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Sánchez Roldán MÁ, Moncho D, Velasco M, Petriman EM, Duque H, Vilallonga R, Armengol M, González Ó. Role of the Laryngeal Adductor Reflex in the Prevention of Thermal Injury to the Recurrent Laryngeal Nerve in Thyroid Surgery: A Case Report. Head Neck 2025; 47:E46-E49. [PMID: 39692044 DOI: 10.1002/hed.28038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 09/19/2024] [Accepted: 12/05/2024] [Indexed: 12/19/2024] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) aims to detect and prevent iatrogenic damage during thyroid surgery. Mechanisms of injury include traction, heat damage, and nerve transection. Continuous IONM (C-IONM) techniques detect impending damage due to traction and heat related when they are still reversible. METHODS We present a 73-year-old woman who underwent a total thyroidectomy due to a goiter. The IONM included intermittent IONM (I-IONM) in combination with C-IONM using the laryngeal adductor reflex (LAR). The intraoperative neurophysiological signals recorded were correlated with the surgical maneuver and the postoperative evaluation. RESULTS During surgery, a significant decrease in left LAR amplitude was observed, coinciding with the use of the harmonic. After some corrective maneuvers, the intraoperative signals recovered, and the postoperative examination showed adequate VF function. CONCLUSIONS C-IONM of the RLN using the LAR can be a valuable tool for detecting and preventing thermal spread injury during thyroid surgery.
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Affiliation(s)
- M Ángeles Sánchez Roldán
- Clinical Neurophysiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Dulce Moncho
- Clinical Neurophysiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mercedes Velasco
- Department of Rehabilitation, Phoniatrics and Speech Therapy Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - E Madalina Petriman
- Department of Rehabilitation, Phoniatrics and Speech Therapy Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Héctor Duque
- Department of Anesthesiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ramón Vilallonga
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of General Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Armengol
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of General Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Óscar González
- Department of General Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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Stanković P, Bette M, Mandić R, Hoch S, Stuck BA, Wilhelm T. Safe distance from facial nerve for bipolar coagulation in parotid surgery-Animal study. Laryngoscope 2025; 135:1120-1126. [PMID: 39479954 DOI: 10.1002/lary.31883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Accepted: 10/14/2024] [Indexed: 11/02/2024]
Abstract
OBJECTIVE Currently no data exist on what distance from facial nerve (FN) it is safe to perform bipolar cautery (BC) in parotid surgery, although frequently performed. METHODS The degree of damage was measured using continuous intraoperative neuromonitoring (cIONM, NIM™ 3, Medtronic) in 16 Wistar rats. Amplitude drop of at least 50% (A50) or a loss of signal (LOS) in the cIONM was defined as harmful; BC was performed in power range 20-60 W. RESULTS BC ≤30 W did not cause LOS (0/14 nerves). When applying 35 W, A50 occurred at 4 mm from FN and LOS was noted in 1 of 5 nerves. BC at a power of 40 to 60 W demonstrated LOS in all nerves (12/12) at a 5 mm distance. CONCLUSION BC up to 30 W can be safely applied up to 3 mm distance from FN. 40 to 60 W should be avoided and used only at a distance of over 6 mm from FN. LEVEL OF EVIDENCE NA/animal study. Laryngoscope, 135:1120-1126, 2025.
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Affiliation(s)
- Petar Stanković
- Department of Otolaryngology, Head/Neck and Facial Plastic Surgery, Sana Kliniken Leipziger Land, Borna, Germany
| | - Michael Bette
- Institute of Anatomy and Cell Biology, Philipps-Universität Marburg, Marburg, Germany
| | - Robert Mandić
- Department of Otolaryngology, Head and Neck Surgery, Philipps-Universität Marburg, Marburg, Germany
| | - Stephan Hoch
- Department of Otolaryngology, Head and Neck Surgery, Philipps-Universität Marburg, Marburg, Germany
| | - Boris A Stuck
- Department of Otolaryngology, Head and Neck Surgery, Philipps-Universität Marburg, Marburg, Germany
| | - Thomas Wilhelm
- Department of Otolaryngology, Head/Neck and Facial Plastic Surgery, Sana Kliniken Leipziger Land, Borna, Germany
- Medical Faculty, Philipps-Universität Marburg, Marburg, Germany
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Huang TY, Wang SW, Tseng HY, Randolph GW, Dionigi G, Lin YC, Chuang CH, Lu IC, Lin CH, Chan LP, Chiang FY, Wu CW. Thyroid Radiofrequency Ablation-Thermal Effects on Recurrent Laryngeal Nerve Using Continuous Intraoperative Neuromonitoring Animal Model. Otolaryngol Head Neck Surg 2025; 172:63-73. [PMID: 39403827 DOI: 10.1002/ohn.1017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 09/18/2024] [Accepted: 09/30/2024] [Indexed: 01/04/2025]
Abstract
OBJECTIVE When performing radiofrequency ablation for thyroid nodules, it is essential to avoid thermal injury to the recurrent laryngeal nerve. This porcine animal model study used continuous intraoperative neuromonitoring to investigate the thermal safety parameters of thyroid radiofrequency ablation. STUDY DESIGN Porcine animal study. SETTING University animal laboratory. METHODS Twelve piglets were tested at different radiofrequency power levels, and the real-time electromyography signal changes were recorded under continuous intraoperative neuromonitoring. The spread heat study (8 piglets) included spontaneous recovery tests and cold water irrigation tests to investigate the safety distance from the recurrent laryngeal nerve to the active tip during 5-second activation with standard stimulation patterns. The residual heat study (4 piglets) investigated the safety cooling durations by touching the recurrent laryngeal nerve with the tip after a 5-second activation. RESULTS In the spread heat study, substantial signal attenuation events were observed at an spread heat distance of 2, 3, 5, and 5 mm when the power was set as 10, 20, 30, and 50 W, respectively. No signal recovery could be observed in 20 minutes with or without cold water irrigation in the injured recurrent laryngeal nerve area. The residual heat study shows the residual thermal effect of the tip is minimal, and no substantial signal attenuation event was observed at all experiments. CONCLUSIONS This innovative study established the thermal safety parameters for radiofrequency ablation in a porcine model at various power levels, which can potentially assist operators in delineating a precise ablation field and providing effective thyroid ablation treatment safely.
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Affiliation(s)
- Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, School of Post-Baccalaureate Medicine and School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Gangshan Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Wei Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W Randolph
- Department of Otolaryngology-Head and Neck Surgery, Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS (Istituto di ricovero e cura a carattere scientifico), Piazzale Brescia, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Yi-Chu Lin
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Hsun Chuang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hung Lin
- Department of Pathology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Pathology, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Leong-Perng Chan
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, School of Post-Baccalaureate Medicine and School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, School of Post-Baccalaureate Medicine and School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Wang C, Li Z, Zhong W, Jiang S, Li W. Application of continuous intraoperative neuromonitoring in the study of spinal nerve root thermal injury in a porcine model. BMC Musculoskelet Disord 2024; 25:1012. [PMID: 39695478 DOI: 10.1186/s12891-024-08177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 12/09/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND A warning system to avoid potential nerve root thermal injury caused by automatic spine robot is essential. However, there is a lack of basic research to support the development of such warning system. The aims of this study are to confirm the feasibility of continuous intraoperative neuromonitoring (CIONM) in spinal nerve root monitoring and study the exposure time of spinal nerve root thermal injury at different temperature in a porcine model. METHODS The experiment was carried out on 32 nerve roots of 4 pigs (bilateral L4-S1 nerve roots). Sham group (CIONM only), control group (Room temperature stimulation with CIONM), and 40 °C, 45 °C, 50 °C, 55 °C, 60 °C, 65 °C temperature stimulation groups were conducted at random in each pig. The change of EMG was recorded continuously. The exposure time of nerve root injury at different temperatures was recorded. Histological analysis of the nerve roots was performed to confirm the injury. RESULTS The EMG of the sham, control, 40 °C and 45 °C groups were stable during the experiment, and no significant nerve root injury was observed on histological analysis. The time of 50% EMG amplitude decrease in 50℃, 55℃, 60℃ and 65℃ groups were 277.5 ± 18.2, 59.5 ± 6.2, 20.8 ± 1.0 and 16.5 ± 1.3 s, respectively. And the nerve specimens of these groups showed varying degrees of damage. CONCLUSIONS CIONM can be used for continuous monitoring of spinal nerve roots. For 5 min, 40℃ and 45℃ did not cause significant nerve root injury. However, when the temperature reached 50℃ and above, nerve roots appeared injury.
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Affiliation(s)
- Chengxia Wang
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Zhuofu Li
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Woquan Zhong
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Shuai Jiang
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China.
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China.
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Morikawa T, Hamamoto S, Gonda M, Taguchi K, Unno R, Torii K, Isogai M, Kawase K, Nagai T, Iwatsuki S, Etani T, Naiki T, Okada A, Yasui T. Evaluation of thermal effects of surgical energy devices: ex vivo study. Sci Rep 2024; 14:27365. [PMID: 39521906 PMCID: PMC11550423 DOI: 10.1038/s41598-024-78624-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 11/04/2024] [Indexed: 11/16/2024] Open
Abstract
This study evaluated the direct and indirect thermal effects of various surgical energy devices using an ex-vivo model. Two types of three devices were evaluated: ENSEAL™ X1 Curved Jaw Tissue Sealer (X1) and ENSEAL™ G2 Curved Tissue Sealer (G2) as vessel sealing systems (VSSs), and HARMONIC® HD1000i Shears (HA) as an ultrasonic activating device (USAD). Each device was activated once under DRY or WET conditions. The tissue's maximum temperature (MT), steam MT surrounding the activation site, and steam spread area (SSA) were measured. Under WET conditions, the median MT of a porcine common carotid artery at 1 mm from the activation site by X1, G2, and HA were 84.4, 83.3, and 50.5 °C, respectively. The direct thermal effect of HA was the lowest among the three devices. VSSs showed higher tissue MT under WET conditions compared with DRY conditions. Conversely, USAD showed the opposite trend. G2 demonstrated a significantly higher MT than X1 and HA (P < 0.05). A significant decrease in SSA was observed with decreasing grasping range. In conclusion, VSSs generated higher temperatures than USAD, especially under WET conditions. Surgeons should consider minimizing thermal effects by creating DRY conditions or performing gradual incisions when using VSS devices.
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Affiliation(s)
- Toshiharu Morikawa
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Shuzo Hamamoto
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Masakazu Gonda
- Department of Urology, Nagoya City University Midori Municipal Hospital, Nagoya, Japan
| | - Kazumi Taguchi
- Department of Urology, Nagoya City University East Medical Center, Nagoya, Japan
| | - Rei Unno
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Koei Torii
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Masahiko Isogai
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Kengo Kawase
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takashi Nagai
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Shoichiro Iwatsuki
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Toshiki Etani
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Taku Naiki
- Department of Urology, Nagoya City University West Medical Center, Nagoya, Japan
| | - Atsushi Okada
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takahiro Yasui
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
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Lederer AK, Staubitz-Vernazza JI, Margies R, Wild F, Musholt TJ. Continuous Intraoperative Nerve Monitoring of a Non-Recurrent Laryngeal Nerve: Real-Life Data of a High-Volume Thyroid Surgery Center. Cancers (Basel) 2024; 16:1007. [PMID: 38473368 DOI: 10.3390/cancers16051007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/18/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Thyroid surgery is associated with a risk of injury to the recurrent laryngeal nerve, especially in the presence of anatomical variants such as a non-recurrent laryngeal nerve (NRLN). Injury to the nerve leads to transient or permanent vocal cord palsy (VCP). A novel method to prevent VCP is continuous intraoperative nerve monitoring (cIONM), but less is known about the applicability of this method in patients with NRLN. The aim of this study was to evaluate our own data regarding feasibility and detailed characteristics of cIONM in NRLN patients. We performed a monocentric retrospective cohort analysis including clinical data and intraoperative nerve monitoring data (measured by Inomed Medizintechnik GmbH, Emmendingen, 'C2' and 'C2 Xplore' device) of all thyroid surgery patients, showing NRLN between 2014 and 2022. Of 1406 patients who underwent thyroid surgery with cIONM between 2014 and 2022, 12 patients (0.9%) showed NRLN intraoperatively. Notably, cIONM was feasible in eight patients (67%). In all cases the onset latency of the right vagus nerve was shorter (<3.0 ms) than usually expected, suggesting that a short latency might be suitable to distinguish NRLN. None of the patients had a post-operative VCP. Overall, cIONM appears to be feasible and safe in NRLN patients and provides helpful information to prevent VCP.
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Affiliation(s)
- Ann-Kathrin Lederer
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Complementary Medicine, Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Julia I Staubitz-Vernazza
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Rabea Margies
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Florian Wild
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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Kajiwara M, Fujikawa T, Hasegawa S. Tissue pad degradation of ultrasonic device may enhance thermal injury and impair its sealing performance in liver surgery. World J Hepatol 2022; 14:1357-1364. [PMID: 36158911 PMCID: PMC9376783 DOI: 10.4254/wjh.v14.i7.1357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/12/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ultrasonic devices are widely used in many surgical fields, including hepatectomy; however, the negative effects of tissue pad degradation of ultrasonic devices, including those in liver surgery, remain unknown. The Harmonic® 1100 (H-1100) scalpel has advanced heat control technology than previous models, such as the Harmonic® HD1000i (H-HD1000i). We hypothesized that, because of its advanced temperature-control technology, the H-1100 scalpel would show less tissue pad degradation, resulting in superior sealing performance, compared to that with the H-HD1000i scalpel.
AIM To elucidate ultrasonic device tissue pad degradation effects on instrument temperature and sealing performance using ex vivo porcine liver/vessel models.
METHODS Two different harmonic scalpels were used and compared: A newer model, the H-1100 scalpel, and an older model, the H-HD1000i scalpel. Using ex vivo porcine livers, each instrument was activated until the liver parenchyma was dissected. The device temperature (passive jaw temperature) was measured after every 10 consecutive activations, until 300 transections of the porcine liver were performed. Tissue pad degradation was evaluated after 300 activations. Sealing performance was evaluated using excised porcine carotid vessels; vessel sealing speed and frequency of vessel burst pressure below 700 mmHg were determined after 300 transections of porcine liver parenchyma.
RESULTS The temperature of the H-HD1000i scalpel was approximately 10°C higher than that of the H-1100 scalpel, and gradually increased as the number of activations increased. The median passive jaw temperature of the H-HD1000i scalpel was significantly higher than that of the H-1100 scalpel (73.4°C vs 65.1°C; P < 0.001). After 300 transections of porcine liver parenchyma, less tissue pad degradation was observed with the H-1100 scalpel than with the H-HD1000i scalpel (0.08 mm vs 0.51 mm). The H-1100 scalpel demonstrated faster vessel-sealing speed (4.9 sec. vs 5.1 sec.) and less frequent vessel burst pressure < 700 mmHg (0% vs 40%) after 300 activations than the H-HD1000i scalpel; however, the difference did not reach statistical significance (P = 0.21 and P = 0.09, respectively).
CONCLUSION In an ex vivo porcine hepatectomy model, the H-1100 scalpel shows lower passive jaw temperature and maintains its sealing performance by avoiding tissue pad degradation compared to that with the H-HD1000i.
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Affiliation(s)
- Masatoshi Kajiwara
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka 814-0180, Fukuoka, Japan
| | - Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu 802-8555, Fukuoka, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka 814-0180, Fukuoka, Japan
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Shibuya Y, Hirano K, Machida H, Miyamoto M, Watabe K, Mitsuma T, Nakazato Y, Tachibana K, Tanaka R, Kondo H. Bilateral recurrent laryngeal nerve paralysis diagnosed using dynamic digital radiography during the COVID-19 pandemic. Clin Case Rep 2022; 10:e6124. [PMID: 35898737 PMCID: PMC9309747 DOI: 10.1002/ccr3.6124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/22/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022] Open
Abstract
Dynamic digital radiography (DDR) is a motion-detecting technique with high temporal resolution. Flexible laryngoscopy is a common modality for the observation of the larynx; however, it generates aerosol. DDR is an easy and less risky screening test for the diagnosis of recurrent laryngeal nerve paralysis during the COVID-19 pandemic.
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Affiliation(s)
- Yukimi Shibuya
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Koichi Hirano
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Haruhiko Machida
- Department of Radiology, Faculty of MedicineKyorin UniversityTokyoJapan
- Department of RadiologyTokyo Women's Medical University Adachi Medical CenterTokyoJapan
| | - Makoto Miyamoto
- Department of Otolaryngology‐Head and Neck Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Kozue Watabe
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Tomoya Mitsuma
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Yoko Nakazato
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Keisei Tachibana
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Ryota Tanaka
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
| | - Haruhiko Kondo
- Department of Thoracic and Thyroid Surgery, Faculty of MedicineKyorin UniversityTokyoJapan
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Thermal Dynamics of a Novel Radio-Frequency Device for Endoscopic Spine Surgery: An Experimental Model. Spine (Phila Pa 1976) 2022; 47:720-729. [PMID: 35019880 DOI: 10.1097/brs.0000000000004320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Experimental study. OBJECTIVE In this study, the ambient temperature of a radiofrequency (RF) electrode tip was compared and analyzed in terms of products, mode, flow quantity, and flow rate. SUMMARY OF BACKGROUND DATA Endoscopic spine surgery is a widely used operation for degenerative lumbar stenosis and herniated lumbar disc. To perform endoscopic spine surgery, dedicated instruments like a RF generator and electrode are essential. METHODS An evaluation system capable of measuring temperature under equal conditions at a certain distance from the electrode tip was manufactured. The distance between the electrode tip and the temperature sensor was set to 1, 5, and 10 mm. The flow quantities of 0, 50, 100, and 150 mL/min and the flow rates of 0, 0.20, 0.53, and 0.80 m/s were compared and statistically analyzed. RESULTS The temperatures measured in the experiments conducted on the four combinations of RF device showed similar values, and showed differences according to the characteristics of each mode of the RF. As the distance between the electrode tip and the temperature sensor increased, the temperature decreased, and as flow quantity or flow rate increased, the temperature decreased. The maximum temperatures differed significantly according to flow quantity, between flow quantities of 0 and 100 mL/min (P = 0.03) and between 0 and 150 mL/min (P ≤ 0.01). The maximum temperatures also differed significantly between the flow rate of 0 m/s, and the flow rates of 0.20, 0.53, and 0.80 m/s, with P ≤ 0.01 in all three comparisons. CONCLUSION This is the first study in which we made a customized RF temperature evaluation system and verified the temperature changes in various environments. When irrigation was performed, we could confirm that the maximum temperature was less than 60°C. Irrigation is considered essential in endoscopic spine surgery. LEVEL OF EVIDENCE 3.
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Pace-Asciak P, Russell JO, Tufano RP. Improving Voice Outcomes after Thyroid Surgery and Ultrasound-Guided Ablation Procedures. Front Surg 2022; 9:882594. [PMID: 35599805 PMCID: PMC9114795 DOI: 10.3389/fsurg.2022.882594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
The field of endocrine surgery has expanded from the traditional open neck approach to include remote access techniques as well as minimally invasive approaches for benign and malignant thyroid nodules. In experienced hands and with careful patient selection, each approach is considered safe, however complications can and do exist. Post-operative dysphonia can have serious consequences to the patient by affecting quality of life and ability to function at work and in daily life. Given the significance of post-procedural dysphonia, we review the surgical and non-surgical techniques for minimizing and treating recurrent laryngeal nerve injury that can be utilized with the traditional open neck approach, remote access thyroidectomy, or minimally invasive thermal ablation.
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Affiliation(s)
- Pia Pace-Asciak
- Department of Otolaryngology – Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Jon O. Russell
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Ralph P. Tufano
- Sarasota Memorial Health Care System Multidisciplinary Thyroid and Parathyroid Center, Sarasota, Florida, United States
- Correspondence: Ralph P. Tufano
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11
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Changes of Functional, Morphological, and Inflammatory Reactions in Spontaneous Peripheral Nerve Reinnervation after Thermal Injury. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:9927602. [PMID: 35154578 PMCID: PMC8826209 DOI: 10.1155/2022/9927602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/25/2021] [Accepted: 01/04/2022] [Indexed: 12/27/2022]
Abstract
In recent decades, the use of energy-based devices has substantially increased the incidence of iatrogenic thermal injury to nerves (cauterization, etc.). While recovery of the nerve after thermal injury is important, the changes in neural structure, function, and peripheral inflammatory reactions postinjury remain unclear. This study is aimed at demonstrating the changes mentioned above during the acute, subacute, and chronic stages of nerve reinnervation after thermal injury. Spontaneous reinnervation was evaluated, including the neural structures, nerve conduction abilities, and muscle regeneration. These effects vary depending on the severity of thermal injury (slight, moderate, and severe). Peripheral inflammatory reactions, as impediments to reinnervation, were found in significant numbers 3 days after thermal injury, exhibiting high expression of IL-1β and TNF-α, but low expression of IL-10. Our findings reveal the pathogenesis of peripheral nerve reinnervation after thermal injury, which will assist in selecting appropriate treatments in further research.
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Tseng HY, Huang TY, Lin YC, Wang JJ, Ko HY, Chuang CH, Lu IC, Chang PY, Randolph GW, Dionigi G, Chang NC, Wu CW. Safety Parameters of Quantum Molecular Resonance Devices During Thyroid Surgery: Porcine Model Using Continuous Neuromonitoring. Front Endocrinol (Lausanne) 2022; 13:924731. [PMID: 35813650 PMCID: PMC9260785 DOI: 10.3389/fendo.2022.924731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Quantum molecular resonance (QMR) devices have been applied as energy-based devices in many head and neck surgeries; however, research on their use in thyroid surgery is lacking. This study aimed to investigate the safety parameters of QMR devices during thyroidectomy when dissection was adjacent to the recurrent laryngeal nerve (RLN). METHODS This study included eight piglets with 16 RLNs, and real-time electromyography (EMG) signals were obtained from continuous intraoperative neuromonitoring (C-IONM). QMR bipolar scissor (BS) and monopolar unit (MU) were tested for safety parameters. In the activation study, QMR devices were activated at varying distances from the RLN. In the cooling study, QMR devices were cooled for varying time intervals, with or without muscle touch maneuver (MTM) before contacting with the RLN. RESULTS In the activation study, no adverse EMG change occurred when QMR BS and MU were activated at distances of 2 mm or longer from the RLNs. In the cooling study, no adverse EMG change occurred when QMR BS and MU were cooled in 2-second intervals or immediately after MTM. CONCLUSION QMR devices should be carefully used when performing RLN dissection during thyroid surgery. According to the activation and cooling safety parameters in this study, surgeons can avoid RLN injury by following standard procedures when using QMR devices.
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Affiliation(s)
- Hsin-Yi Tseng
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia Joanna Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - How-Yun Ko
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Hsun Chuang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology—Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano (IRCCS), Milan, Italy
- Department of Pathophysiology and Transplantation, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Ning-Chia Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Ning-Chia Chang,
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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13
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Glushkov PS, Azimov RK, Shemyatovsky KA, Gorsky VA. [Principles of safe endoscopic surgery on the endocrine organs of the neck]. Khirurgiia (Mosk) 2022:63-68. [PMID: 36223152 DOI: 10.17116/hirurgia202210163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To emphasize the main stages of safe endoscopic surgery on endocrine organs of the neck. MATERIAL AND METHODS There were 79 patients with diseases of thyroid and parathyroid glands who underwent surgery between 2018 and 2021. Of these, 69 ones underwent transaxillary thyroidectomy, 10 patients underwent transaxillary parathyroidectomy. RESULTS At initial stage of development of this technique, we obtained 2 intraoperative and 2 postoperative complications. Adverse events were completely cured. CONCLUSION Endoscopic procedures on the endocrine organs of the neck are a safe alternative to traditional approaches. There are certain advantages of this approach. Compliance with surgical technique and focusing on dangerous stages minimize the risk of complications.
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Affiliation(s)
- P S Glushkov
- Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - R Kh Azimov
- Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - K A Shemyatovsky
- Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - V A Gorsky
- Pirogov Russian National Research Medical University, Moscow, Russia
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Huang HY, Lien CF, Wang CC, Wang CC, Hwang TZ, Shih YC, Wu CW, Dionigi G, Huang TY, Chiang FY. Necessity of Routinely Testing the Proximal and Distal Ends of Exposed Recurrent Laryngeal Nerve During Monitored Thyroidectomy. Front Endocrinol (Lausanne) 2022; 13:923804. [PMID: 35846324 PMCID: PMC9279689 DOI: 10.3389/fendo.2022.923804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Intraoperative neuromonitoring (IONM) is a useful tool to evaluate the function of recurrent laryngeal nerve (RLN) in thyroid surgery. This study aimed to determine the necessity and value of routinely testing the proximal and distal ends of RLN. METHODS In total, 796 patients undergoing monitored thyroidectomies with standardized procedures were enrolled. All 1346 RLNs with visual integrity of anatomical continuity were routinely stimulated at the most proximal (R2p signal) and distal (R2d signal) ends after complete RLN dissection. The EMG amplitudes between R2p and R2d signals were compared. If the amplitude of R2p/R2d ratio reduction (RPDR) was over 10% or loss of signal (LOS) occurred, the exposed RLN was mapped to identify the injured point. Pre- and post-operative vocal cord (VC) mobility was routinely examined with video-laryngofiberscope. RESULTS Nerve injuries were detected in 108 (8%) RLNs, including 94 nerves with incomplete LOS (RPDR between 13%-93%) and 14 nerves with complete LOS. The nerve injuries were caused by traction in 80 nerves, dissecting trauma in 23 nerves and lateral heat spread of energy-based devices in 5 nerves. Symmetric VC mobility was found in 72 nerves with RPDR ≤50%. The occurrence of abnormal VC mobility (weak or fixed) was 14%, 67%, 100%, and 100% among the different RPDR stratifications of 51%-60%, 61%-70%, 71%-80%, and 81-93%, respectively. Of the 14 nerves with complete LOS, all showed fixed VC mobility. Permanent VC palsy occurred in 2 nerves with thermal injury. CONCLUSION Routinely testing the proximal and distal ends of exposed RLN helps detect unrecognized partial nerve injury, elucidate the injury mechanism and determine injury severity. The procedure provides accurate information for evaluating RLN function after nerve dissection and should be included in the standard IONM procedure.
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Affiliation(s)
- Hsiao-Yu Huang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Ching-Feng Lien
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Chun Wang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chien-Chung Wang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzer-Zen Hwang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Chen Shih
- Department of Otolaryngology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico (IRCSS), Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Tzu-Yen Huang, ; Feng-Yu Chiang,
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- *Correspondence: Tzu-Yen Huang, ; Feng-Yu Chiang,
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15
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Lu IC, Tan H, Wu SH, Huang TY, Tseng HY, Wang JJ, Dionigi G, Chai YJ, Chiang FY, Chang PY, Wu CW. A comparison between cisatracurium and rocuronium-induced neuromuscular block on laryngeal electromyography recovery after neostigmine reversal in a porcine model. Front Endocrinol (Lausanne) 2022; 13:875597. [PMID: 36004347 PMCID: PMC9393356 DOI: 10.3389/fendo.2022.875597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/29/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Inducing and reversing neuromuscular block is essential to a positive outcome of thyroid surgery, with intraoperative neuromonitoring (IONM) being used to decrease recurrent and superior laryngeal nerve injuries and improve vocal outcome. Neostigmine is a non-specific broad-spectrum and inexpensive reversal agent for neuromuscular blocking agents (NMBAs). The aim of this porcine study was to explore the effect of neostigmine on electromyography (EMG) signal recovery profile following the commonly used NMBAs, cisatracurium and rocuronium. METHODS Twelve piglets were allocated into two groups with six piglets in each group. When stable baseline EMG signals were obtained, a neuromuscular block was induced by intravenous cisatracurium 0.2 mg/kg (group C) or rocuronium 0.6 mg/kg (group R) for each piglet. We compared laryngeal EMG tracing with spontaneous recovery (control) and neostigmine (0.04 mg/kg) reversal for each group. The time course of real-time laryngeal EMG signals was observed for 30 min from NMBA injection. Effects of neostigmine on EMG signal were assessed at 50% EMG recovery and by the maximum neuromuscular block recovery degree from the baseline value. RESULTS Neostigmine shortened the recovery time to 50% EMG amplitude in both group C (16.5 [2.5] vs. 29.0 [2.0] min, P<0.01) and group R (16.5[2.5] vs. 26.5 [1.5] min, P<0.05) compared to spontaneous recovery, respectively. Neostigmine reversal also enhanced the maximum degree of EMG amplitude recovery in both group C (83.6 [5.1] vs. 47.2 [6.1] %, P<0.01) and group R (85.6 [18.2]vs. 57.1 [6.3] %, P<0.05) compared to spontaneous recovery, respectively. The reversal effect of neostigmine did not differ significantly between cisatracurium and rocuronium. CONCLUSIONS This porcine model demonstrated that neostigmine provides an adequate and timely IONM signal suppressed by both cisatracurium and rocuronium. These results can potentially expand the options for precision neuromuscular block management during IONM to improve vocal outcomes in thyroid surgery patients.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hao Tan
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia-Joanna Wang
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano, Istituto di ricovero e cura a carattere scientifico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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16
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Wang JJ, Huang TY, Wu CW, Lin YC, Tseng HY, Liu CH, Lu IC, Chang PY, Chen HC, Chen HY, Dionigi G, Chiang FY, Wang LF. Improving Voice Outcomes After Thyroid Surgery - Review of Safety Parameters for Using Energy-Based Devices Near the Recurrent Laryngeal Nerve. Front Endocrinol (Lausanne) 2021; 12:793431. [PMID: 34899616 PMCID: PMC8662988 DOI: 10.3389/fendo.2021.793431] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Technological advances in thyroid surgery have rapidly increased in recent decades. Specifically, recently developed energy-based devices (EBDs) enable simultaneous dissection and sealing tissue. EBDs have many advantages in thyroid surgery, such as reduced blood loss, lower rate of post-operative hypocalcemia, and shorter operation time. However, the rate of recurrent laryngeal nerve (RLN) injury during EBD use has shown statistically inconsistent. EBDs generate high temperature that can cause iatrogenic thermal injury to the RLN by direct or indirect thermal spread. This article reviews relevant medical literatures of conventional electrocauteries and different mechanisms of current EBDs, and compares two safety parameters: safe distance and cooling time. In general, conventional electrocautery generates higher temperature and wider thermal spread range, but when applying EBDs near the RLN adequate activation distance and cooling time are still required to avoid inadvertent thermal injury. To improve voice outcomes in the quality-of-life era, surgeons should observe safety parameters and follow the standard procedures when using EBDs near the RLN in thyroid surgery.
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Affiliation(s)
- Jia Joanna Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Hsin Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Chun Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsiu-Ya Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Ling-Feng Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, International Thyroid Surgery Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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17
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A worthy technique for transcanal drilling during endoscopic ear surgery. World J Otorhinolaryngol Head Neck Surg 2021; 7:265-269. [PMID: 34632337 PMCID: PMC8486694 DOI: 10.1016/j.wjorl.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the necessity and effectiveness of a preplanned technique for drilling during transcanal endoscopic ear surgery. Methods Study design: Retrospective case series study from June 2011 to June 2015. Setting: Private tertiary care hospital. Patients: Eighty-five ears of 78 patients, age ranging from 9 to 57 years underwent transcanal endoscopic drilling for various types of pathology in their middle and external ear. Interventions: Application of a preplanned technique for transcanal drilling in endoscopic ear surgery that involved short timed drilling with use of intermittent irrigation and suction. Every events of the procedure were done one after another with the single hand of the surgeon. An attachment providing protecting sheath around rotating burr was used during each time of drilling. Main outcomes measure: Efficacy of such drilling technique in single handed endoscopic ear surgery. Presence of any postoperative thermal injury of facial nerve and any lacerated injury of skin of external ear. Results This preplanned technique was found suitable for transcanal endoscopic drilling with the single hand of the surgeon. Postoperative facial nerve palsy or laceration of skin of external ear was not noted in any patient. Conclusion After using the present technique, transcanal endoscopic drilling could be done easily and safely with single hand of the surgeon.
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18
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Yu X, Liu C, Yan M, Gong W, Wang Y. Hyperthermal liquid, spray, and smog may be potential risk factors for recurrent laryngeal nerve thermal injury during thyroid surgeries. Endocrine 2021; 72:198-207. [PMID: 32779090 DOI: 10.1007/s12020-020-02451-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The hyperthermal liquid, spray and smog caused by energy-based surgical devices (EBDs) may be the potential risk factors for recurrent laryngeal nerve (RLN) thermal injury, but not been reported previously. We aim to demonstrated it both in thyroid surgeries and animal experiments. METHODS 321 thyroid patients and 32 rats were divided into two groups respectively. A type of endoscopic gauze was implemented in the protected group to prevent nerve from thermal risks. Electromyography and laryngoscope were recorded to determine nerve's conductive ability. Microstructural morphological damage to nerves and muscles were evaluated by light and electron microscopy in the animal experiments. RESULTS After thyroid surgeries, the incidence of transient vocal cord (VC) palsy was decreased in the protected group (1.4%) compared with the conventional group (4.7%) (P = 0.037). In animal experiments, the average nerve conductive velocity was significantly decreased in the conventional group (5.8 ± 2.1 vs. 25.5 ± 4.7 m/s, P < 0.01). Typical acute morphological thermal changes of edema, coagulation and homogenization in nerve tissues were recorded by light microscopy in the conventional group. Four weeks later, the average weight of gastrocnemius muscles in the injured limb was significantly decreased (1.3 ± 0.2 vs. 2.2 ± 0.2 g, P < 0.01), while no significant difference was noted in the protected group (2.0 ± 0.3 vs. 2.3 ± 0.4 g, P = 0.61). CONCLUSIONS Hyperthermal liquid, spray or smog may represent risk factors contributing to RLN thermal injury caused by EBDs. Damage to the nerve's conductive ability and morphological changes in nerves and muscles likely represent typical responses to thermal injury. Implementation of endoscopic gauze may be a promising method to protect the RLN from thermal damage especially in endoscopic thyroid surgeries.
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Affiliation(s)
- Xing Yu
- Department of Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Chang Liu
- College of Medicine, Zhejiang University, Hangzhou, 310058, China
| | - Maoxiao Yan
- Department of Otorhinolaryngology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Weihua Gong
- Department of Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
| | - Yong Wang
- Department of Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
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Zhao Y, Zhang D, Zhou L, Li S, Wang T, Li F, Han Y, Dionigi G, Sun H. Proprieties of adhesive surface arrays to thyroid cartilage for recurrent laryngeal nerve monitoring. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:690. [PMID: 33987388 PMCID: PMC8106000 DOI: 10.21037/atm-21-1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background To investigate the optimal placement and size of adhesive thyroid cartilage electrodes (ATCEs) placed on the thyroid cartilage in porcine models for evaluating recurrent laryngeal nerve function compared with the other 3 recording electrode types. Methods Four Meishan piglets were used for this study. The electromyogram (EMG) signal stability was detected by intraoperative nerve monitoring (IONM). Best location and size of ATCEs were detected, and the EMG signals from each were compared. Latency data were tested by stimulating the different nerve points, and 6 manipulations of the trachea and endotracheal tube (ET) were applied to test the stability of EMG signals. ET electrodes, needle electrodes, and transcutaneous recording electrodes were simultaneously tested with comparison to ATCEs. Results The optimal placement locations and sizes of ATCEs were determined. The amplitudes and latencies recorded from the ATCEs were consistent with those of the ET electrodes. More anti-interference was observed with the ATCEs than with the ET electrodes in surgical manipulations. ATCEs could be used during intermittent and continuous monitoring in similar fashion to ET electrodes and needle electrodes. Conclusions ATCEs had consistent monitoring function with ET electrodes and needle electrodes. Feasibility, EMG stability, and optimal location and size of ATCEs for IONM were resolved. The EMG profiles from the ATCEs were more stable during surgical manipulations.
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Affiliation(s)
- Yishen Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Le Zhou
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Shijie Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Fang Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Yujia Han
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, China
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20
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Yu M, Ge M. Non-energy devices to dissect recurrent laryngeal nerve lymph nodes of non-small cell lung cancer under video-assisted thoracic surgery. BMC Surg 2021; 21:172. [PMID: 33785015 PMCID: PMC8008666 DOI: 10.1186/s12893-021-01179-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background Systematic nodal dissection plays a crucial role in improving survival and staging in resectable non-small cell lung cancer (NSCLC) patients but at the cost of increasing the occurrence of recurrent laryngeal nerve injury. Technology should be improved to protect the recurrent laryngeal nerve (RLN) during surgery. Methods NSCLC patients who underwent video-assisted thoracic surgery (VATS) surgical treatment by the same surgeon at our hospital from January 2016 to December 2017 were included as the research subjects and were divided into an energy-device group and a non-energy-device group. Their procedures included anatomic pulmonary resection, normative N1 dissection, and systemic N2 dissection. Results The rate of metastatically involved recurrent laryngeal nerve lymph nodes (RLNLNs) was 5.19% (39/752). Dissection device, side of primary, FEV1, operative time and BMI were independent predictors of recurrent laryngeal nerve injury (RLNI) (hazard ratio (HR) = 3.576, 95% confidence interval (CI): 1.490–8.583, P = 0.004; HR = 0.175, 95% CI: 0.072–0.424, P = < 0.001; HR = 3.008, 95% CI: 1.30–6.927, P = 0.010; HR = 0.328, 95% CI: 0.136–0.794, P = 0.013; HR = 0.344, 95%CI: 0.147–0.801, P = 0.013, respectively). Patients in the non-energy-device group had significantly less RLNI than the energy-device group (P = 0.016) and nearly half of the non-thermal RLNI recovered in 2 weeks (P = 0.025) whereas most thermal RLNI required 3 months for recovery. Conclusions Every station of RLNLN had some degree of cancer metastasis in NSCLC patients and when dissecting RLNLNs, dissection device was an independent and artificially controlled predictor of RLNI. Using a non-energy device is a feasible method to protect the RLN as well as an improved recovery time of RLNI.
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Affiliation(s)
- Minhao Yu
- Department of Thoracic Surgery, Chengdu BOE Hospital, Chengdu, 610200, China
| | - Mingjian Ge
- Department of Thoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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21
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Wu CW, Randolph GW, Barczyński M, Schneider R, Chiang FY, Huang TY, Karcioglu AS, Konturek A, Frattini F, Weber F, Liu CH, Dralle H, Dionigi G. Training Courses in Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery- The INMSG Consensus Statement. Front Endocrinol (Lausanne) 2021; 12:705346. [PMID: 34220726 PMCID: PMC8253252 DOI: 10.3389/fendo.2021.705346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 01/04/2023] Open
Abstract
Intraoperative neural monitoring (IONM) is now an integral aspect of thyroid surgery in many centers. Interest in IONM and the number of institutions that perform monitored thyroidectomies have increased throughout the world in recent years. For surgeons considering the introduction of IONM in their practice, specific training in IONM devices and procedures can substantially shorten the learning curve. The International Neural Monitoring Study Group (INMSG) has been at the forefront of IONM technology and procedural adoption since the introduction of neural monitoring in thyroid and parathyroid surgery. The purpose of this document is to define the INMSG consensus on essential elements of IONM training courses. Specifically, this document describes the minimum training required for teaching practical application of IONM and consensus views on key issues that must be addressed for the safe and reliable introduction of IONM in surgical practice. The intent of this publication is to provide societies, course directors, teaching institutions, and national organizations with a practical reference for developing IONM training programs. With these guidelines, IONM will be implemented optimally, to the ultimate benefit of the thyroid and parathyroid surgical patients.
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Affiliation(s)
- Che-Wei Wu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of Surgery, University Hospital Halle, Martin-Luther-University, Halle-Wittenberg, Germany
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Amanda Silver Karcioglu
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Aleksander Konturek
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Francesco Frattini
- Department of Surgery, Ospedale di Circolo, ASST Settelaghi, Varese, Italy
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Cheng-Hsin Liu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy
- *Correspondence: Gianlorenzo Dionigi,
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Wu R, Zhang C, Wang H, Li M, Lei S, Zeng J, He J. Clinical observation of end-to-end neuroanastomosis in the treatment of complete injury of the unilateral recurrent laryngeal nerve. Gland Surg 2020; 9:2017-2025. [PMID: 33447552 DOI: 10.21037/gs-20-633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Complete injury of the recurrent laryngeal nerve (RLN) is a serious complication of thyroid surgery. Increasingly researches focus on the voice recovery of patients with RLN injury. This paper studied the effect of immediate end-to-end neuroanastomosis after complete injury of the unilateral RLN during thyroid surgery on postoperative vocal function. Methods Thirteen patients who underwent end-to-end neuroanastomosis for the treatment of complete injury of the unilateral RLN caused by thyroid surgery in Hunan Provincial People's Hospital between October 2009 and January 2020 were selected. The basic information, cause of RLN injury, postoperative voice recovery, recovery time, and subjective assessment of voice by auditory perception results (Grade, Roughness, Breathiness, Asthenia, and Strain, the GRBAS score) of the patients were recorded. Results Among the 13 cases with RLN injury, the cause of RLN injury in 10 cases was transection by sharp instruments, and the voice was recovered one day after the operation. The cause of RLN injury in one case was suture of the RLN branch, and the voice was recovered one day after the operation. The cause of RLN injury in two cases was thermal injury, and the times for voice recovery after end-to-end neuroanastomosis were 3 and 4 months. The patients with a GRBAS score of 0 or 1 recovered their voice one day after the operation. The GRBAS score reached 1 in the two thermal injury cases, with voice recovery at 3 and 4 months after surgery. By 6 months, the voice recovery rate of the patients was 100%. Conclusions After complete injury of the unilateral RLN, immediate end-to-end anastomosis of the RLN can maximally preserve the postoperative vocal function of patients.
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Affiliation(s)
- Runzhang Wu
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
| | - Chaojie Zhang
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
| | - Huiling Wang
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
| | - Meiliang Li
- Department of Pathology, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
| | - Shanshan Lei
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
| | - Jie Zeng
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
| | - Jie He
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Hunan Normal University/Hunan Provincial People's Hospital, Changsha, China
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Park D, You JY, Yang HW, Tufano RP, Kim HY. Shaw scalpel use for recurrent laryngeal nerve dissection: safety parameter findings from continuous intraoperative neuromonitoring in swine models. Gland Surg 2020; 9:1363-1369. [PMID: 33224811 DOI: 10.21037/gs-20-336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Precise dissection with hemostasis while preserving important structures is critical in thyroid surgeries. In this study, we tested the safety of the Hemostatix Shaw scalpel (HSS) around the recurrent laryngeal nerve (RLN) in porcine models. Methods Four piglets were used to obtain continuous intraoperative neuromonitoring data. The HSS was applied at various distances from the RLN, with various temperature settings. Monopolar electrosurgical pencil and Harmonic scalpel were also tested for comparison. Results The use of HSS did not show adverse electromyographic (EMG) events when activated at 3- and 5-mm distances from the RLN. At a 1-mm distance, adverse event was observed at 300 °C after 2 seconds of activation. At 210 °C, adverse event was observed when the instrument was directly adjacent to the RLN. For comparison, an electrosurgical pencil, set at coagulation mode (25W), showed an irreversible adverse EMG event during 5 seconds of activation at 1-mm distance from the RLN. Harmonic ACE+, activation power at level 5, was also applied in one RLN and reversable adverse EMG event was observed at <0.1-mm (contact) distance after 3 seconds of activation. Conclusions The safety distance of the HSS was 3 mm for the 300 °C setting and >1 mm for the 210 °C setting in the swine models in this study. Surgeons must understand the specific characteristics of various energy devices and apply them appropriately for safe operation.
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Affiliation(s)
- Dawon Park
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Ji Young You
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hsien Wen Yang
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Ralph P Tufano
- Head and Neck Endocrine Surgery Division, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
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Abstract
BACKGROUND Loss of the neuromonitoring signal (LOS) during thyroidectomy signifies recurrent laryngeal nerve (RLN) injury, which is one of the common complications, especially by traction injury. Transient intraoperative LOS means spontaneous recovery of nerve function during surgery or within 6-month post-surgery. Few articles discuss intraoperative recovery time and transient LOS, and there is no consensus on the risk factors for RLN traction injury and its recovery course; thus, we wanted to determine the maximum intraoperative recovery time. MATERIALS AND METHODS This retrospective study included patients who had undergone thyroidectomies at Tainan National Cheng Kung University Hospital between January 2015 and August 2018. A total of 775 patients (with 1000 nerves at risk) who underwent intermittent intraoperative neuromonitoring during thyroidectomy were included in this study. The LOS nerves were divided into 4 groups based on the LOS subtype and the intraoperative status of the recovery. The postoperative vocal cord function was determined by thyroid ultrasound and/or laryngoscope. All the patients would be followed up postoperatively in 2-3 days, 1 week, 2 weeks, and 4-6 weeks. RESULTS LOS occurred in 67 of 775 (8.6%) patients and in 70 of 1000 nerves at risk (7.0%). There were 2 in 70 nerves (2.9%) with LOS type 1 (segmental nerve traction injury) with intraoperative recovery (Group 1), 5 (7.1%) with LOS type 1 without intraoperative recovery (Group 2), 47 (67.1%) with LOS type 2 (global injury) with intraoperative recovery (Group 3), and 16 (22.8%) with LOS type 2 without intraoperative recovery (Group 4). All LOS type 1 (segmental nerve injury) nerves had pathologic lesions near the RLN or vagus nerve, but none had invaded the nerves (p < 0.05). The resolving time intraoperatively in the 2 patients in Group 1 was 5 min and 10 min, respectively. The resolving time intraoperatively in Group 3 was 1-20 min, and the average time was 4.8 min. In Group 2, 3 injured nerves recovered within 6 weeks postoperatively, and 2 nerves in 12 weeks. In Group 4, all the 16 injured nerves recovered within 6 weeks postoperatively. CONCLUSION Applying intermittent intraoperative neuromonitoring during thyroidectomy, traction recurrent laryngeal nerve injury still happened in 7.0%. 70% of the injured nerves recovered the function intraoperatively after releasing the traction, and the longest duration of recovery is 20 min.
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25
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Lin E, Lin S, Fu J, Lin F, Luo Y, Hong X, Chai B, Liang K, Wu G. Neural monitoring during ultrasound-guided radiofrequency ablation of thyroid nodules. Int J Hyperthermia 2020; 37:1229-1237. [PMID: 33131338 DOI: 10.1080/02656736.2020.1778109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Intraoperative neurological monitoring is important in locating and assessing nerves during surgery. This study aimed to investigate the feasibility of neural monitoring during ultrasound-guided radiofrequency ablation (RFA) of thyroid nodules. METHODS From February 2019 to August 2019, 16 patients (age, 42.8 ± 15.9 years; range, 17-74 years) with benign thyroid nodules who underwent ultrasound-guided RFA with neural monitoring in Zhongshan Hospital, Xiamen University, were included. A neuromonitoring system stimulated the vagus nerve to obtain electromyographic (EMG) signals and predict the function of recurrent laryngeal nerves (RLNs) during RFA. The hydrodissection technique was used to protect the RLN area. Thyroid nodules were treated with the moving-shot technique. The EMG signal value results were recorded and analyzed. All patients underwent laryngoscopic investigation 1 day after the procedure. RESULTS Twenty vagus nerves were stimulated preprocedure and postprocedure, and the EMG signals were successfully recorded (100%). The mean initial (before ablation) and final (final ablation) vagus nerve amplitudes were 612.7 ± 130.4 μV (range, 455-882 μV) and 592.7 ± 127.3 μV (range, 410-817 μV), respectively. Based on the EMG signals, all 20 RLNs were judged to be in good condition, consistent with the postprocedure laryngoscopic results. The maximum lesion size and volume at 6 months after RFA were significantly lesser than those at baseline (p < 0.05). The volume reduction rate was 68.5% ± 21.5% (range, 13.0-97.3%). Cosmetic and symptom scores were significantly lower than those at baseline. No complications from neural monitoring occurred. CONCLUSIONS Neural monitoring during ultrasound-guided RFA of thyroid nodules is feasible to predict RLN function.
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Affiliation(s)
- EnDe Lin
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - SuQiong Lin
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - JinBo Fu
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - FuSheng Lin
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - YeZhe Luo
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - XiaoQuan Hong
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - Bin Chai
- Department of Anesthesiology, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - KunHui Liang
- Department of Anesthesiology, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
| | - GuoYang Wu
- Department of General Surgery, Zhongshan Hospital Affiliated with Xiamen University, Xiamen, China
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Derriks JHG, Hilgersom NFJ, Middelkoop E, Samuelsson K, van den Bekerom MPJ. Electrocautery in arthroscopic surgery: intra-articular fluid temperatures above 43 °C cause potential tissue damage. Knee Surg Sports Traumatol Arthrosc 2020; 28:2270-2278. [PMID: 31250052 DOI: 10.1007/s00167-019-05574-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 06/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The use of electrocautery during arthroscopy may heat intra-articular saline and subsequently damage intra- and extra-articular tissue. Newer electrocautery devices have the ability to measure the outflow fluid temperature and switch off before reaching a certain threshold; however, the scientific evidence establishing these temperature thresholds' potential for inadvertent damage is lacking. The aim of this study was to analyse current available literature on temperature thresholds for tissue damage after exposure to heated fluid and provide a recommendation for the maximum temperature of intra-articular fluid to prevent tissue damage. METHODS In February 2018, a systematic literature review was performed using the MEDLINE/PubMed and Embase databases. Inclusion was limited to studies investigating temperature thresholds for thermal damage to at least one of the tissues of interest: skin, bone, cartilage, soft tissues, and nerves. Studies not reporting specific temperature thresholds for thermal damage were excluded. RESULTS Twenty articles were selected for the final evaluation and data extraction. Varying temperature thresholds, based on the lowest reported temperature causing tissue damage, were found for the different tissues of interest: 44 °C for dermal tissues, between 47 and 50 °C for bony tissues, 50 °C for cartilage, between 43 and 55 °C for soft tissues, and 43 °C for nerves. CONCLUSION Based on the current literature, a temperature threshold for intra-articular fluid of 43 °C during an arthroscopic procedure is recommended to prevent tissue damage. Higher temperatures may cause damage to surrounding intra- and extra-articular tissues. The threshold for irreversible damage is likely to be higher. In clinical practise, one should be aware of possible heating of intra-articular fluid when using electrocautery and related risk of tissue damage. LEVEL OF EVIDENCE III.
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Affiliation(s)
- J H G Derriks
- Department of Orthopaedic Surgery, St Maartenskliniek, Nijmegen, The Netherlands.
| | - N F J Hilgersom
- Department of Orthopaedic Surgery, Amsterdam University Medical Centres, Location AMC, Amsterdam, The Netherlands
| | - E Middelkoop
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centres, Location VUMC, Amsterdam, The Netherlands
- Association of Dutch Burn Centers, Beverwijk, The Netherlands
| | - K Samuelsson
- Department of Orthopaedic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M P J van den Bekerom
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Huang TY, Lin YC, Tseng HY, Dionigi G, Kim HY, Chai YJ, Lu IC, Chang PY, Chiang FY, Wu CW. Safety parameters of ferromagnetic device during thyroid surgery: Porcine model using continuous neuromonitoring. Head Neck 2020; 42:2931-2940. [PMID: 32567742 DOI: 10.1002/hed.26334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/28/2020] [Accepted: 05/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The ferromagnetic (FM) device is a new surgical energy modality. This study investigated dynamic recurrent laryngeal nerve (RLN) electromyographic (EMG) data to define safety parameters for using FM devices in thyroidectomy. METHODS Real-time EMG tracings obtained under continuous neuromonitoring were recorded from 24 RLNs (12 piglets). In the activation study, FM devices were activated at varying distances from the RLN. In the cooling study, FM devices were cooled for varying time intervals, or muscle touch maneuver was performed, before contact with the RLN. RESULTS During the FMwand/FMsealer activation, no adverse EMG events occurred at distances of 2 mm or longer. The cooling study revealed no adverse EMG events after 1-second (FMwand) or 3-second (FMsealer) intervals or after muscle touch maneuver. CONCLUSIONS An FM device should be activated at a distance of 2 mm from the RLN and should be adequately cooled before further contact with the RLN. Surgeons can avoid RLN injury by observing standard procedures for using FM devices.
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Affiliation(s)
- Tzu-Yen Huang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, South Korea
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.,Department of Otolaryngology, E-Da Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Faculty of Medicine, College of Medicine, and Cohort Research Center, Kaohsiung Medical University, Shin-Chuan 1st Road, Kaohsiung, Sanmin Dist., 80708, Taiwan
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Huang TY, Chiang FY, Wu CW. In Reference to Awake Thyroidectomy-"Squeeze" Technique for Nerve Monitoring. Laryngoscope 2020; 131:E314. [PMID: 32542813 DOI: 10.1002/lary.28783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Tzu-Yen Huang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Cohort Research Center, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, No.100, Shin-Chuan 1st Road, Sanmin Dist., Kaohsiung, 80708, Taiwan
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Huang TY, Lin YC, Tseng HY, Dionigi G, Kim HY, Lu IC, Chang PY, Chiang FY, Wu CW. Safety of Ligasure exact dissector in thyroidectomy with continuous neuromonitoring: a porcine model. Gland Surg 2020; 9:702-710. [PMID: 32775260 DOI: 10.21037/gs.2020.03.17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The purpose of this study was to investigate and define safety parameters for using the Ligasure exact dissector (LED) for dissection close to the recurrent laryngeal nerve (RLN) during thyroidectomy. Methods Real-time electrophysiologic electromyographic (EMG) tracings were recorded in 16 RLNs (8 piglets) during various applications of LED under continuous intraoperative monitoring in this prospective porcine model study. In the activation study, LED was activated at varying distances from the RLN. In the cooling study, LED was activated with different cooling times or after touching the sternocleidomastoid muscle before application to the RLN. Results In the activation study, no adverse EMG events occurred at distances longer than 1 mm. In the cooling study, no adverse EMG events occurred after a 2-second cooling time. Additionally, no adverse EMG events occurred when a sternocleidomastoid muscle touch maneuver was used for cooling. Conclusions The LED can be safely used at distance of 1 mm or longer, and it should be cooled for at least 2 seconds or by muscle touch maneuver. Thyroid surgeons can avoid RLN injury if standard procedures for LED use are observed.
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Affiliation(s)
- Tzu-Yen Huang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hoon-Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Korea
| | - I-Cheng Lu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.,Department of Otolaryngology, E-Da Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abt NB, Puram SV, Kamani D, Modi R, Randolph GW. Neuromonitored Thyroid Surgery: Optimal Stimulation Based on Intraoperative EMG Response Features. Laryngoscope 2020; 130:E970-E975. [DOI: 10.1002/lary.28613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/10/2020] [Accepted: 02/19/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas B. Abt
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Sidharth V. Puram
- Department of Otolaryngology‐Head and Neck Surgery and Department of Genetics Washington University School of Medicine St. Louis Missouri U.S.A
| | - Dipti Kamani
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Rahul Modi
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Division of Surgical Oncology, Department of Surgery Massachusetts General Hospital, Harvard Medical School Boston Massachusetts U.S.A
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Safety Profile of the New Harmonic Focus: Different Emissivity and Temperature Behavior Between the Active and the Inactive Blade. Surg Laparosc Endosc Percutan Tech 2020; 29:e79-e83. [PMID: 31453911 PMCID: PMC6818976 DOI: 10.1097/sle.0000000000000712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ultrasonic devices disperse less energy in the tissues. The new Harmonic Focus+ (HF+) seems to be more efficient but thermal damages have been reported. This study examined the temperature and the emissivity profile of the active and passive blades of the HF+, on a pig tissue model at different power settings. The FLIR System B series thermal imaging camera has been used on various biological pig tissues to evaluate the emissivity of the ultrasonic device. The active blade heats up faster than the passive one and the increase in power increases the speed of the temperature raising only on the active blade. Increasing the power setting reduces the dissection time and the temperature of both blades. Active blade temperatures of <60°C are obtained with cutting times close to 5 seconds; with these cutting times, the inactive blade does not exceed 30°C. The HF+ emissivity profiles demonstrate that the behavior of the inactive blade is significantly different from the active one. To prevent thermal damages, keep the active blade toward the operator, do not exceed 5 seconds of activation, use the maximum power, and avoid the use of the instrument as a dissector immediately after its activation.
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Radcliffe K, Akhtar S, Wilson A. Bilateral hypoglossal nerve damage due to the use of the harmonic focus scalpel. BMJ Case Rep 2020; 13:e231573. [PMID: 31988056 PMCID: PMC7021158 DOI: 10.1136/bcr-2019-231573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2020] [Indexed: 11/03/2022] Open
Abstract
We describe the case of a 68-year-old man who presented with an anterior floor of mouth squamous cell carcinoma and underwent bilateral neck dissection. Subsequently, the patient developed permanent bilateral hypoglossal palsies, causing significant dysphagia, dysarthria and breathing difficulties. Hypoglossal nerve damage from surgical causes is uncommon, occurring in only 0.42% of functional neck dissections. However, it is the bilateral and permanent features of this case which make it unique. This injury may have been caused by incorrect use of the Harmonic Focus scalpel. Therefore, we discuss the literature demonstrating that the Harmonic Focus scalpel causes more lateral thermal damage than alternative tools, and the widely accepted 3 mm safety limit is not enough to protect important surrounding structures. This case report aims to highlight the need for proper training and specific identification of the hypoglossal nerve to prevent this rare and debilitating complication occurring in future patients.
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Affiliation(s)
- Katherine Radcliffe
- Maxillofacial Surgery, Royal Preston Hospital, Preston, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Shakeel Akhtar
- Maxillofacial Surgery, Royal Preston Hospital, Preston, UK
| | - Ajay Wilson
- Maxillofacial Surgery, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
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33
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Hayami M, Watanabe M, Mine S, Imamura Y, Okamura A, Yuda M, Yamashita K, Shoji Y, Toihata T, Kozuki R, Ishizuka N. Steam induced by the activation of energy devices under a wet condition may cause thermal injury. Surg Endosc 2019; 34:2295-2302. [PMID: 31811453 DOI: 10.1007/s00464-019-07312-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND During esophagectomy for esophageal cancer, meticulous attention is needed to prevent thermal injury to the vital organs, such as the recurrent laryngeal nerve (RLN) and tracheobronchus. In order to clarify the novel mechanism behind thermal injury induced by energy devices, we investigated the temperature of steam with the use of two different devices under wet and dry conditions. METHODS An ultrasonic device (Sonicision™) and a vessel sealing device (Ligasure™) were studied. We evaluated the temperature at the tip of the devices and the steam when the devices were activated under different grasping ranges, under four different combinations of device and muscle, and under four different wet/dry conditions (dry-dry, dry-wet, wet-dry, and wet-wet). RESULTS Although the maximum temperature of the devices was significantly higher with Sonicision™ than with Ligasure™, the maximum temperature of the steam was significantly higher with Ligasure™ than with Sonicision™ in almost all situations. At 1 mm away from Sonicision™, the critical temperature more than 60 °C was observed only when used with one-third grasping range under the wet-dry or the wet-wet conditions. In case of Ligasure™, high-temperature steam was observed when used with one-third grasping under the wet-dry or the wet-wet condition and two-third grasping under the dry-wet, the wet-dry, or the wet-wet condition. Under the wet condition, the emission of steam from the non-grasping part of Ligasure™ caused a spike in temperature that exceeded the critical temperature. CONCLUSION We demonstrated that the use of energy devices under a wet condition generates steam from the non-grasping part of the devices. The temperatures of steam from Ligasure™ were significantly higher than that from Sonicision™. To prevent thermal injury to the vital organs, a very attentive and meticulous surgical technique is imperative considering the characteristics of each device.
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Affiliation(s)
- Masaru Hayami
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masami Yuda
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshiaki Shoji
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryotaro Kozuki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Ishizuka
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Tsuzuki N, Wasano K, Kawasaki T, Sasaki S, Ogawa K. Thyroid lobe size predicts risk of postoperative temporary recurrent laryngeal nerve paralysis. Laryngoscope Investig Otolaryngol 2019; 4:708-713. [PMID: 31890892 PMCID: PMC6929579 DOI: 10.1002/lio2.321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/09/2019] [Accepted: 10/18/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES In patients who had undergone thyroidectomy in Japan for benign tumor, we determined whether thyroid lobe size correlates with temporary recurrent laryngeal nerve paralysis (T-RLNP). METHODS We retrospectively collected medical record data on usage of intraoperative neuromonitoring, laterality of thyroidectomy, amount of bleeding during surgery, duration of surgery, and whether the surgeon was a board certified otorhinolaryngologist as determined by the Oto-Rhino-Laryngological Society of Japan. Thyroid size was measured in preoperative axial computed tomography (CT) images. Receiver operating characteristic (ROC) curve analysis was used to determine the thyroid size that predicted a high risk of T-RLNP or permanent recurrent laryngeal nerve paralysis (P-RLNP). RESULTS Of the 146 eligible patients identified, 9 (6.2%) developed T-RLNP and 2 (1.4%) developed P-RLNP. The amount of bleeding during thyroidectomy was significantly greater in T-RLNP patients than in P-RLNP patients. Thyroid sizes in CT images were significantly larger in T-RLNP patients compared to patients who did not develop RLNP (referred to hereafter as N-RLNP). ROC analysis revealed that 1.3% of thyroid lobes with an area of less than 1000.0 mm2, and 9.9% of thyroid lobes with an area of greater than 1000.0 mm2 were at risk for T-RLNP. CONCLUSION We presented evidence that thyroid sizes, as measured on preoperative axial CT images, were larger in T-RLNP patients than in N-RLNP patients. Our results indicate a connection between benign thyroid tumor stretch injuries and T-RLNP. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nobuyoshi Tsuzuki
- Department of OtolaryngologyJapanese Red Cross Shizuoka HospitalShizuokaJapan
| | - Koichiro Wasano
- National Hospital Organization Tokyo Medical CenterNational Institute of Sensory OrgansTokyoJapan
| | - Taiji Kawasaki
- Department of OtolaryngologyJapanese Red Cross Shizuoka HospitalShizuokaJapan
| | - Shun‐ichi Sasaki
- Department of OtolaryngologyJapanese Red Cross Ashikaga HospitalTochigiJapan
| | - Kaoru Ogawa
- Department of OtolaryngologyHead and Neck Surgery, Keio University School of MedicineTokyoJapan
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35
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Mok A, Allen J, Haney MM, Deninger I, Ballenger B, Caywood V, Osman KL, Zitsch B, Hopewell BL, Thiessen A, Szewczyk M, Ohlhausen D, Newberry CI, Leary E, Lever TE. A Surgical Mouse Model for Advancing Laryngeal Nerve Regeneration Strategies. Dysphagia 2019; 35:419-437. [PMID: 31388736 DOI: 10.1007/s00455-019-10045-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/06/2019] [Accepted: 07/31/2019] [Indexed: 01/16/2023]
Abstract
Iatrogenic recurrent laryngeal nerve (RLN) injury is a morbid complication of anterior neck surgical procedures. Existing treatments are predominantly symptomatic, ranging from behavioral therapy to a variety of surgical approaches. Though laryngeal reinnervation strategies often provide muscle tone to the paralyzed vocal fold (VF), which may improve outcomes, there is no clinical intervention that reliably restores true physiologic VF movement. Moreover, existing interventions neglect the full cascade of molecular events that affect the entire neuromuscular pathway after RLN injury, including the intrinsic laryngeal muscles, synaptic connections within the central nervous system, and laryngeal nerve anastomoses. Systematic investigations of this pathway are essential to develop better RLN regenerative strategies. Our aim was to develop a translational mouse model for this purpose, which will permit longitudinal investigations of the pathophysiology of iatrogenic RLN injury and potential therapeutic interventions. C57BL/6J mice were divided into four surgical transection groups (unilateral RLN, n = 10; bilateral RLN, n = 2; unilateral SLN, n = 10; bilateral SLN, n = 10) and a sham surgical group (n = 10). Miniaturized transoral laryngoscopy was used to assess VF mobility over time, and swallowing was assessed using serial videofluoroscopy. Histological assays were conducted 3 months post-surgery for anatomical investigation of the larynx and laryngeal nerves. Eight additional mice underwent unilateral RLN crush injury, half of which received intraoperative vagal nerve stimulation (iVNS). These 8 mice underwent weekly transoral laryngoscopy to investigate VF recovery patterns. Unilateral RLN injury resulted in chronic VF immobility but only acute dysphagia. Bilateral RLN injury caused intraoperative asphyxiation and death. VF mobility was unaffected by SLN transection (unilateral or bilateral), and dysphagia (transient) was evident only after bilateral SLN transection. The sham surgery group retained normal VF mobility and swallow function. Mice that underwent RLN crush injury and iVNS treatment demonstrated accelerated and improved VF recovery. We successfully developed a mouse model of iatrogenic RLN injury with impaired VF mobility and swallowing function that can serve as a clinically relevant platform to develop translational neuroregenerative strategies for RLN injury.
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Affiliation(s)
- Alexis Mok
- Department of Communication Science and Disorders, University of Missouri School of Health Professions, Columbia, MO, USA
| | - Jakob Allen
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Megan M Haney
- Department of Veterinary Pathobiology, University of Missouri College of Veterinary Medicine, Columbia, MO, USA
| | - Ian Deninger
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Brayton Ballenger
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Victoria Caywood
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Kate L Osman
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Bradford Zitsch
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Bridget L Hopewell
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Aaron Thiessen
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Marlena Szewczyk
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Daniel Ohlhausen
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | | | - Emily Leary
- Department of Orthopedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Teresa E Lever
- Department of Otolaryngology - Head & Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA. .,One Hospital Dr. MA314, Columbia, MO, 65212, USA.
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36
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Hayami M, Watanabe M, Mine S, Imamura Y, Okamura A, Yuda M, Yamashita K, Toihata T, Shoji Y, Ishizuka N. Lateral thermal spread induced by energy devices: a porcine model to evaluate the influence on the recurrent laryngeal nerve. Surg Endosc 2019; 33:4153-4163. [PMID: 30847557 DOI: 10.1007/s00464-019-06724-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) paralysis is a frequently observed complication after esophagectomy, and thermal injury is considered to be one of the causes. The difference in the lateral thermal spread associated with the grasping range of various energy devices remains unknown. METHODS Ultrasonic devices (Harmonic® HD1000i and Sonicision™) and a vessel-sealing device (Ligasure™) were studied. We evaluated the temperature of these devices, the activation time required, and the thermal spread on porcine muscle when the devices were used with different grasping ranges (thermal spread study). In addition, we evaluated the influence of thermal spread by short grasping use of the energy devices on the viability of RLN in a live porcine model (NIM study). RESULTS In the thermal spread study, the temperature of the ultrasonic devices lowered as grasping range increased, whereas the highest temperature of Ligasure was observed when used with two-thirds grasping. The activation time of ultrasonic devices became longer as grasping range increased, whereas the grasping range did not influence the activation time of Ligasure. Thermal spreads 1 mm from the energy devices were unaffected by the grasping ranges. Although the temperature of the Ligasure was lower than that of the ultrasonic devices, thermal spread by Ligasure was significantly greater than that induced by the ultrasonic devices. In the NIM study, the activation of the Sonicision with one-third grasping range did not cause EMG changes at distances of up to 1 mm from the RLN, whereas applying Ligasure with a one-third grasping range 1 mm away from the RLN led to a critical result. CONCLUSIONS The grasping range did not influence the thermal spread induced by the energy devices. Ultrasonic devices may be safer in terms of lateral thermal spread to the RLN than Ligasure.
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Affiliation(s)
- Masaru Hayami
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masami Yuda
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshiaki Shoji
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Ishizuka
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Takeuchi M, Kawakubo H, Abe Y, Kanazawa A, Ehara K, Kinugasa Y, Kinoshita T, Nomura A, Kitagawa Y. Assessment of the Safety of the New Hybrid Pencil Type Energy (NP) Device Used Close to the Recurrent Laryngeal Nerve in a Porcine Model: Comparison With a Conventional Electrosurgical Knife. Surg Innov 2018; 26:219-226. [PMID: 30539682 DOI: 10.1177/1553350618817646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) paralysis is mainly associated with esophagectomy, and it may result in not only other morbidities, such as aspiration pneumonia, but also in long-term issues. Therefore, an approach to prevent RLN paralysis is necessary. The present study was designed to determine the technical usability of the new hybrid pencil type energy (NP) device developed by Olympus Corporation (Tokyo, Japan) and compare it with a conventional electrosurgical knife (EK) for resection around the RLN lymph nodes. METHODS This nonsurvival (acute) study included 10 pigs (20 RLNs) and investigated the threshold for thermal RLN damage with the NP device and a conventional EK. To obtain basic information for our study, a preliminary experiment for heat spread was performed. RESULTS When using the EK device, the amplitude value disappeared at a distance of 1 mm from the RLN, but when using the NP device, the amplitude value was maintained up to a distance of 0.5 mm. There were significant differences at distances of 0 mm, 0.5 mm, and 1 mm between the NP and EK devices. Furthermore, heat spread was lower with the NP device than with the EK device. CONCLUSIONS The new energy device developed by Olympus Corporation was found to be technically safe for resection of the RLN lymph nodes in a porcine model. To the best of our knowledge, this is the first study to demonstrate the potential advantages of using this new energy device in a clinical aspect.
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Affiliation(s)
| | | | - Yuta Abe
- 1 Keio University, School of Medicine Tokyo, Japan
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38
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Translational Study on Recurrent Laryngeal Nerve Temperature Susceptibility. J Surg Res 2018; 234:7-12. [PMID: 30527502 DOI: 10.1016/j.jss.2018.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/29/2018] [Accepted: 08/24/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) injury is the most common and serious complication after thyroid surgery. However, little is known about the temperature threshold leading to RLN injury. In this study, we investigated threshold temperatures that cause RLN injury during thyroid surgery using continuous intraoperative neuromonitoring in swine models. METHODS Four pigs weighing 30 to 40 kg were used for this study. We applied automatic periodic stimulation to the vagus nerve and dissected the RLN. The operative field was then filled with water at various temperatures (1.9°C to 87.4°C). The threshold temperature was defined as the temperature measured before filling the operative field that was associated with adverse events (latency increase of more than 10% or amplitude decrease of more than 50%). Loss of signal was defined as the electromyography (EMG) signal disappearing and not recovering during 30 min of observation. RESULTS The low and high threshold temperatures were 2.5°C and 81.5°C, respectively. There were no adverse events at surrounding temperatures between 5.9°C and 77.5°C. The EMG signals in the RLNs exposed to the low threshold temperatures recovered, and there was no loss of signal. In contrast, the RLNs that showed adverse events at the high threshold temperatures showed loss of signal and no recovery of EMG signals. CONCLUSIONS The RLN was found to be resistant to cold injury, whereas surrounding temperatures above 81.5°C may cause permanent thermal injury to the RLN. The surrounding temperature should be controlled within the safe range during thyroid surgery to avoid RLN injury.
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39
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Zhao Y, Li C, Zhang D, Zhou L, Liu X, Li S, Wang T, Dionigi G, Sun H. Experimental study of needle recording electrodes placed on the thyroid cartilage for neuromonitoring during thyroid surgery. Br J Surg 2018; 106:245-254. [PMID: 30273975 DOI: 10.1002/bjs.10994] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/11/2018] [Accepted: 08/02/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing recurrent laryngeal nerve (RLN) function during thyroid surgery. Needle electrodes placed on the TC were evaluated in an experimental porcine model. METHODS Continuous intraoperative neuromonitoring was used to record the electromyogram. Each TC side was delineated into nine areas to determine the optimal placement of the electrode, and needle electrode area, depth and orientation for optimal electromyographic (EMG) amplitudes were evaluated. RLN root locations were stimulated at four locations: vagus nerve distal to the neuromonitoring electrode, and most proximal, middle and laryngeal entry points of the nerve. A nerve retraction injury model was adapted to compare RLN monitoring by TC versus ET electrodes. RESULTS An optimal site for placement of needle electrodes was identified, and electromyograms obtained from the various needle insertion depths and orientations were similar. Latencies recorded from the TC and ET electrodes were similar. The amplitude profile of TC electrodes responded earlier to RLN injury than that of ET electrodes. Amplitude and drop to loss of signal were also registered earlier. CONCLUSION EMG amplitudes obtained using TC electrodes were higher, and identified RLN injury earlier than ET electrodes. Surgical relevance Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing the function of the recurrent laryngeal nerve (RLN) in thyroid surgery. This study used an experimental porcine model to evaluate the use of needle electrodes inserted in the TC, compared with ET electrodes, for producing an electromyographic (EMG) profile of the RLN. Nine areas of the TC, with various needle insertion depths and orientations, were compared. Perichondral insertion into the avascular area of the TC was found to be safe. The EMG amplitude and latency features recorded via the TC and ET electrodes were compared, using both intermittent and continuous monitoring. Changes in EMG amplitudes in response to nerve traction injury were registered earlier with TC electrodes than with ET electrodes, and the amplitudes were higher and more stable. Latencies obtained via the TC and ET electrodes were similar. These results indicate that the development of a non-invasive monitoring electrode with improved function, easy placement and low cost is possible.
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Affiliation(s)
- Y Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - C Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - D Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - L Zhou
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - X Liu
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - S Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - T Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
| | - G Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood 'Gaetano Barresi', University Hospital G. Martino, University of Messina, Messina, Italy
| | - H Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, China
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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; 42:137-142. [PMID: 28815342 DOI: 10.1007/s00268-017-4159-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is a serious complication of thyroid surgery. During intraoperative neuromonitoring (IONM) of the RLN in thyroid surgery, repeated shifting between surgical instruments and the nerve stimulator is cumbersome and time-consuming. Therefore, we developed a simple detachable magnetic nerve stimulator that may be connected to all metallic surgical instruments. This study aimed to investigate the feasibility and efficacy of this detachable magnetic nerve stimulator for IONM in a porcine model and humans. METHODS Eight RLNs in four pigs and thirteen in nine patients that underwent thyroidectomy were examined. We developed a detachable nerve stimulator that combined surgical instruments with the nerve-stimulating probe. We evaluated the electromyography (EMG) amplitudes of the RLNs in pigs and patients using conventional nerve probes and surgical instruments with the novel detachable magnetic nerve stimulator attached. RESULTS The EMG amplitudes of the eight RLNs in pigs and thirteen in patients were analyzed. The detachable magnetic nerve stimulator was feasible and safe. There was no significant difference in the EMG amplitude between instruments (P = 0.423 in animals, P = 0.446 in humans). CONCLUSIONS The application of stimulating dissection using a detachable magnetic nerve stimulator during thyroidectomy with IONM is simple, convenient, and effective. It provides surgeons with real-time feedback of the EMG response during intermittent IONM. We propose that this novel device could be an essential guide for most surgeons, especially for less experienced head and neck surgeons.
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Affiliation(s)
- Eui-Suk Sung
- Department of Otolaryngology - Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, College of Medicine, Pusan National University, Yangsan, Korea
| | - Jin-Choon Lee
- Department of Otolaryngology - Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, College of Medicine, Pusan National University, Yangsan, Korea
| | - Sung-Chan Shin
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Medical Research Institute, Pusan National University, 305 Gudeok-ro Seo-gu, Busan, 49241, Korea
| | - Sung-Won Choi
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Medical Research Institute, Pusan National University, 305 Gudeok-ro Seo-gu, Busan, 49241, Korea
| | - Da-Woon Jung
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Medical Research Institute, Pusan National University, 305 Gudeok-ro Seo-gu, Busan, 49241, Korea
| | - Byung-Joo Lee
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Medical Research Institute, Pusan National University, 305 Gudeok-ro Seo-gu, Busan, 49241, Korea.
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Thermal effects of the Thunderbeat ™ device on the recurrent laryngeal nerve during thyroid surgery. Surg Today 2018; 48:1076-1080. [PMID: 29987357 DOI: 10.1007/s00595-018-1692-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To investigate the safety of the Thunderbeat™ (TB) device in thyroid surgery by clarifying its thermal effects on the recurrent laryngeal nerve (RLN). METHODS We performed thyroidectomy using TB on four female pigs under general anesthesia. TB was applied 0, 1, and 2 mm from the RLN. The effects of incisions made in tissues in the vicinity of the RLN were evaluated by intraoperative neuromonitoring and pathological examination. RESULTS The value of the neural integrity monitor (NIM) was unchanged at 2 and 1 mm, but there was loss of signal at 0 mm. The differences between 2 and 0 mm were not clear from the pathological findings. CONCLUSIONS When using the TB device during thyroid surgery, it is recommended that it is visually kept from making any contact with the RLN.
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Liu X, Zhang D, Zhang G, Zhao L, Zhou L, Fu Y, Li S, Zhao Y, Li C, Wu CW, Chiang FY, Dionigi G, Sun H. Laryngeal nerve morbidity in 1.273 central node dissections for thyroid cancer. Surg Oncol 2018. [PMID: 29525322 DOI: 10.1016/j.suronc.2018.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM We assess the prevalence and mechanism of recurrent laryngeal nerve (RLN) injury in central neck dissection (CND) for thyroid cancer. METHODS CND with intraoperative neural monitoring was outlined in 1.273 nerves at risk (NAR). RLN lesions were stratified according to: timing (during thyroidectomy versus CND), segmental vs. diffuse injury, mechanism, severity, location, number of lymph nodes dissected and metastastatic. EMG parameters were recorded. RESULTS 49/1.273NAR (3,8%) documented RLN palsy. 25 nerves were injured during thyroidectomy, 8 while CND. In 16 no precise moment or mechanism of injury was identified. A disrupted point could be identified in 19/25 (76%) and 7/8 (87%) respectively for thyroidectomy and CND steps. Diffuse injury, occurred in 24% and 12,5% respectively for thyroidectomy and CND. Nerves were injured in the all cervical nerve course without any major location for incidence for CND; for thyroidectomy most nerves were injured in the last 1 cm course. Traction (36%) was the leading cause of RLN injury for thyroidectomy. For solely CND, traction, entrapment and thermal injuries were equally frequent. Permanent vs. transient injuries were respectively 8% (4/49) and 92% (n.45/49), overall. Permanent lesions were equally distributed. CONCLUSIONS During CND, RLN palsy still occurs with routine exposure of the nerve even combined with IONM. The incidence of nerve lesions during thyroidectomy is higher than that of CND.
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Affiliation(s)
- Xiaoli Liu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Daqi Zhang
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Guang Zhang
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Lina Zhao
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Le Zhou
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Yantao Fu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Shijie Li
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Yishen Zhao
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Changlin Li
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi" University Hospital - Policlinico "G. Martino" - The University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China.
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Sun H, Wu CW, Kim HY, Dionigi G. Neural monitoring represent central safety asset for new technologies in thyroid surgery in translational protocols. Am J Surg 2018; 216:1235-1236. [PMID: 29395017 DOI: 10.1016/j.amjsurg.2018.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/08/2018] [Indexed: 11/25/2022]
Abstract
Commentary on the published paper by Chávez KV, Barajas EM, Soroa F, Gamboa-Dominguez A, Ordóñez S, Pantoja JP, Sierra M, Velázquez-Fernández D, Herrera MF. Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model. Am J Surg. 2018 Jan;215(1):186-190. doi: 10.1016/j.amjsurg.2017.04.013. Epub 2017 Jun 7. PubMed PMID: 28622836.
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Affiliation(s)
- Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center Korea University, Anam Hospital, Seoul, South Korea
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy.
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Chávez KV, Barajas EM, Soroa F, Gamboa-Dominguez A, Ordóñez S, Pantoja JP, Sierra M, Velázquez-Fernández D, Herrera MF. Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model. Am J Surg 2017. [PMID: 28622836 DOI: 10.1016/j.amjsurg.2017.04.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Advanced bipolar and ultrasonic energy have demonstrated reduction of operating time and blood loss in thyroidectomy. However, these devices generate heat and thermal dispersion that may damage adjacent structures such as the recurrent laryngeal nerve (RLN). This study was designed to evaluate the safety profile of the Harmonic Focus+® (HF+) device through the evaluation of thermal injury to the RLN using different algorithms of distance and time with state of the art technology. METHODS 25 Vietnamese pigs underwent activation of HF+ in the proximity of their RLN. They were divided into 4 groups according to activation distance (3 mm, 2 mm, 1 mm and on the RLN). Time of activation, time between tones of the ultrasonic generator, changes in the electromyographic signal using continuous nerve neuromonitoring, vocal fold mobility assessed by direct laryngoscopy and histological thermal damaged were evaluated. RESULTS None of the pigs had loss of signal in the electromyography during the procedure; only one pig had isolated transient decrease in amplitude and one increase in latency. One pig had transient vocal fold paresis in the group with activation on the nerve. Evaluation of the nerves by histology and immunohistochemistry did not show significant changes attributed to thermal injury. CONCLUSIONS The use of ultrasonic energy close to the RLN is safe, provided that activation time does not exceed the necessary time to safely transect the tissue.
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Affiliation(s)
- Karla V Chávez
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elpidio M Barajas
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Francisco Soroa
- Service of Otolaryngology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Armando Gamboa-Dominguez
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Samuel Ordóñez
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan P Pantoja
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mauricio Sierra
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Velázquez-Fernández
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel F Herrera
- Service of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Pre-operative Screening and Manual Drilling Strategies to Reduce the Risk of Thermal Injury During Minimally Invasive Cochlear Implantation Surgery. Ann Biomed Eng 2017; 45:2184-2195. [PMID: 28523516 DOI: 10.1007/s10439-017-1854-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
This article presents the development and experimental validation of a methodology to reduce the risk of thermal injury to the facial nerve during minimally invasive cochlear implantation surgery. The first step in this methodology is a pre-operative screening process, in which medical imaging is used to identify those patients that present a significant risk of developing high temperatures at the facial nerve during the drilling phase of the procedure. Such a risk is calculated based on the density of the bone along the drilling path and the thermal conductance between the drilling path and the nerve, and provides a criterion to exclude high-risk patients from receiving the minimally invasive procedure. The second component of the methodology is a drilling strategy for manually-guided drilling near the facial nerve. The strategy utilizes interval drilling and mechanical constraints to enable better control over the procedure and the resulting generation of heat. The approach is tested in fresh cadaver temporal bones using a thermal camera to monitor temperature near the facial nerve. Results indicate that pre-operative screening may successfully exclude high-risk patients and that the proposed drilling strategy enables safe drilling for low-to-moderate risk patients.
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Dionigi G, Wu CW, Kim HY, Rausei S, Boni L, Chiang FY. Severity of Recurrent Laryngeal Nerve Injuries in Thyroid Surgery. World J Surg 2017; 40:1373-81. [PMID: 26817650 DOI: 10.1007/s00268-016-3415-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies in the literature have reported recovery data for different types of recurrent laryngeal nerve injuries (RLNIs). This study is the first attempt to classify RLNIs and rank them by severity. METHODS This prospective clinical study analyzed 281 RLNIs in which a true loss of signal was identified by intraoperative neuromonitoring (IONM), and vocal cord palsy (VCP) was confirmed by a postoperative laryngoscope. For each injury type, the prevalence of VCP, the time of VCP recovery, and physical changes on nerves were analyzed. Additionally, different RLNI types were experimentally induced in a porcine model to compare morphological change. RESULTS The overall VCP rate in at-risk patients/nerves was 8.9/4.6 %, respectively. The distribution of RLNI types, in order of frequency, was traction (71 %), thermal (17 %), compression (4.2 %), clamping (3.4 %), ligature entrapment (1.6 %), suction (1.4 %), and nerve transection (1.4 %). Complete recovery from VCP was documented in 91 % of RLNIs. Recovery time was significantly faster in the traction group compared to the other groups (p < 0.001). The rates of temporary and permanent VCP were 98.6 and 1.4 % for traction lesion, 72 and 28 % for thermal injury, 100 and 0 % for compression injury, 50 and 50 % for clamping injury, 100 and 0 % for ligature entrapment, 100 and 0 % for suction injury, and 0 and 100 % for nerve transection, respectively. Physical changes were noted in 14 % of RLNIs in which 56 % of VCP was permanent. However, among the remaining 86 % IONM-detectable RLNIs without physical changes, only 1.2 % of VCP was permanent. A porcine model of traction lesion showed only distorted outer nerve structure, whereas the thermal lesion showed severe damage in the inner endoneurium. CONCLUSIONS Different RNLIs induce different morphological alterations and have different recovery outcomes. Permanent VCP is rare in lesions that are visually undetectable but detectable by IONM. By enabling early detection of RLNI and prediction of outcome, IONM can help clinicians plan intra- and postoperative treatment.
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Affiliation(s)
- Gianlorenzo Dionigi
- 1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100TzYou 1st Road, Kaohsiung City, 807, Taiwan.
| | - Hoon Yub Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Minimally Invasive Surgery and Robotic Surgery Center, Korea University Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, Korea
| | - Stefano Rausei
- 1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy
| | - Luigi Boni
- 1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100TzYou 1st Road, Kaohsiung City, 807, Taiwan
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Siebold MA, Dillon NP, Fichera L, Labadie RF, Webster RJ, Fitzpatrick JM. Safety margins in robotic bone milling: from registration uncertainty to statistically safe surgeries. Int J Med Robot 2016; 13. [PMID: 27650366 DOI: 10.1002/rcs.1773] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND When robots mill bone near critical structures, safety margins are used to reduce the risk of accidental damage due to inaccurate registration. These margins are typically set heuristically with uniform thickness, which does not reflect the anisotropy and spatial variance of registration error. METHODS A method is described to generate spatially varying safety margins around vital anatomy using statistical models of registration uncertainty. Numerical simulations are used to determine the margin geometry that matches a safety threshold specified by the surgeon. RESULTS The algorithm was applied to CT scans of five temporal bones in the context of mastoidectomy, a common bone milling procedure in ear surgery that must approach vital nerves. Safety margins were generated that satisfied the specified safety levels in every case. CONCLUSIONS Patient safety in image-guided surgery can be increased by incorporating statistical models of registration uncertainty in the generation of safety margins around vital anatomy.
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Affiliation(s)
- Michael A Siebold
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, USA
| | - Neal P Dillon
- Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Loris Fichera
- Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Robert F Labadie
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J Webster
- Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - J Michael Fitzpatrick
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee, USA
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Dionigi G, Wu CW, Kim HY, Liu X, Liu R, Randolph GW, Anuwong A. Safety of energy based devices for hemostasis in thyroid surgery. Gland Surg 2016; 5:490-494. [PMID: 27867863 DOI: 10.21037/gs.2016.09.01] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Energy based devices (EBD) have been developed, implemented and increasingly applied in thyroid surgery because they can provide a combined dissection and haemostatic effect. In particular, advantages of EBD have been described in terms of efficacious haemostasis, reduction of procedure-associated time, reduced incision length, less operative blood loss and transfusion need, decreased postoperative drain, pain and hospital stay. In addition, EBD are essential for endoscopic procedures. On the contrary, a potential drawback is the increased health care costs. This paper reviews relevant medical literature published on the safety of new devices for achieving hemostasis and dissection around the recurrent laryngeal nerve (RLN).
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Affiliation(s)
- Gianlorenzo Dionigi
- 1st Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hoon-Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Korea
| | - Xiaoli Liu
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Changchun 130031, China
| | - Renbin Liu
- Division of Thyroid and Breast Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
| | - Angkoon Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
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Wu CW, Randolph GW, Lu IC, Chang PY, Chen YT, Hun PC, Lin YC, Dionigi G, Chiang FY. Intraoperative neural monitoring in thyroid surgery: lessons learned from animal studies. Gland Surg 2016; 5:473-480. [PMID: 27867861 PMCID: PMC5106378 DOI: 10.21037/gs.2016.09.06] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 09/09/2016] [Indexed: 12/31/2022]
Abstract
Recurrent laryngeal nerve (RLN) injury remains a significant morbidity associated with thyroid and parathyroid surgery. In the past decade, surgeons have increasingly used intraoperative neural monitoring (IONM) as an adjunct technique for localizing and identifying the RLN, detecting RLN injury, and predicting the outcome of vocal cord function. In recent years, many animal studies have investigated common pitfalls and new applications of IONM. For example, the use of IONM technology in animal models has proven valuable in studies of the electrophysiology of RLN injury. The advent of animal studies has substantially improved understanding of IONM technology. Lessons learned from animal studies have immediate clinical applications in establishing reliable strategies for preventing intraoperative RLN injury. This article gives an overview of the research progress on IONM-relevant animal models.
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Affiliation(s)
- Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pao-Chu Hun
- Laboratory Animal Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- 1 Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
PURPOSE OF REVIEW Laryngeal nerve injury, resulting in speech and swallowing dysfunction, is a feared complication of thyroid operations. Routine visualization of the recurrent laryngeal nerve (RLN) has decreased the likelihood of nerve injury, and intraoperative nerve monitoring has been applied in the hope of further enhancing safety. RECENT FINDINGS There is conflicting evidence about the value of nerve monitoring during thyroid operations, despite ample research. The data favor nerve monitoring in certain situations, such as neck re-explorations, contralateral RLN injury, extensive or challenging dissections, invasive tumors or large goiters, and nonrecurrent or branching recurrent laryngeal nerves. Continuous intraoperative nerve monitoring may reduce the chances of excessive traction, which is the most common mechanism of injury. Nerve monitoring may also identify and protect the external branches of the superior laryngeal nerve. SUMMARY Surgeons should routinely identify recurrent laryngeal nerves during thyroid operations, and intraoperative nerve monitoring might be a useful adjunct to prevent injury. As a result of the relatively low probability of permanent recurrent laryngeal nerve injury, it is difficult to establish the absolute value of nerve monitoring. Further research may focus on continuous nerve monitoring and intraoperative monitoring of the external branches of the superior laryngeal nerves.
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Affiliation(s)
- Ivy H Gardner
- aBoston University School of MedicinebDepartment of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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