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Kim, Tufano, Chai, Barczynski, Makay, Wu, Berber, Sun, Dionigi, and The Korean Intraoperative Neural Monitoring Society (KINMoS): Intraoperative Neural Monitoring in Thyroid Surgery: Role and Responsibility of Surgeon
Review Article

J Endocr Surg. 2018;18(1):49-60.

Published online: 5 March 2018

DOI: https://doi.org/10.16956/jes.2018.18.1.49

Intraoperative Neural Monitoring in Thyroid Surgery: Role and Responsibility of Surgeon

Hoon Yub Kim1, Ralph P. Tufano2, Young Jun Chai3, Marcin Barczynski4, Özer Makay5, Che-Wei Wu6, Eren Berber7, Hui Sun8, Gianlorenzo Dionigi9; The Korean Intraoperative Neural Monitoring Society (KINMoS)

1KUMC Thyroid Center, Korea University Anam Hospital, Seoul, Korea

2Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

3Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea

4Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University College of Medicine, Kraków, Poland

5Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, İzmir, Turkey

6Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan

7Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH, USA

8Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Changchun, China

9Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

Correspondence to Hui Sun Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, 126 Xiantai St., Erdao Qu, Changchun 130033, China. E-mail: thyroidjl@163.com

Gianlorenzo Dionigi Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Via C. Valeria 1, Messina 98125, Italy. E-mail: gdionigi@unime.it

Received NaN 15 2017       Accepted NaN July 2018

Copyright © 2018 Korean Association of Thyroid and Endocrine Surgeons

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

Surgeons who introduce intraoperative neural monitoring (IONM) or a new IONM accessory, or related procedure in their practice should have completed relevant surgical training, possess operating privileges in the affected endocrine system, and be able to address anticipated complications. Surgeon responsibility in monitoring is dual component. First, technical component is using and setting up the IONM equipment correctly and understanding the inherent properties of the system to avoid an erroneous setup (e.g., no muscle relaxation, correct electrode placement, low impedance, etc.). Second, interpretive component is performing the monitoring able to distinguish between a true response versus an artifactual one. Organizations such as the International Neural Study Group and the Korean Intraoperative Neural Monitoring Society provide training courses for surgeon, as well as a means to certify levels of monitoring interpretative competence.

Keywords: Neural monitoring, Thyroid surgery, Recurrent laryngeal nerve, Training

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Fig. 1.
RLN anatomy studies from 1927 to 2015 (peer-reviewed papers, edited books, abstract meetings) (n=711). RLN = recurrent laryngeal nerve; IONM = intraoperative neural monitoring.
jes-18-49f1.tif
Fig. 2.
RLN anatomy studies from 1927 to 2015 (peer-reviewed papers, edited books, abstract meetings) (n=711). RLN = recurrent laryngeal nerve; IONM = intraoperative neural monitoring.
jes-18-49f2.tif
Fig. 3.
The different anatomical course of the right and left RLN. RLN = recurrent laryngeal nerve.
jes-18-49f3.tif
Fig. 4.
Up to 30 positional variations between RLN and inferior thyroid artery have been reported, in particular the 3 main variants to note are the retrovascular course, the antevascular course, and the intervascular course. RLN = recurrent laryngeal nerve.
jes-18-49f4.tif
Fig. 5.
Postoperative laryngeal examination represent the final asset of safety evaluation. EBD = energy based device; IONM = intraoperative neural monitoring; RF = radio frequency.
jes-18-49f5.tif
Table 1.
Intraoperative RLN injury causes

  • Section

  • Ligature

  • Mistake in hemostasis and dissection maneuvers

  • Stretch/traction

  • Compression/contusion/pressure

  • Thermal/electrical injury

  • Ischemia

RLN = recurrent laryngeal nerve.

Table 2.
Standardization of IONM in thyroid surgery
L1 Pre-operative laryngoscopy
V1 Test vagus nerve before identification of RLN
R1 Test RLN when it was identified at the tracheo-esophageal grove
R2 Test RLN after it was completely dissected from Berry's ligament
V2 Test vagus nerve after complete hemostasis
L2 Postoperative laryngoscopy

IONM = intraoperative neural monitoring; RLN = recurrent laryngeal nerve.

Table 3.
Structure of informed consent form for monitored thyroidectomy

  • Type of surgery

  • Surgical objectives

  • Consequence of thyroidectomy

  • Risk and benefits of doing nothing

  • Risks of thyroidectomy

  • Consequences of IONM

    • - Stage thyroidectomy (rate 2.5%)

    • - Technological failures (prevalence <1%)

IONM = intraoperative neural monitoring.

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