Recurrent Laryngeal Nerve Monitoring During Sutureless Total Thyroidectomy

Introduction: injury to cranial nerve represent 5% of negligence litigation against general surgeons and of all malpractice jury verdicts in endocrine surgery 60% accounts for recurrent nerve injuries and 15% for anoxic brain injuries from RLN injuries, unrecognized post-operatively. During Total Thyroidectomy is reported an incidence of failure to find the nerve in as many as (5-18%)of cases and if we think that routine identification of the RLN during thyroid surgery has reduced the injury rate from 10% to less than 4% and that the incidence of nerve paralysis was 3 to 4 times greater in cases where the nerve was not exposed than in cases where was routinely exposed, then we understand the importance of a clear identification during every thyroid dissectionObjective: in the present study the Authors assess the advantages of new technologies in thyroid surgery: The first objective is to prevent nerve injury by using an intra-operative continuous nerve-monitoring techniques; the second objective is to compare the real advantages of advanced coagulation devices in thyroid surgery.Materials and methods: Among a series of 440 thyroidectomies (jen 2004-feb 2006)performed during the last years, the Authors reviewed charts from two groups, selected by a double blind, statistically designed study and again compared in a multivariate analysis:1) 240 total thyroidectomies performed during the previous year using the traditional monopolar electrocautery,non-absorbable stitches for the upper and lower vascular pedicles and absorbable sutures for all other vascular knots.2) 140 total thyroidectomies performed by the conventional surgical technique, but with the use of the dedicated small bipolar electro thermal coagulator (Ligasure-Precise (R)). The Authors analyzed the incidence of major and minor complications, in order to evaluate the advantages of Precise (R). 3) Since 2006 in a double blind group selection of 70, we've performed Sutureless Thyroidectomy with continuous intra-operative nerve monitoring using dedicated endotracheal tube and avoiding use of neuromuscular blocking agents during anesthesiological procedure (only induction).The following parameters were analyzed: mean operative time, postoperative bleeding, seromas, post-operative stay, incidence of transient or definitive laryngeal nerve lesions, uni- or bilateral, incidence of permanent or transient hypocalcaemia, costs of the different proceduresResults: the incidence of major complications in thyroid surgery in the first two groups (total Thyroidectomy performed by Traditional Technique and by Advanced Devices - Precise), as well as compared with the data of the literature are absolutely over-imposable, only significative difference is a reduction of incidence of transient hypocalcaemia in the Precise group, but if we compare data of the 3(rd) group (NIM), we find a significative reduction of transient and permanent laryngeal nerve palsy incidence:. The reliability of the NIM signal was reflected by a specificity of 88,5% and when the neuromonitoring signal was changing during operation 8 cases, 12,5% of the patients suffered from transient vocal cord immobility and nobody had permanent loss of vocal cord function. There was one case of temporary RLN paralysis probably secondary to thermal spread that resolved 9 weeks postoperatively (temporary paralysis rate: 1.4% of patients). With regard to the duration of the operations, the middle operating time of the exeresis with Precise (R) in comparison to the conventional exeresis has been, certainly, reduced, in average, of 20 minutes around, time that the 3(rd) group (NIM) spend almost completely to search and to monitor the nerve.Discussion and conclusion: this new technology offers several advantages: (1) atraumatic; (2) easy to use; (3) continuous monitoring and audio feedback to the surgeon (4) works outside the operation field (5) high sensitiveness. NIM and Ligasure seem to be expensive and time consuming procedures, but the cost-analysis confirm that NIM+Ligasure have same cost (something less), almost same time (something less) and very probably less complications then traditional Total Thyroidectomy. Anyway we trust that this lack of money and time will surely paid back by an increased customer satisfaction and much less number of injury verdicts against surgeons.