Skip to main content

Advertisement

SpringerLink
Log in

Application of transoral continuous intraoperative neuromonitoring in natural orifice transluminal endoscopic surgery for thyroid disease: a preliminary study

  • New Technology
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The novel concept of continuous intraoperative neuromonitoring (Cont-IONM) through stimulation of the vagal nerve has been used in thyroidectomies to prevent imminent injury of the recurrent laryngeal nerve (RLN). This article reports on this technology and the results of using transoral Cont-IONM in natural orifice transluminal endoscopic surgery for thyroid disease.

Methods

Cont-IONM of the RLN was achieved through automatic cyclical stimulation of the vagal nerve using a C2 monitor and delta stimulating electrode. During the operation, three vestibular incisions were made, and the stimulating electrode was transorally inserted, with its cable line lying outside the trocar. The vagal nerve was gently dissected, looped, and then enveloped by the electrode cuff. Electromyography (EMG) of the vocalis muscle was performed, and the alarm was set to activate when the EMG amplitude reduced by 50% and latency was prolonged by 10%. Demographic data and outcome variables, including incremental time required to achieve Cont-IONM, were obtained.

Results

A total of 20 patients (28 nerves at risk) undergoing a transoral endoscopic thyroidectomy vestibular approach were enrolled in this study. All Cont-IONM procedures were successfully completed. In all patients, the stimulation was set at 0.7 milliamps every 1 s, and Cont-IONM use was unassociated with any untoward neural, cardiovascular, or gastrointestinal sequelae. On average, the ipsilateral Cont-IONM procedure required 10.33 ± 2.57 min to complete. Except for one instance, no significant problems occurred with electrode displacement. In one patient, a combined EMG event occurred, which improved after releasing the thyroid retractor, and the patient had no vocal cord paralysis postoperatively.

Conclusion

Cont-IONM is feasible and safe to use during transoral endoscopic thyroidectomies and may assist in the early detection of adverse EMG changes, thereby preventing paralysis of the RLNs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, Brauckhoff M, Carnaille B, Cherenko S, Chiang FY, Dionigi G, Finck C, Hartl D, Kamani D, Lorenz K, Miccolli P, Mihai R, Miyauchi A, Orloff L, Perrier N, Poveda MD, Romanchishen A, Serpell J, Sitges-Serra A, Sloan T, Van Slycke S, Snyder S, Takami H, Volpi E, Woodson G (2011) Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 121(Suppl 1):S1–S16

    Article  PubMed  Google Scholar 

  2. Shedd DP, Burget GC (1966) Identification of the recurrent laryngeal nerve. Arch Surg 92:861–864

    Article  CAS  PubMed  Google Scholar 

  3. Ghani U, Assad S (2016) Role of intraoperative nerve monitoring during parathyroidectomy to prevent recurrent laryngeal nerve injury. Cureus 8:e880

    PubMed  PubMed Central  Google Scholar 

  4. Hermann M, Hellebart C, Freissmuth M (2004) Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg 240:9–17

    Article  PubMed  PubMed Central  Google Scholar 

  5. Caragacianu D, Kamani D, Randolph GW (2013) Intraoperative monitoring: normative range associated with normal postoperative glottic function. Laryngoscope 123:3026–3031

    Article  PubMed  Google Scholar 

  6. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW (2008) Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg 206:123–130

    Article  PubMed  Google Scholar 

  7. Liu XL, Wu CW, Zhao YS, Wang T, Chen P, Xin JW, Li SJ, Zhang DQ, Zhang G, Fu YT, Zhao LN, Zhou L, Dionigi G, Chiang FY, Sun H (2016) Exclusive real-time monitoring during recurrent laryngeal nerve dissection in conventional monitored thyroidectomy. Kaohsiung J Med Sci 32:135–141

    Article  PubMed  Google Scholar 

  8. Chiang FY, Lu IC, Chang PY, Sun H, Wang P, Lu XB, Chen HC, Chen HY, Kim HY, Dionigi G, Wu CW (2015) Stimulating dissecting instruments during neuromonitoring of RLN in thyroid surgery. Laryngoscope 125:2832–2837

    Article  PubMed  Google Scholar 

  9. Lamade W, Meyding-Lamade U, Buchhold C, Brauer M, Brandner R, Uttenweiler V, Motsch J, Klar E, Herfarth C (2000) First continuous nerve monitoring in thyroid gland surgery. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 71:551–557

    Article  CAS  PubMed  Google Scholar 

  10. Lorincz BB, Mockelmann N, Busch CJ, Hezel M, Knecht R (2016) Automatic periodic stimulation of the vagus nerve during single-incision transaxillary robotic thyroidectomy: feasibility, safety, and first cases. Head Neck 38:482–485

    Article  PubMed  Google Scholar 

  11. Witzel K, von Rahden BH, Kaminski C, Stein HJ (2008) Transoral access for endoscopic thyroid resection. Surg Endosc 22:1871–1875

    Article  CAS  PubMed  Google Scholar 

  12. Anuwong A (2016) Transoral endoscopic thyroidectomy vestibular approach: a series of the first 60 human cases. World J Surg 40:491–497

    Article  PubMed  Google Scholar 

  13. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, Hsieh MC, Wu CW (2010) Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg 34:223–229

    Article  PubMed  Google Scholar 

  14. Schneider R, Randolph GW, Sekulla C, Phelan E, Thanh PN, Bucher M, Machens A, Dralle H, Lorenz K (2013) Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck 35:1591–1598

    Article  PubMed  Google Scholar 

  15. Mattsson P, Hydman J, Svensson M (2015) Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve. Gland Surg 4:27–35

    PubMed  PubMed Central  Google Scholar 

  16. Paniello RC, Rich JT, Debnath NL (2015) Laryngeal adductor function in experimental models of recurrent laryngeal nerve injury. Laryngoscope 125:E67–E72

    Article  PubMed  Google Scholar 

  17. Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW (2008) The mechanism of recurrent laryngeal nerve injury during thyroid surgery–the application of intraoperative neuromonitoring. Surgery 143:743–749

    Article  PubMed  Google Scholar 

  18. Lamade W, Ulmer C, Seimer A, Molnar V, Meyding-Lamade U, Thon KP, Koch KP (2007) A new system for continuous recurrent laryngeal nerve monitoring. Minim Invasive Ther Allied Technol 16:149–154

    Article  PubMed  Google Scholar 

  19. Schneider R, Przybyl J, Pliquett U, Hermann M, Wehner M, Pietsch UC, Konig F, Hauss J, Jonas S, Leinung S (2010) A new vagal anchor electrode for real-time monitoring of the recurrent laryngeal nerve. Am J Surg 199:507–514

    Article  PubMed  Google Scholar 

  20. Lamade W, Ulmer C, Rieber F, Friedrich C, Koch KP, Thon KP (2011) New backstrap vagus electrode for continuous intraoperative neuromonitoring in thyroid surgery. Surg Innov 18:206–213

    Article  PubMed  Google Scholar 

  21. Lipton RJ, McCaffrey TV, Litchy WJ (1988) Intraoperative electrophysiologic monitoring of laryngeal muscle during thyroid surgery. Laryngoscope 98:1292–1296

    Article  CAS  PubMed  Google Scholar 

  22. Dionigi G, Donatini G, Boni L, Rausei S, Rovera F, Tanda ML, Kim HY, Chiang FY, Wu CW, Mangano A, Rulli F, Alesina PF, Dionigi R (2013) Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal. Int J Surg 11(Suppl 1):S44–S46

    Article  PubMed  Google Scholar 

  23. Friedrich C, Ulmer C, Rieber F, Kern E, Kohler A, Schymik K, Thon KP, Lamade W (2012) Safety analysis of vagal nerve stimulation for continuous nerve monitoring during thyroid surgery. Laryngoscope 122:1979–1987

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Han-Kun Chen, Chun-Liang Chen, and Kuo-Shan Wen and contributed equally as first authors.

Authors and Affiliations

  1. Department of General Surgery, Chi Mei Medical Center, Tainan, Taiwan

    Han-Kun Chen & Yi-Feng Lin

  2. Department of Surgery, Chi-Mei Hospital Chiali, Tainan, Taiwan

    Chun-Liang Chen

  3. Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan

    Kuo-Shan Wen

  4. Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan

    Kai-Yuan Lin

  5. Superintendent’s Office, Chi-Mei Hospital Chiali, Chiali 606, Shin-Hwa Road, Chiali District, Tainan, 722, Taiwan

    Yih-Huei Uen

Authors
  1. Han-Kun Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chun-Liang Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kuo-Shan Wen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yi-Feng Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kai-Yuan Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yih-Huei Uen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yih-Huei Uen.

Ethics declarations

Disclosure

All authors, Drs. Han-Kun Chen, Chun-Liang Chen, Yi-Feng Lin, Kai-Yuan Lin, Yih-Huei Uen, and Mr. Kuo-Shan Wen have no conflicts of interest or financial ties to disclose.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (WMV 310806 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, HK., Chen, CL., Wen, KS. et al. Application of transoral continuous intraoperative neuromonitoring in natural orifice transluminal endoscopic surgery for thyroid disease: a preliminary study. Surg Endosc 32, 517–525 (2018). https://doi.org/10.1007/s00464-017-5656-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-017-5656-0

Keywords

Search

Navigation