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.

Transoral thyroidectomy: why is it needed?

Transoral thyroidectomy (TOT) represents reasonably the desirable minimally invasive approach to the gland due to the scarless non-visible incisions, the limited distance between the gland and the access that minimize tissue dissection and respect of the surgical anatomical planes. Patients are routinely selected according to an extensive inclusion criteria: (I) ultrasonographically (US) estimated thyroid diameter not larger than 10 cm; (II) US gland volume ≤45 mL; (III) nodule size ≤50 mm; (IV) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (V) follicular neoplasm; (VI) papillary microcarcinoma without lymph node metastasis. The operation is realized through median, central approach which allows bilateral exploration of the thyroid gland and central compartment. TOT is succeed both endoscopically adopting ordinary endoscopic equipments or robotically. In detail three ports are placed at the inferior oral vestibule: one 10-mm port for 30° endoscope and two 5-mm ports for dissecting, coagulating and neuromonitoring instruments. Low CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles similar to that of conventional thyroidectomy. TOT is now reproducible in selective high volume endocrine centers.

Early intact PTH (iPTH) is an early predictor of postoperative hypocalcemia for a safer and earlier hospital discharge: an analysis on 260 total thyroidectomies.

BACKGROUND: Hypocalcemia is the most frequent complication after thyroidectomy. Serum calcium levels are reliable only 48-72 hours postoperatively. Early intact PTH (iPTH) has been proposed as early predictor of postoperative hypocalcemia. Our aim is to assess the ability of iPTH in predicting postoperative hypocalcemia. METHODS: Two hundred and sixty patients underwent thyroidectomy with postoperative iPTH evaluation. The iPTH samplings were early performed after thyroidectomy. The calcium levels were dosed postoperatively. Age, sex, clinical diagnosis, obesity, comorbidities, previous neck surgery, preoperative therapy, type of surgery, dissectors used, lymphadenectomy, post-operative complications, reoperation and histological diagnosis were considered. The primary end-point was the postoperative hospital stay. The secondary end-points were serum calcium and iPTH. Three iPTH cut-offs were tested to assess which was the best value (10.0, 15.0, and 20.0 pg/mL). RESULTS: The iPTH cut-off value of 10.0 pg/mL was the most accurate and specific for hypocalcemia. Comparing the iPTH value with the different values of calcium respectively 24 and 48 hours after surgery, a statistically stronger association with the serum calcium levels 48 hours postoperatively has been shown. iPTH ≥10 pg/mL 3-6 hours after surgery was strongly correlated to early discharge. CONCLUSIONS: The correlation of iPTH with hypocalcemia is significant since a few hours after surgery and the value of iPTH ≥10 pg/mL is able to select those patients for a safe and early discharge. The use of the iPTH might avoid unnecessary extensions of hospitalization.

Continuous intraoperative neuromonitoring in thyroid surgery: Safety analysis of 400 consecutive electrode probe placements with standardized procedures.

BACKGROUND: Continuous intraoperative neuromonitoring (C-IONM) is a new technology and it is appropriate to analyze its safety. METHODS: C-IONM was performed according to a standardized technique to control any adverse events and electrode positioning issues. RESULTS: Four hundred vagal nerve dissections were analyzed considering vagal nerve diameter, mean time effort for C-IONM probe positioning, and electrode dislocation rate. A significant superior dislocation rate in case of: (a) when a 3 mm automatic periodic stimulating (APS) electrode size was used in a vagal nerve diameter <2 mm; (b) anterior access; and (c) vagal nerve A subtype in relation (p < .05). No related additional local or systemic morbidity was registered in this series. There was a statistically significant positive relationship between increased diameter of vagal nerve and increased electromyography (EMG) amplitude (p = .03). There was also a significant increase of amplitude between initial and final vagal nerve stimulation in uneventful cases (p = .02). CONCLUSION: We analyzed the technical issues to achieve improved vagal nerve critical view of safety dissection, stimulation, and C-IONM probe placement. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1568-E1574, 2016.