Utility of intraoperative neuromonitoring in detecting recurrent nerve's anatomical anomalies during thyroidectomy.

Anatomical variations such as a non-recurrent laryngeal nerve (NRLN) are very rare (reported rates within 0.6-1% to the right side and only four cases to the left side) but they can lead to serious risk of nerve lesion during thyroidectomy. It is known that to prevent inferior laryngeal nerve lesions, it is mandatory to obtain a correct and wide exposure of the nerve during all kind of thyroid surgeries but in case of laryngeal nerve position anomalies, it is hard to achieve a safe nerve identification. Continuous intraoperative neuromonitoring (C-IONM) technology can detect the presence of NRLN. In this study we present seven cases of NRLN incidentally found during our last 10-year experience, in a total of 1074 procedures, including total thyroidectomy and lobectomy. Three out of seven cases were identified with the help of C-IONM. On the other hand, the other four cases of non-recurrent laryngeal nerve were identified during an extensive dissection of the thyroid lodge. We registered no nerve palsy in the group of patients who underwent surgery with the help of C-IONM, while we had two nerve palsies (out of four cases) in the group of patients without the help of C-IONM. In our experience we also registered a reduction of surgery time when we used the C-IONM. In our opinion C-IONM is a safe method to discover anatomical anomalies such as a non-recurrent laryngeal nerve and may help to reduce nerve palsy rate.

Indocyanine green fluorescence angiography: a new ERAS item.

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case-control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.