Efficacy of intraoperative neural monitoring in remote access thyroidectomy

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    The efficacy of intraoperative neural monitoring (IONM) is not determined well in robotic and endoscopic thyroidectomy. The aim of this study was to assess the efficacy of IONM in remote access thyroidectomy.

    We studied 104 consecutive patients (122 nerves at risk, NAR) who underwent robotic or endoscopic thyroidectomy via a postauricular facelift approach (46 cases) or transoral approach (58 cases) with intermittent IONM. Preoperative and postoperative vocal cord mobility was examined with laryngofiberscopy.

    IONM was successful in 86/104 patients (82.7%). Success rate was was significantly lower in the early 15 cases than later cases in the transoral group (7/15 vs. 41/43, p<0.001). The standardized IONM procedure (checking V1, R1, R2, V2 signals) was performed in 32/42 NAR (76.2%) in the facelift group and 10/58 NAR (17.2%) in the transoral group (p<0.001). Of 104 cases, 4 temporary RLN palsy occurred postoperatively. Loss of signal occurred in 6/100 NAR. True positive, false positive and false negative occurred in 1, 5 and 1/100 NAR, respectively. Sensitivity, specificity, positive and negative predictive values of IONM were 50.0%, 94.9% 16.7% and 98.9%, respectively.

    The failure rate of IONM in robotic/endoscopic thyroidectomy was relatively high, and it is also relatively difficult to perform the standardized IONM procedure and follow the trouble shooting algorithm for evaluation of loss of signal due to limited working space and difficult surgical techniques. However, IONM is very effective in confirming the RLN and predicting function of the RLN in remote access thyroidectomy.


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