Prevention of recurrent laryngeal nerve injury in thyroid surgery
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RE VIE W AR T I CL E
Prevention of Recurrent Laryngeal Nerve Injury in Thyroid Surgery H. Markogiannakis, G.C. Zografos, A. Manouras
Abstract RLN injury is an important and rather frequent complication of thyroid surgery. Risk factors for nerve palsy should be considered. Deep knowledge of the surgical anatomy of the nerve is required to protect it from injury. Anatomical landmarks and surgical techniques that are helpful for investigation and identification of the RLN are very important. Exploration, visual identification and anatomical dissection of the nerve constitute the gold standard technique to prevent its injury. Key words: Recurrent laryngeal nerve; paresis; paralysis; thyroidectomy
Introduction
Review
The recurrent laryngeal nerve (RLN) was initially reported in the 2nd century AD [1]. Galen was the first to describe its anatomy, route and function, demonstrating its highly significant role in voice [1]. RLN injury results in variable changes in phonation, swallowing and breathing which may have an important impact on a patient's life [2-6]. It is a relatively frequent complication of thyroid surgery with a reported incidence that ranges from 0 to 4% and from 0 to 15% regarding permanent and transient injury, respectively [2-7]. One of the most challenging topics addressed at the Spring Meeting of the Greek Association of Endocrine Surgeons, held on 8th and 9th of March 2014 in Athens, Greece, titled “Recommendations for guidelines development on thyroid surgery – 1st Scientific Meeting”, was the value of exploration, visual identification and dissection of the RLN in thyroid surgery. The following three main questions were addressed during the literature review and discussion: (a) Should searching/exploration and visual identification of the RLN be performed in all cases during thyroid surgery or not? (b) Should dissection of the RLN be performed in all cases during thyroidectomy or not? and (c) Should dissection of the RLN be extensive or limited?
(i) Studies
H. Markogiannakis, G.C. Zografos, A. Manouras Endocrine Surgery Unit, 1st Department of Propaedeutic Surgery, Hippocratio Hospital, University of Athens, Athens Medical School, Greece Corresponding Author: Haridimos Markogiannakis 239 Aristeidou street, Kallithea, 17673, Athens, Greece, Tel.: 0030 6976 788806, Fax: 0030 213 2088293 e-mail: [email protected] Received 10 Jan 2015; Accepted 10 Feb 2015 Hellenic Journal of Surgery 87
Thorough literature research revealed 1035 papers. Following careful evaluation, 125 articles published in the English language were finally identified as directly related to the value of exploration, visual identification and dissection of the RLN in thyroidectomy. These publications were analyzed for the purpose of the present review. Interestingly, the first article was published in 1927 [8]. In a prospective study, Steurer et al. reported a temporary RLN palsy rate of 3.4% in benign and 7.2% in malignant thyroid disease; the rates for permanent palsy were 0.3% and 1.2%, respectively [5]. They found that
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