Evaluation of the Learning Curve for Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerves in Thyroid Surgery*
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Intraoperative neuromonitoring facilitates identification of the recurrent laryngeal nerves (RLN) and allows for predicting their postoperative function. Nevertheless, the outcome of thyroid surgery monitoring is affected by both the experience of the operator and his mastering of the technique.The aim of the study was the assessment of the learning curve for intraoperative RLN neuromonitoring.Material and methods. The prospective analysis included 100 consecutive thyroid operations performed by a single surgeon during implementation of RLN neuromonitoring in a district surgical ward in Staszów. RLN neuromonitoring was performed in keeping with the recommendations of the International Neural Monitoring Study Group using a C2 NerveMonitor (Inomed, Germany). The outcomes of initial 50 procedures (group I: 08/2012-07/2013) were compared with the results of subsequent 50 operations (group II: 08/2013-07/2014). The evaluation included demographic and intraoperative data along with predictive value of the method and complications.Results. In group II as compared to group I, a significant reduction of operative time was noted (102.1±19.4 vs 109.9±19; p=0.045), along with an increased percentage of identified RLNs (99% vs 89.2%; p=0.006), a decreased percentage of correction-requiring technical errors (8% vs 24%; p=0.029), an improved negative predictive (99% vs 89.3%; p<0.001) and positive value (75% vs 55.6%; p<0.001), as well as a decreased percentage of RLN injuries (3% vs 14%; p=0.006).Conclusions. Mastering the technique of intraoperative RLN neuromonitoring in thyroid surgery requires the surgeon to perform independently approximately 50 monitored procedures, what allows for achieving the predictive value of the method that is comparable to outcomes published by referral centers.
1 - 3 - 2015
2 - 11 - 2014
- 1. Lahey FH: Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy. Surg Gynecol Obstet 1938; 66: 775-77.
- 2. Rieddell V: Thyroidectomy: prevention of bilateral recurrent laryngeal nerve palsy: results of identification of the nerve over 23 consecutive years (1946 - 1969) with description of an additional safety measure. Br J Surg 1970; 57: 1-11.
- 3. Jatzko GR, Lisborg PH, Müller MG et al.: Recurrent laryngeal nerve palsy after thyroid operations: principal nerve identification and literature review. Surgery 1994; 115: 139-44.
- 4. Hermann M, Alk G, Roka R et al.: Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27.000 nerves at risk. Ann Surg 2002; 235: 261-68.
- 5. Barczyński M, Konturek A, Stopa M et al.: Totalthyroidectomy for benign thyroid disease: is it really worthwhile? Ann Surg 2011; 254: 724-29.[WoS]
- 6. Shedd DP, Burget GC: Identification of the recurrent laryngeal nerve. Arch Surg 1966; 92: 861-64.
- 7. Dralle H, Sekulla C, Lorenz K et al.: withGerman IONM Study Group. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg 2008; 32: 1358-66.[WoS]
- 8. Randolph GW, Dralle H, International Nerve Monitoring Study Group et al.: Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 2011; 121 Suppl 1: S1-16.[WoS]
- 9. Barczyński M, Randolph GW, Cernea CR et al.: External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery International Neural Monitoring Study Group standards guideline statement. Laryngoscope 2013; 123 Suppl 4: S1-14.[WoS]
- 10. B arczyński M, Konturek A, Cichoń S: Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 2009; 96: 240-46.
- 11. B arczyński M, Konturek A, Pragacz K et al.: Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg 2014; 38: 599-606.[WoS]
- 12. D ralle H, Sekulla C, Lorenz K et al.: Loss of the nerve monitoring signal during bilateral thyroid surgery. Br J Surg 2012; 99: 1089-95.
- 13. Melin M, Schwarz K, Lammers BJ et al.: IONMguided goiter surgery leading to two-stage thyroidectomy - indication and results. Langenbecks Arch Surg 2013; 398: 411-18.[WoS]
- 14. S nyder S, Hendricks J: Introperative neurophysiology testing of the RLN: plaudits and pitfalls. Surgery 2005; 138: 1183-92.
- 15. Chan WF, Lo CY: Pitfalls of intraoperative neuromonitoring for predicting postoperative recurrent laryngeal nerve function during thyroidectomy. World J Surg 2006; 30: 806-12.
- 16. Dionigi G, Bacuzzi A, Barczyński M et al.: Implementation of systematic neuromonitoring training for thyroid surgery. Updates Surg 2011; 63: 201-07.
- 17. J onas J, Bãhr R: Intraoperatives Neuromonitoring des Nervuslaryngeusrecurrens - Ergebnisse und Lernkurve. Zentralbl Chir 2006; 131: 443-48.
- 18. D ionigi G, Bacuzzi A, Boni L et al.: What is the learning curve for intraoperative neuromonitoring in thyroid surgery? Int J Surg 2008; 6 (Suppl 1): S7-12.
- 19. H ax AC, Majluf NS: Competitive cost dynamics: the experience curve. Interfaces 1982; 12: 50-61.
- 20. Kielar M: Neuromonitoring nerwów krtaniowych. Służba Zdrowia 2011; 60-68: 70-72.
- 21. B arczyński M, Konturek A, Stopa M et al.: Ocena wartości klinicznej śródoperacyjnego neuromonitoringu nerwu krtaniowego wstecznego w poprawie wyników leczenia operacyjnego zróżnicowanego raka tarczycy. Pol Przegl Chir 2011; 83: 362- 73.
- 22. H orne SK, Gal TJ, Brennan JA: Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy. Otolaryngol Head Neck Surg 2007; 136: 952-56.[WoS]
- 23. S turgeon C, Sturgeon T, Angelos P: Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons. World J Surg 2009; 33: 417-25.[WoS]
- 24. D uclos A, Lifante JC, Ducarroz S et al.: Influence of intraoperative neuromonitoring on surgeons' technique during thyroidectomy. World J Surg 2011; 35: 773-78.[WoS]
- 25. A lesina PF, Hinrichs J, Meier B et al.: Intraoperative neuromonitoring for surgical training in thyroid surgery: its routine use allows a safe operation instead of lack of experienced mentoring. World J Surg 2014; 38: 592-98.[WoS]
- 26. S teurer M, Passler C, Denk DM et al.: Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 2002; 112: 124-33.
- 27. Chan WF, Lang BHH, Lo CY: The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: A comparative study on 1000 nerves at risk. Surgery 2006; 140: 866-73.
- 28. Chiang FY, Lu IC, Kuo WR et al.: The mechanism of recurrent laryngeal nerve injury during thyroid surgery: the application of intraoperative neuromonitoring. Surgery 2008; 143: 743-49.
- 29. S nyder SK, Lairmore TC, Hendricks JC et al.: Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg 2008; 206: 123-30.
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