Approach to the recurrent laryngeal nerve in thyroid surgery

Yıl 2003, Cilt: 11 Sayı: 2, 46 - 51, 20.03.2003

Sinan Kocatürk Ünsal Erkam

Öz

Objectives: We evaluated our surgical approach to the identification of the recurrent laryngeal nerve RLN under the guidance of operation microscope and RLN dissections during thyroidectomy.Patients and Methods: Twenty-three patients 20 females, 3 males; mean age 37 years undergoing thy­ roidectomy were included in the study. Thirty RLN dis­ sections were performed, being unilateral in 16 patients, and bilateral in seven patients. The recurrent laryngeal nerveswere identifiedatthe inferior thoracic inlet with the use of the operation microscope having an ocular lens of 250 mm, followed by a total dissection up to the laryn­ geal entrance. Endoscopic laryngeal examinations were performed for vocal cord movements one day before surgery and postoperatively on days 1,3, and 7.Results: No abnormal vocal cord movements were detected preoperatively. Following surgery, none of the patients developed persistent RLN paralysis.Two patients exhibited transient vocal cord paralysis limitation in vocal cord movements . The use of the operation microscope for RLN dissections resulted in prolongation of the operation time ranging from 15 to 40 minutes for each side, which tended to decrease with enhanced experience of the surgeon.Conclusion: The use of the operation microscope enables safe RLN dissections during thyroidectomy operations.

Anahtar Kelimeler

Parathyroidectomy, recurrent laryngeal nerve/ anatomy & histology/injuries, thyroid diseases/surgery, thy­roid gland/blood supply, thyroidectomy

Tiroit cerrahisinde rekürrent larenjeal sinire yaklaşımımız

Öz

Amaç: Tiroidektomi yapılan olgularda rekürrent larengeal sinirin RLS tanınmasına yönelik mikroskobik yaklaflımımız ve RLS diseksiyonu ile ilgili komplikasyonlar değerlendirildi.Hastalar ve Yöntemler: Çalıflmaya tiroidektomi yapılan 23 hasta 20 kadın, 3 erkek; ort. yafl 37 alındı.On altı hastada tek taraflı, yedi hastada iki taraflı olmak üzere toplam 30 RLS diseksiyonu yapıldı. Tümolgularda, 250 mm oküler lens takılı ameliyat mikroskobu kullanılarak RLS inferior torasik giriflte bulunduve larenkse girifl yerine kadar total diseksiyon yapıldı. Hastalarda kord vokal hareketlerini değerlendirmeye yönelik endoskopik larenjeal muayenelerameliyattan bir gün önce ve ameliyat sonrası 1, 3 ve7. günlerde yapıldı.Bulgular: Ameliyattan önceki muayenelerde hiçbirhastada kord vokal hareket bozukluğu görülmedi.Ameliyat sonrasında kalıcı RLS paralizisine rastlanmazken, iki hastada geçici RLS parezisi kord vokalhareket kısıtlılığı gözlendi. Sinir diseksiyonununmikroskop ile yapılmasının ameliyat süresini tek sinir için 15-40 dakika arasında uzattığı görüldü; ancak bu sürenin cerrahın deneyimi arttıkça düfltüğügözlendi. Sonuç: Tiroidektomi sırasında ameliyat mikroskobukullanımının RLS diseksiyonunda güvenilir bir yaklaflım olduğu sonucuna varıldı

Anahtar Kelimeler

Paratiroidektomi, rekürrent larenjeal sinir, anatomi ve histoloji/yaralanma, tiroit hastalıkları/cerrahi, tiroit bezi/kan desteği, tiroidektomi

Kaynakça

• R a ffaelli M, Iacobone M, Henry JF. The “false” nonre c u r- rent inferior laryngeal nerve. Surgery 2000;128:1082-7.
• Summers GW. Thyroid and parathyroid surgery. In: Krespi YP, Ossoff RH, editors. Complications in head and neck surgery. Philadelphia: W. B. Saunders; 1992. p. 199-213.
• Eisele DW. Complications of thyroid surgery. In: Eisele DW, editor. Complications of head and neck surgery. 2nd ed. St. Louis: Mosby; 1993. p. 423-37.
• Sturniolo G, D'Alia C, Tonante A, Gagliano E, Taranto F, Lo Schiavo MG. The recurrent laryngeal nerve relat- ed to thyroid surgery. Am J Surg 1999;177:485-8.
• Kocatürk S, Özdemir N, İçöz G, Nuroğlu AE, Erkam Ü, Babila A. Bilateral kord vokal paralizilerinin Thor- nell tekniği ile cerrahi tedavisi: 15 yıllık deneyimimiz. KBB Bafl Boyun Cerrahisi Dergisi 2002;10:38-42.
• Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathy- roidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 2002;112:124-33.
• Pelizzo MR, Toniato A, Gemo G. Zuckerkandl’s tuber- culum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg 1998;187:333-6.
• Hermann M, Roka R, Richter B, Freissmuth M. Early relapse after operation for Graves' disease: postopera- tive hormone kinetics and outcome after subtotal, near-total, and total thyroidectomy. Surgery 1998;124: 894-900.
• Lore JM Jr, Kim DJ, Elias S. Preservation of the laryn- geal nerves during total thyroid lobectomy. Ann Otol Rhinol Laryngol 1977;86:777-88.
• Martensson H, Terins J. Recurrent laryngeal nerve palsy in thyroid gland surgery related to operations and nerves at risk. Arch Surg 1985;120:475-7.
• Sinclair IS. The risk to the recurrent laryngeal nerves in thyroid and parathyroid surgery. J R Coll Surg Edinb 1994;39:253-7.
• Scheuller MC, Ellison D. Laryngeal mask anesthesia with intraoperative laryngoscopy for identification of the recurrent laryngeal nerve during thyroidectomy. Laryngoscope 2002;112:1594-7.
• Nielsen TR, Andreassen UK, Brown CL, Balle VH, Thomsen J. Micro s u rgical technique in thyroid surg e r y - a 10-year experience. J Laryngol Otol 1998;11 2 : 5 5 6 - 6 0 .
• Timon CI, Rafferty M. Nerve monitoring in thyroid surgery: is it worthwhile? Clin Otolaryngol 1999;24: 487-90.
• Procacciante F, Picozzi P, Pacifici M, Picconi S, Ruggeri S, Fantini A, et al. Palpatory method used to identify the recurrent laryngeal nerve during thyroidectomy. World J Surg 2000;24:571-3.
• Thompson NW. Differentiated thyroid carcinoma in children. In: Robbins J, editor. Proceedings of a work- shop, Treatment of thyroid cancer in childhood. September 10-11, 1992; NIH, Bethesda, Maryland. p. 77-91.
• Sasou S, Nakamura S, Kurihara H. Suspensory liga- ment of Berry: its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head Neck 1998;20:695-8.
• Debry C, Schmitt E, Senechal G, Siliste CD, Quevauvilliers J, Renou G. Analyse des complications de la chiru rgie thyroidienne: paralysie re c u r rentielle et h y p o p a r a t h y roidie. Sur une serie de 588 cas. Ann Otolaryngol Chir Cervicofac 1995;11 2 : 2 11 - 7 .
• Randolph GW. Thyroid and parathyroid glands. In: Lee KJ, editor. Lee’s essential otolaryngology-head and neck surgery. 8th ed. New York: McGraw-Hill; 2002. p. 617-54.
• Wafae N, Vieira MC, Vorobieff A. The recurrent laryn- geal nerve in relation to the inferior constrictor muscle of the pharynx. Laryngoscope 1991;101:1091-3.
• Jatzko GR, Lisborg PH, Muller MG, Wette VM. R e c u r rent nerve palsy after thyroid operations-principal nerve identification and a literature re v i e w. Surg e r y 1 9 9 4 ; 11 5 : 1 3 9 - 4 4 .
• Aydoğan B, Kıroğlu F, Soylu L, Kıroğlu M, Çetik F, Akçalı Ç ve ark. Tiroid cerrahisi sonuçlarımız. KBB Bafl Boyun Cerrahisi Dergisi 1999;7:135-8.
• Nemiroff PM, Katz AD. Extralaryngeal divisions of the recurrent laryngeal nerve. Surgical and clinical signifi- cance. Am J Surg 1982;144:466-9.
• Keminger K, Depisch D. Surgery of the thyroid gland. In: Naumann HH. Head and neck surg e r y. Vol. 3, 2nd ed. New York: Thieme Medical Publishers; 1998. p. 421-42.