Download PDF
CC BY-NC-ND 4.0 · Int Arch Otorhinolaryngol 2022; 26(02): e219-e225
DOI: 10.1055/s-0041-1731812
Original Article

Selecting the Right Plane of Dissection in Thyroidectomy: Along the Recurrent Laryngeal Nerve or the Thyroid Capsule? A Retrospective Analysis

Talat Waseem 
1   Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
,
Safia Zahir Ahmed
1   Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
,
Fatima Tuz Zahara
1   Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
,
Muhammad Hasham Ashraf
1   Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
,
Khwaja Muhammad Azim
1   Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Introduction Total thyroidectomy remains highly technical, with a significant risk of recurrent laryngeal nerve (RLN) compromise and hypoparathyroidism. After identifying RLN, at the level of the ligament of Berry, local factors may compel the surgeon to either dissect along the nerve or the thyroid capsule.

Objective The objective of the present study is to compare these two approaches in terms of outcomes and complication rates.

Methods This is a retrospective analysis from September, 2013 to April 2019 of 511 consecutive patients undergoing thyroidectomy. General demographics and disease parameters were recorded. At the discretion of the surgeon and according to the demands of the local operative factors, the patients either had dissection along the RLN or along the thyroid capsule. Perioperative and postoperative parameters such as blood loss, duration of surgery, hospital stay, pain scores, analgesia requirements and complications were recorded. The groups were compared with the Pearson chi-squared test or with the Fisher exact test. A p-value < 0.05 was considered statistically significant.

Results The incidence of transient hypocalcaemia and transient RLN compromise were higher when dissection was performed along the nerve as opposed to the plane along the thyroid capsule. Other parameters including operative time, hospital stay, pain scores, analgesia requirement, wound infection, seroma, hemorrhage, and recurrence did not differ between the groups. Subgroup analysis of the patients who presented with complications showed that local factors, malignancy, and extent of surgery correlated positively with complications when dissected along the RLN.

Conclusion Dissection along the capsule of the thyroid during thyroidectomy is a safer plane in terms of low rate of transient RLN injury and hypoparathyroidism as opposed to dissection along the nerve.

Keywords

dissection - thyroidectomy - plane of dissection - recurrent laryngeal nerve injury - hypoparathyroidism


Publication History

Received: 20 August 2020

Accepted: 02 January 2021

Article published online:
23 August 2021

© 2021. Fundação Otorrinolaringologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Hannan SA. The magnificent seven: a history of modern thyroid surgery. Int J Surg 2006; 4 (03) 187-191
    CrossrefPubMedGoogle Scholar
  • 2 Seybt MW, Terris DJ. Outpatient thyroidectomy: experience in over 200 patients. Laryngoscope 2010; 120 (05) 959-963 http://www.ncbi.nlm.nih.gov/pubmed/20422690 . Cited 2020 Jun 17
    CrossrefPubMedGoogle Scholar
  • 3 Conzo G, Avenia N, Bellastella G. et al. The role of surgery in the current management of differentiated thyroid cancer. Vol. 47. Endocrine. Humana Press Inc.; 2014: 380-8
    Google Scholar
  • 4 Duclos A, Peix JL, Colin C. et al; CATHY Study Group. Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ 2012; 344 (7843): 1-11
    CrossrefPubMedGoogle Scholar
  • 5 Sarı S, Erbil Y, Sümer A. et al. Evaluation of recurrent laryngeal nerve monitoring in thyroid surgery. Int J Surg 2010; 8 (06) 474-478
    CrossrefPubMedGoogle Scholar
  • 6 Lee MS, Lee UY, Lee JH, Han SH. Relative direction and position of recurrent laryngeal nerve for anatomical configuration. Surg Radiol Anat 2009; 31 (09) 649-655
    CrossrefPubMedGoogle Scholar
  • 7 Hayward NJ, Grodski S, Yeung M, Johnson WR, Serpell J. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg 2013; 83 (1-2): 15-21
    CrossrefPubMedGoogle Scholar
  • 8 Serpell JW, Lee JC, Yeung MJ, Grodski S, Johnson W, Bailey M. Differential recurrent laryngeal nerve palsy rates after thyroidectomy. Surgery 2014; 156 (05) 1157-1166
    CrossrefPubMedGoogle Scholar
  • 9 Tsai S-H, Chien S-C, Nguyen P-A. et al. Incidences of Hypothyroidism Associated With Surgical Procedures for Thyroid Disorders: A Nationwide Population-Based Study. Front Pharmacol 2019; 10: 1-8
    CrossrefPubMedGoogle Scholar
  • 10 Kaisha W, Wobenjo A, Saidi H. Topography of the recurrent laryngeal nerve in relation to the thyroid artery, Zuckerkandl tubercle, and Berry ligament in Kenyans. Clin Anat 2011; 24 (07) 853-857
    CrossrefPubMedGoogle Scholar
  • 11 Antakia R, Edafe O, Uttley L, Balasubramanian SP. Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis. Thyroid 2015; 25 (01) 95-106
    CrossrefPubMedGoogle Scholar
  • 12 Gray SW, Skandalakis JE, Akin Jr JT. Embryological considerations of thyroid surgery: developmental anatomy of the thyroid, parathyroids and the recurrent laryngeal nerve. Am Surg 1976; 42 (09) 621-628
    Google Scholar
  • 13 Rulli F, Ambrogi V, Dionigi G. et al. Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring. Acta Otorhinolaryngol Ital 2014; 34 (04) 223-229
    PubMedGoogle Scholar
  • 14 Aytac B, Karamercan A. Recurrent laryngeal nerve injury and preservation in thyroidectomy. Saudi Med J 2005; 26 (11) 1746-1749
    PubMedGoogle Scholar
  • 15 Page C, Peltier J, Charlet L, Laude M, Strunski V. Superior approach to the inferior laryngeal nerve in thyroid surgery: anatomy, surgical technique and indications. Surg Radiol Anat 2006; 28 (06) 631-636
    CrossrefPubMedGoogle Scholar
  • 16 Sreejayan MP, Arun S, Jose J. Inferior Approach: a Safe Method for Identification of Recurrent Laryngeal Nerve During Thyroidectomy. Indian J Surg 2019; 81 (05) 474-478
    CrossrefGoogle Scholar
  • 17 Patoir A, Payet C, Peix J-L. et al; CATHY Study Group. Determinants of operative time in thyroid surgery: A prospective multicenter study of 3454 thyroidectomies. PLoS One 2017; 12 (07) 1-11 . Available from: https://dx.plos.org/10.1371/journal.pone.0181424
    CrossrefPubMedGoogle Scholar
  • 18 Hemmaoui B, Bouaiti EA, Sahli M. et al. [The inferior laryngeal nerve: anatomical and surgical considerations about 60 thyroidectomy]. Pan Afr Med J 2019; 33: 1-5
    PubMedGoogle Scholar
  • 19 D'Orazi V, Sacconi A, Trombetta S. et al. May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score. BMC Surg 2019; 18 (Suppl. 01) 1-8
    Google Scholar
  • 20 Wong KP, Mak KL, Wong CKH, Lang BHH. Systematic review and meta-analysis on intra-operative neuro-monitoring in high-risk thyroidectomy. Int J Surg 2017; 38: 21-30
    CrossrefPubMedGoogle Scholar
  • 21 Vieni S, Graceffa G, Rizzo GEM, Latteri F, Latteri MA, Cipolla C. An evaluation score of the difficulty of thyroidectomy considering operating time and preservation of recurrent laryngeal nerve. Updates Surg 2019; 71 (03) 569-577
    CrossrefPubMedGoogle Scholar
  • 22 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 (03) 342-347
    CrossrefPubMedGoogle Scholar
  • 23 Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surgery 2003; 133 (02) 180-185
    CrossrefPubMedGoogle Scholar
  • 24 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 (07) 1358-1366
    CrossrefPubMedGoogle Scholar
  • 25 Liu JB, Sosa JA, Grogan RH. et al. Variation of thyroidectomy-specific outcomes among hospitals and their association with risk adjustment and hospital performance. JAMA Surg 2018; 153 (01) 1-10
    CrossrefGoogle Scholar
  • 26 Serpell JW, Lee JC, Chiu WK, Edwards G. Stressing the recurrent laryngeal nerve during thyroidectomy. ANZ J Surg 2015; 85 (12) 962-965
    CrossrefPubMedGoogle Scholar