Published in:
01-05-2009 | Letter to the Editor
Reply to G. Dionigi’s letter: energy based devices and recurrent laryngeal nerve injury: the need for safer instruments
Published in: Langenbeck's Archives of Surgery | Issue 3/2009
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Proper training of the surgical team before these devices are used is essential because it is of paramount importance to maintain an adequate safety distance not only from recurrent laryngeal nerve (RLN) but also from other vital structures as the trachea. However, as reported by Bergenfelz [6], even with a distance exceeding the one recommended by the maker, the rate of transient RLN palsies was higher in patients submitted to surgery with HCS.
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In literature, there are no data about the new Harmonic Focus® device, which has a smaller tip than the traditional HCS scissor and an aluminum coating which, as reported in product leaflet, should further reduce heat dispersion. Moreover, results of the Ethicon® (Ethicon Endo Surgery INC, Cincinnati, OH, USA) study about safety margins close to the nerves are not available yet.
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Chan [7] in 2006 reported intraoperative neurophysiological monitoring (IONM) as not effective in preventing RLN injury, and Delbridge [8], the following year, added it is unuseful in resident training and considered it as a “technological toy” which can be harmful if viewed as a substitute of training by an experienced thyroid surgeon. Moreover, it is very expensive and not cost effective.
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The German study, the largest ever published about IONM, demonstrated that visual identification of the RLN is the gold standard for nerve protection in all types of thyroid surgery [9]; IONM may be useful only in special cases. The same group in 2008 reviewed world literature on this topic, trying to detect some evidence-based guidelines; they concluded the additional use of IONM did not result in significantly decreased rates of postoperative RLN palsies when compared to visual dissection [10].
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Probably, at least as long as new and hopefully safer devices are developed, near by the nerve, the safest hemostatic method is still represented by tiny stitches or vascular clips which, as pointed out by Prof. Dionigi, can even be removed.