Top

Langenbeck's Archives of Surgery

Published in:

Open Access 01-06-2017 | RAPID COMMUNICATIONS

The learning curve for intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery

Authors: Beata Wojtczak, Krzysztof Kaliszewski, Krzysztof Sutkowski, Mateusz Głód, Marcin Barczyński

Published in: Langenbeck's Archives of Surgery | Issue 4/2017

Abstract

Purpose

Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) is often used in thyroid surgery. However, this procedure is complex and requires a learning period to master the technique. The aim of the study was to evaluate the learning curve for IONM.

Methods

A 3-year period (2012–2014) of working with IONM (NIM3.0, Medtronic) was prospectively analyzed with a special emphasis on comparing the initial implementation phase in 2012 (101 patients, 190 RLNs at risk) with subsequent years of IONM use in 2013 (70 patients, 124 RLNs at risk) and 2014 (65 patients, 120 RLNs at risk).

Results

The rate of successful IONM-assisted RLN identification increased gradually over the 3-year study period (92.11 % in 2012 vs. 95.16 % in 2013 vs. 99.16 % in 2014; p = 0.022), with a corresponding decrease in the rate of technical problems (12.87, 4.3, and 4.6 %, respectively; p = 0.039). The rate of RLN injuries tended to decrease over time: 3.68, 1.55, and 0.83 %, respectively (p = 0.220). Between 2012 and 2014, increases in the sensitivity (71.4 vs. 100 %), specificity (98 vs. 99 %), positive predictive value (62.5 vs. 75 %), negative predictive value (98 vs. 100 %), and overall accuracy of IONM (97.4 vs. 99.6 %) were observed (p = 0.049). Increasing experience with IONM resulted in more frequent utilization of total thyroidectomy (92 % in 2012 vs. 100 % in 2013–2014; p = 0.004).

Conclusions

There was a sharp decrease in the number of technical problems involving equipment setup from 2012 to 2014.

Randolph GW, Dralle H, International Nerve Monitoring Study Group (2006) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 121(suppl 1):S1–16. doi:10.1002/lary.21119

Randolph GW, Kamani D (2014) Intraoperative neural monitoring in thyroid cancer surgery. Langenbacks Arch Surg 399:199–207. doi:10.1007/s00423-013-1141-y CrossRef

Melin M, Schwarz K, Lammers BJ, Goretzki PE (2013) IONM-guided goiter surgery leading to two-stage thyroidectomy-indication and results. Langenbacks Arch Surg 393:411–418. doi:10.1007/s00423-012-1032-7 CrossRef

Jatzko GR, Lisborg PH, Muller MG, Vette VM (1994) Recurrent nerve palsy after thyroid operations-principal nerve identification and a literature review. Surgery 115:139–144PubMed

Hermann M, Alk G, Roka R, Glaser K, Freissmuth M (2002) Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon on more than 27,000 nerves at risk. Ann Surg 235:261–268CrossRefPubMedPubMedCentral

Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A, German IONM Study Group (2008) Intraoperative monitoring of the recurrent laryngeal nerve and thyroid surgery. World J Surg 32:1358–1366. doi:10.1007/s00268-008-9483-2 CrossRefPubMed

Shedd DP, Burget GC (1966) Identyfication of the recurrent laryngeal nerve. Arch Surg 92:861–864. doi:10.1001/archsurg.1966.01320240049010 CrossRefPubMed

Dionigi G, Bacuzzi A, Barczyński M, Biondi A, Chiang FY, Dralle H, Randolph GW, Rausei S, Sacco R, Sitges-Serra A (2011) Implementation of systematic neuromonitoring training for thyroid surgery. Updates Surg 63:201–207. doi:10.1007/s13304-011-0098 CrossRefPubMed

Dionigi G, Bacuzzi A, Boni L, Rovera F, Dionigi R (2008) What is the learning curve for intraoperative neuromonitoring in thyroid surgery? Int J Surg 6(Suppl 1):7–12. doi:10.1016/j.ijsu.2008.12.023 CrossRef

10.

Jonas J, Bahr R (2006) Intraoperative neuromonitoring of the recurrent laryngeal nerve—results and learning curve. Zentralbl Chir 131:443–448. doi:10.1055/s-2006-955453 CrossRefPubMed

11.

Pragacz K, Barczynski M (2015) Evaluation of the learning curve for intraoperative neural monitoring of the recurrent laryngeal nerves in thyroid surgery. Pol Przegl Chir 12:584–593. doi:10.1515/pjs-2015-0005

12.

Chan WF, Lo CY (2006) Pitfalls of intraoperative neuromonitoring for predicting postoperative recurrent laryngeal nerve function during thyroidectomy. World J Surg 30:806–812CrossRefPubMed

13.

Timmerman W, Hammelamnn W (2004) Thyroid surgery: neuromonitoring of the RLN during thyroid surgery. Dtsch Arztebl 101:7

14.

Snyder S, Hendricks J (2005) Intaoperative neurophysioloy testing of the RLN: plauds and pitfals. Surgery 138:1183–1192. doi:10.1016/j.surg.2005.08.027 CrossRefPubMed

15.

Chan WF, Lang BH, Lo CY (2006) The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 100 nerves at risk. Surgery 140:866–873. doi:10.1016/j.surg.2006.07.017 CrossRefPubMed

16.

Lorenz K, Abuazab M, Sekulla C, Schneider R, Nguyen Thanh P, Dralle H (2014) Results of intraoperative neuromonitoring in thyroid surgery and preoperative vocal cord paralysis. World J Surg 38:582–91. doi:10.1007/s00268-013-2402-1 CrossRefPubMed

17.

Barczynski M, Randolph GW, Carnea CR, Dralle H, Dionigi G, Alesina PF et al (2013) External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope 123(Suppl 4):S1–14. doi:10.1002/lary.24301 CrossRefPubMed

18.

Kielar M (2011) Neuromonitoring nerwów krtaniowych. Służba Zdrowia 68:70–72

19.

Pragacz K, Barczyński M (2014) Evaluation of implementation phase of intraoperative neural monitoring of the recurrent laryngeal nerves in thyroid surgery in a district hospital. Przegl Lek 71:532–536PubMed

20.

Duclos A, Lifante JC, Ducarroz S, Soardo P, Colin C, Peix JL (2011) Influence of intraoperative neuromonitoring on surgeons’ technique during thyroidectomy. World J Surg 35:773–778. doi:10.1007/s00268-011-0963-4 CrossRefPubMed

21.

Dionigi G, Bacuzzi A, Boni L, Rovera F, Rausei S, Frattini F, Dionigi R (2010) The technique of intraoperative neuromonitoring in thyroid surgery. Surg Technol Int 19:25–37. doi:10.1007/s13304-011-0098-z PubMed

22.

Carnea CR, Brandao LG, Brandao J (2012) Neuromonitoring in thyroid surgery. Curr Opin Otolaryngol Head Neck Surg 20:125–129. doi:10.1097/MOO.0b013e32834fa8e6 CrossRef

23.

Barczyński M, Konturek A, Cichoń S (2009) Randomized clinical trial of visualisation versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 96:240–246. doi:10.1002/bjs.6417 CrossRefPubMed

24.

Barczyński M, Konturek A, Cichoń S (2006) Value of intraoperative neuromonitoring in surgery for thyroid cancer in identification and prognosis of function of the recurrent laryngeal nerves. Endocrinol Pol 57:343–346

25.

Eisele DW (1996) Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 106:443–449CrossRefPubMed

26.

Dralle H, Stang A, Sekulla C, Rusner C, Lorenz K, Machens A (2014) Surgery for benign goiter in Germany: fewer operations, changed resectional strategy, fewer complications. Chirurg 85:236–245. doi:10.1007/s00104-013-2705-7 CrossRefPubMed

27.

Alesina PF, Hinrichs J, Meier B, Cho EY, Bolli M, Walz MK (2014) Intraoperative neuromonitoring for surgical training in thyroid surgery: its routine use allows a safe operation instead of lack of experienced mentoring. World J Surg 38:592–598. doi:10.1007/s00268-013-2372-3 CrossRefPubMed

28.

Tomoda C, Hirokawa Y, Uruno T, Takamura Y, Ito Y, Miya A, Kobayashi K, Matsuzuka F, Kuma K, Miyauchi A (2006) Sensitivity and specifity of intraoperative recurrent laryngeal nerve stimulation test for predicting vocal cord palsy after thyroid surgery. World J Surg 30:1230–1233CrossRefPubMed

Title: The learning curve for intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery
Authors: Beata Wojtczak
Krzysztof Kaliszewski
Krzysztof Sutkowski
Mateusz Głód
Marcin Barczyński
Publication date: 01-06-2017
Publisher: Springer Berlin Heidelberg
Published in: Langenbeck's Archives of Surgery / Issue 4/2017
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-016-1438-8

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

The learning curve for intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 4/2017

EMG changes during continuous intraoperative neuromonitoring with sustained recurrent laryngeal nerve traction in a porcine model

Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy

Effective downsizing but enhanced intratumoral heterogeneity following neoadjuvant sorafenib in patients with non-metastatic renal cell carcinoma

The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses

Primary liver resection for patients with cirrhosis and hepatocellular carcinoma: the role of surgery in BCLC early (A) and intermediate stages (B)

Increased carcinoembryonic antigen (CEA) following neoadjuvant chemotherapy predicts poor prognosis in patients that undergo hepatectomy for liver-only colorectal metastases