were considered. Results Forty-five relevant studies were selected for the analysis [respectively 16 concerning robotic thyroidectomy (RT), 22 endoscopic thyroidectomy (ET), 6 mini-invasive video assisted thyroidectomy (MIVAT), 1 conventional thyroidectomy (CT)]. The number of procedures required for a single surgeon to achieve competence and the parameters used to define surgical proficiency were fully investigated for each individual technique. Conclusions Our research shows how the current literature lacks an objective definition of the LC concept. The heterogeneity of analysis methodologies and parameters evaluated, the various surgical techniques and training background of single surgeons, make it impossible to draw univocal results. Future studies should consider confounding factors and establish criteria that should be consensually recognized in the assessment of surgical performances and skills.

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Success rate and learning curve of intraoperative neural monitoring of the external branch of the superior laryngeal nerve in thyroidectomy

Cited by 3 publications

References 35 publications

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery

The feasibility of laryngeal nerve protection during thyroidectomy using sternocleidomastoid intermuscular approach with intraoperative neuromonitoring: a case series and step-by-step description of surgical procedure

Definition of learning curve for thyroidectomy: systematic review on the different approaches

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