Self-Retaining Retractor Widox® for Thyroid Surgeries: Technical Note.

During a thyroidectomy, perfect exposure of the vascular nerve structures, parathyroid gland, trachea, larynx, esophagus, and lymphnodes is crucial to facilitate the surgeon in the meticulous dissection. WIDOX® (MOSS Spa, Lesa, Italy) is an atraumatic self-retaining thyroidectomy retractor specifically designed for thyroid surgeries with an octagonal shape and six retractors (Fig. 1). It is a sterile, single-use device which keeps the surgical wound and the neck muscles retracted allowing the proper exposure of the operatory field. The device substitutes the manual retractors held by the surgeon's assistants. In our institute, we started using the self-retaining retractor WIDOX® from May 2015 for a total of 50 patients. From our preliminary experience, the self-retaining retractor WIDOX® is simple and practical and can be adapted to each patient. The use of energy-based devices and the neuromonitoring is not prevented by the presence of this retractor.

Continuous Intraoperative Neuromonitoring (C-IONM) Technique with the Automatic Periodic Stimulating (APS) Accessory for Conventional and Endoscopic Thyroid Surgery.

One of the most important trends in intraoperative neural monitoring (IONM) in thyroid surgery is currently the real-time monitoring of the vagus nerve (VN) in order to prevent recurrent laryngeal nerve (RLN) iatrogenic damages. Notably, continuous intraoperative neuromonitoring (C-IONM) seems to be superior to intermitted intraoperative neural monitoring (I-IONM) because it enhances standardization by permanent vagus nerve (VN) stimulation, and it provides entire and constant RLN function monitoring as the surgeon dissects and removes the thyroid gland. It also has to be highlighted that the surgical maneuvers for the automatic periodic stimulating (APS) placement must be accurate and standardized in order to avoid a potential iatrogenic morbidity on the VN function. We recommend the experienced surgeon be very careful in each step, with cautious dissection. With this review article we provide a comprehensive analyses of C-IONM technique with the APS accessory for conventional and endoscopic thyroid surgery.

Non-recurrent Laryngeal Nerve During Intraoperative Neuromonitoring Thyroidectomy: A Case Report and Literature Review.

Complete and precise knowledge of the neck anatomy and its eventual anomalies is crucial while performing a safe thyroid and parathyroid surgery. Embryo-genetic malformations of the IV branchial arch can lead to an uncommon anatomical alteration known as non-recurrent inferior laryngeal nerve. Its prevalence varies between 0.7% for the dextral branch and 0.04% for the sinistral. In these cases, the inferior laryngeal nerve branches originate directly from the cervical vagus nerve, entering the larynx without hooking, on the right side around the subclavian artery or on the left around the aortic arch. The presence of a non-recurrent laryngeal nerve is challenging, due to the increased risks of iatrogenic damage to the nerve, which results in hoarseness, dysphagia, glottal obstruction, vocal cords palsy, and serious airway impairment. We present the case of a 58-year-old woman. The patient was admitted to our department for a nodule classified as Bethesda IV in the right thyroid lobe. Through the use of intraoperative neuromonitoring (IONM), surgeons detected intraoperatively a non-recurrent laryngeal nerve. A subsequent computed tomography scan confirmed an anomalous right subclavian artery branching from the left aortic arch, the Lusoria Artery. Anatomical variants represent pitfalls in this case and an accurate knowledge of the neck region is imperative while performing thyroid surgery. Devices such as IONM are useful for detecting abnormalities that may lead to iatrogenic damages.

Vagus nerve stimulation for standardized monitoring: technical notes for conventional and endoscopic thyroidectomy.

Standardization of the intraoperative neuromonitoring (IONM) technique is an essential aspect of modern monitored thyroid surgery. The standardized technique involves vagal nerve stimulation. VN stimulation is useful for technical problem solving, detecting non-recurrent laryngeal nerve (non-RLN), recognizing any recurrent laryngeal nerve (RLN) lesions, and precisely predicting RLN postoperative function. Herein, we present technical notes for the VN identification to achieve the critical view of safety of the VN stimulation with or without dissection.

The safety of energy-based devices in open thyroidectomy: a prospective, randomised study comparing the LigaSure™ (LF1212) and the Harmonic® FOCUS.

PURPOSE: The options for haemostasis and dissection during modern thyroid surgery include the use of a bipolar vessel sealing system and ultrasonic technology. The aim of this study was to compare these energy-based devices (EBDs) with respect to their use in open thyroidectomy. METHODS: The FOCUS Shear (F) and LigaSure LF1212 (L) were evaluated. A total of 182 consecutive patients scheduled for open thyroidectomy were prospectively randomised into two similarly sized groups. The parameters of operative time, morbidity, incision length, postoperative pain and hospital stay were analysed. RESULTS: The main clinically primary endpoints of the two devices were identical in the study as the rate of nerve lesions, bleeding, drainage, operative time and postoperative calcium concentration with no significant differences with respect to the instrument utilised. The mean length of the incision was greater in the F group (p < 0.05). Patients in the F group were more likely to complain of pain while swallowing (p < 0.001). Early postoperative measurements of intact parathyroid hormone plasma levels revealed that although the levels were within the reference range, they were significantly lower in the F group (p < 0.001). Oral calcium supplementation was significantly higher and more prolonged in the F group. CONCLUSIONS: The present study demonstrated no significant difference in the rates of postoperative morbidity associated with these two different EBDs used. Differences in clinically less significant were founded and focused on.

Recurrent laryngeal nerve management in thyroid surgery: consequences of routine visualization, application of intermittent, standardized and continuous nerve monitoring.

The objective is to compare the consequences of routine visualization (RV) and the application of intermitted (I-IONM), standardized (S-IONM), and continuous monitoring (C-IONM) of recurrent laryngeal nerve (RLN) management. RV includes that 698 RLNs managed solely with visual identification. In a second period 777, RLNs were handled by the I-IONM. The third period 768 RLNs monitoring was performed according to the standards. C-IONM via VN stimulation included 626 RLNs. The following issues were analyzed and compared per each period study: RLN identification rate, branching detection, assessment of NRLN, intraoperative recognizable nerve damage, stage thyroidectomy rate, transient or definitive lesions, bilateral nerve palsy, and recovery time. Significance for nerve identification rate was achieved (p = 0.03) when the statistical analysis was applied between RV vs. S-IONM and C-IONM. Extralaryngeal bifurcation was identified in 21, 44, 43, and 46 of RLN dissected, respectively, per period (p = 0.005). The incidence of paralysis in identified and unidentified RLN was 3.8 % (107/2806) and 82 % (52/63), respectively. Rates of temporary/permanent RLNP were 16.7/1.7, 5/1.1, 4.5/1, and 3.1/0 % per period study, respectively (p = 0.07). Recognizable intraoperatively nerve damage was, respectively, 15, 45, 100, and 100 % for period study (p = 0.03). The recovery of injured nerves was significantly faster in C-IONM group. S-IONM and C-IONM cumulate 40-stage procedures. The standardized technique, guidelines adherences, and C-IONM allowed to (1) increase RLN identification; (2) reduce the severity of injuries in terms of (a) reset bilateral RLNP, (b) faster recovery time, and

Intraoperative neuromonitoring in thyroid surgery: a point prevalence survey on utilization, management, and documentation in Italy.

The frequency of neuromonitoring during thyroid surgery is underreported in Italy. The present survey depicts and describes the patterns of use, management, documentation for IONM devices of IONM during thyroid surgery by surgeons in Italy. A point prevalence survey was undertaken. Source data were mixed from Italian surgeons attending the 2014 International Neuromonitoring Study Group (INMSG) meeting, four IONM manufacturers available in Italy and surgical units were identified from Company sales data. Qualitative and quantitative data were used to analyze. Questions probed IONM prevalence, surgeon background, hospital geographic practice locations, type of hospital, rationale for IONM use, sources of initial capital investment for IONM acquisition, type of equipment, use of continuous IONM, monitoring management, use of distinctive standards, and IONM documentation. IONM is currently delivered through 48 units in Italy. In 2013, the distribution of IONM by specialties included: general (50 %), ENT (46 %), and thoracic surgery (4 %). Overall, 12.853 IONM procedures were performed in the period from 2006 to 2013: 253 were performed in 2007 and about 5,100 in 2013. Distribution according to the type of hospital is: public 48 %, academic setting 37 %, and private maintenance 15 %. The use category of high volume thyroid hospitals represented 33 %. Initial capital investment for the acquisition of the monitoring equipment was 67 % public and 33 % with charitable/private funding. Audio plus graphic and EMG electrodes surface endotracheal tube-based monitoring systems accounted for the majority. Continuous IONM was introduced in 5 Academic Centers. Overall motivations expressed are legal (30 %), RLN confirmation (20 %), RLN identification (20 %), prognosis (10 %), helpful in difficult cases (10 %), decrease surgical time (5 %), and educational (5 %). The survey revealed that participants had few experience with the standardized approach of IONM technique (28 %). General IONM information to patients and/or subsequent specific IONM informed consent was initiated in 8 % of centers. EMG determinations were included in medical chart in 20 %. There were no significant associations found between all parameters considered. The present study describes an increased utilization of IONM in Italy. We highlighted areas for improvement in the management and documentation of IONM.

Web-based information on intraoperative neuromonitoring in thyroid surgery.

BACKGROUND: This is a preliminary analysis of intraoperative neuromonitoring (IONM)-related websites available to the general public with respect to thyroid surgery. METHODS: Four key terms and/or phrases (neuromonitoring AND thyroid AND neck surgery, intraoperative neuromonitoring, intraoperative electrophysiological monitoring, IONM) were entered separately into the search engines Google.com, Yahoo.com and Bing.com. The first 50 results obtained for each search procedure were evaluated. Websites were evaluated for content quality using the validated DISCERN rating instrument. Readability was graded by the Flesch Reading Ease Score and the Flesch-Kincaid Grade Level. RESULTS: The results were related to scientific publications in most cases (64%). A large percentage (59%) of the servers are located in the USA. The main language used is English (91%); only 19% of the websites are multilingual or in other languages. 58% of the sites were rated as excellent to good and 42% as fair to poor. The median Flesch Reading Ease Score was 49.6; the median Flesch-Kincaid Grade Level was 13.85. CONCLUSIONS: World Wide Web information about IONM in thyroid surgery is too specific and difficult and poorly accessible to the general public.

Nodule size and fine-needle aspiration biopsy: diagnostic challenges for thyroid malignancy.

BACKGROUND: To investigate the relationship between nodule size and malignancy and the correlation between the dimensional parameter and fine-needle aspiration biopsy (FNAB) in patients with a nodular goiter. METHODS: Histological data of 415 patients who underwent thyroidectomy were used to estimate the actual nodule size and the difference between the diameter of the nodular lesion and the included tumor (intranodular peritumoral tissue [IPT]). FNAB was performed in 338 patients, and its predictive role was evaluated in comparison with histology. RESULTS: The histology revealed 207 cases of thyroid malignancy. The mean nodule size was significantly larger in benign disease compared with malignant. Only age and FNAB malignant category were independently associated with malignancy. The IPT showed a trend toward a statistically significant association with FNAB malignant category. CONCLUSIONS: Nodule size does not appear to be a reliable parameter to improve the clinical management of a nodular goiter because of a high variability between size of nodular area and tumor diameter.