Int J Thyroidol.  2018 Nov;11(2):109-116. 10.11106/ijt.2018.11.2.109.

Development of the Novel Intraoperative Neuromonitoring for Thyroid Surgery

• Sung ES
• Lee BJ

• KMID: 2448980
• DOI: http://doi.org/10.11106/ijt.2018.11.2.109

Abstract

It is very important to identify recurrent laryngeal nerve (RLN) and prevent RLN injury during thyroid surgery. The intraoperative neuromonitoring (IONM) for the prevention of RLN injury is a useful method because it can identify the location and status of RLN and predict postoperative vocal cord function easily. The IONM consists of a stimulating side that applies electrical stimulation to the nerve and a recording side that measures the surface electromyography (EMG) of the vocal cord muscle through electrode endotracheal tube. The nerve stimulator and surgical dissector are separate instruments. So, during IONM for the prevention of the RLN injury in conventional, endoscopic, or robotic thyroid surgery, repeated exchanging between surgical instruments and the nerve stimulator is inconvenient and time consuming. On the recording side, the accuracy of the electrode endotracheal tube which measures the EMG of the vocalis muscle can be affected by contact with between electrode and vocal fold and position change of patient. We would like to introduce recent several researches to overcome the current limitations of IONM.

Keyword

Thyroid surgery; Intraoperative neuromonitoring; Recurrent laryngeal nerve; Attachable nerve stimulator; Surface bio-pressure sensor

MeSH Terms

Electric Stimulation
Electrodes
Electromyography
Humans
Laryngeal Muscles
Methods
Recurrent Laryngeal Nerve
Surgical Instruments
Thyroid Gland*
Vocal Cords

Figure

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  Fig. 1 This is a photograph that automatic periodic stimulation (APS) wraps the left vagus nerve. It can periodically stimulate the vagus nerve to check the laryngeal nerve status in real-time.

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  Fig. 2 A nerve probe composed of magnets. The developed nerve probe (below), which is a magnetically deformed conventional nerve probe (top), can be easily attached to and detached from a metallic surgical instrument.

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  Fig. 3 Endoscopic or robotic nerve probe. A conventional nerve probe was deformed (A) and connected to an endoscopic or robotic surgical instrument (B) to the site where the electrocautery was connected.

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  Fig. 4 A nerve probe attached to an energy based devices. Authors attached a nerve probe to the inactive blade of the harmonic focus (A) and the lower blade of the LigaSure (B).

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  Fig. 5 A laryngeal electromyography electrodes. (A) Medtronic electrode endotracheal tube. (B) Inomed laryngeal adhesive electrode.

Reference

1. Munch S, deKryger L. A piece of my mind. Moral wounds: complicated complications. JAMA. 2001; 285(9):1131–1132.

2. Chiang FY, Wang LF, Huang YF, Lee KW, Kuo WR. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery. 2005; 137(3):342–347.

3. Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW. The mechanism of recurrent laryngeal nerve injury during thyroid surgery--the application of intraoperative neuromonitoring. Surgery. 2008; 143(6):743–749.

4. Randolph GW, Dralle H, Abdullah H, Barczynski M, Bellantone R, et al. International Intraoperative Monitoring Study Group. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011; 121:Suppl 1. S1–S16.

5. Chiang FY, Lu IC, Chen HC, Chen HY, Tsai CJ, Lee KW, et al. Intraoperative neuromonitoring for early localization and identification of recurrent laryngeal nerve during thyroid surgery. Kaohsiung J Med Sci. 2010; 26(12):633–639.

6. Dionigi G, Wu CW, Kim HY, Rausei S, Boni L, Chiang FY. Severity of recurrent laryngeal nerve injuries in thyroid surgery. World J Surg. 2016; 40(6):1373–1381.

7. Dionigi G, Alesina PF, Barczynski M, Boni L, Chiang FY, Kim HY, et al. Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring. Surg Endosc. 2012; 26(9):2601–2608.

8. Kim WW, Kim JS, Hur SM, Kim SH, Lee SK, Choi JH, et al. Is robotic surgery superior to endoscopic and open surgeries in thyroid cancer? World J Surg. 2011; 35(4):779–784.

9. Lee J, Nah KY, Kim RM, Ahn YH, Soh EY, Chung WY. Differences in postoperative outcomes, function, and cosmesis: open versus robotic thyroidectomy. Surg Endosc. 2010; 24(12):3186–3194.

10. Mourad M, Rulli F, Robert A, Scholtes JL, De Meyer M, De Pauw L. Randomized clinical trial on Harmonic Focus shears versus clamp-and-tie technique for total thyroidectomy. Am J Surg. 2011; 202(2):168–174.

11. Ruggiero R, Gubitosi A, Conzo G, Gili S, Bosco A, Pirozzi R, et al. Sutureless thyroidectomy. Int J Surg. 2014; 12:Suppl 1. S189–S193.

12. Phillips CK, Hruby GW, Durak E, Lehman DS, Humphrey PA, Mansukhani MM, et al. Tissue response to surgical energy devices. Urology. 2008; 71(4):744–748.

13. Wu CW, Chai YJ, Dionigi G, Chiang FY, Liu X, Sun H, et al. Recurrent laryngeal nerve safety parameters of the harmonic focus during thyroid surgery: porcine model using continuous monitoring. Laryngoscope. 2015; 125(12):2838–2845.

14. Dionigi G, Chiang FY, Kim HY, Randolph GW, Mangano A, Chang PY, et al. Safety of LigaSure in recurrent laryngeal nerve dissection-porcine model using continuous monitoring. Laryngoscope. 2017; 127(7):1724–1729.

15. Kwak HY, Dionigi G, Kim D, Lee HY, Son GS, Lee JB, et al. Thermal injury of the recurrent laryngeal nerve by THUNDERBEAT during thyroid surgery: findings from continuous intraoperative neuromonitoring in a porcine model. J Surg Res. 2016; 200(1):177–182.

16. Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A. German IONM Study Group. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008; 32(7):1358–1366.

17. Chiang FY, Lu IC, Chang PY, Dionigi G, Randolph GW, Sun H, et al. Comparison of EMG signals recorded by surface electrodes on endotracheal tube and thyroid cartilage during monitored thyroidectomy. Kaohsiung J Med Sci. 2017; 33(10):503–509.

18. Tsai CJ, Tseng KY, Wang FY, Lu IC, Wang HM, Wu CW, et al. Electromyographic endotracheal tube placement during thyroid surgery in neuromonitoring of recurrent laryngeal nerve. Kaohsiung J Med Sci. 2011; 27(3):96–101.

19. Lu IC, Chu KS, Tsai CJ, Wu CW, Kuo WR, Chen HY, et al. Optimal depth of NIM EMG endotracheal tube for intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroidectomy. World J Surg. 2008; 32(9):1935–1939.

20. Wu CW, Wang MH, Chen CC, Chen HC, Chen HY, Yu JY, et al. Loss of signal in recurrent nerve neuromonitoring: causes and management. Gland Surg. 2015; 4(1):19–26.

21. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010; 34(2):223–229.

22. Kandil E, Mohsin K, Murcy MA, Randolph GW. Continuous vagal monitoring value in prevention of vocal cord paralysis following thyroid surgery. Laryngoscope. 2018; 128(10):2429–2432.

23. Dionigi G, Donatini G, Boni L, Rausei S, Rovera F, Tanda ML, et al. Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal. Int J Surg. 2013; 11:Suppl 1. S44–S46.

24. Wu CW, Dionigi G, Sun H, Liu X, Kim HY, Hsiao PJ, et al. Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: a porcine model. Surgery. 2014; 155(2):329–339.

25. Almquist M, Thier M, Salem F. Cardiac arrest with vagal stimulation during intraoperative nerve monitoring. Head Neck. 2016; 38(S1):E2419–E2E20.

26. Chiang FY, Lu IC, Chang PY, Sun H, Wang P, Lu XB, et al. Stimulating dissecting instruments during neuromonitoring of RLN in thyroid surgery. Laryngoscope. 2015; 125(12):2832–2837.

27. Sung ES, Lee JC, Shin SC, Choi SW, Jung DW, Lee BJ. Development of a novel detachable magnetic nerve stimulator for intraoperative neuromonitoring. World J Surg. 2018; 42(1):137–142.

28. Sung ES, Lee JC, Kim SH, Shin SC, Jung DW, Lee BJ. Development of an attachable endoscopic nerve stimulator for intraoperative neuromonitoring during endoscopic or robotic thyroidectomy. Otolaryngol Head Neck Surg. 2018; 158(3):465–468.

29. Shin SC, Sung ES, Choi SW, Kim SD, Jung DW, Kim SH, et al. Feasibility and safety of nerve stimulator attachment to energy-based devices: a porcine model study. Int J Surg. 2017; 48:155–159.

30. Kim HY, Tufano RP, Randolph G, Barczynski M, Wu CW, Chiang FY, et al. Impact of positional changes in neural monitoring endotracheal tube on amplitude and latency of electromyographic response in monitored thyroid surgery: results from the porcine experiment. Head Neck. 2016; 38:Suppl 1. E1004–E1008.

31. Birkholz T, Saalfrank-Schardt C, Irouschek A, Klein P, Albrecht S, Schmidt J. Comparison of two electromyographical endotracheal tube systems for intraoperative recurrent laryngeal nerve monitoring: reliability and side effects. Langenbecks Arch Surg. 2011; 396(8):1173–1179.