Recurrent and superior laryngeal nerves: a new look with implications for the esophageal surgeon Dorothea M.I Liebermann-Meffert, MD, Birgit Walbrun,

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Presentation transcript:

Recurrent and superior laryngeal nerves: a new look with implications for the esophageal surgeon Dorothea M.I Liebermann-Meffert, MD, Birgit Walbrun, MD, Clement A Hiebert, MD, J.Rüdiger Siewert, MD The Annals of Thoracic Surgery Volume 67, Issue 1, Pages 217-223 (January 1999) DOI: 10.1016/S0003-4975(98)01131-X

Fig 1 Innervation of the distal half of the proximal esophagus (1) and the trachea (2) through the right vagus nerve (5). Turning point (5∗ ) of the right RLN (3). A pair of tweezers is inserted into the subclavian artery (9) to pull it upward. The structures of the human en bloc specimen are exposed and photographed from the right aspect. Aorta (10). The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)

Fig 2 Meandering, sinuous course of the left RLN (3) shown before its dissection from the underlaying peritracheal (2) tissues. The thyroid gland (6) is still in place. Esophagus (1), aorta (10), left common carotid artery (7). The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)

Fig 3 Position of the recurrent laryngeal nerve (RLN) in relation to the trachea and esophagus at a level 4 and 1 cm caudal to the cricoid cartilage in the transverse sections of 10 specimens. Shrinkage by fixation was 22%. The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)

Fig 4 The lengths of the two recurrent laryngeal nerves between the lower margin of the cricoid cartilage and their turning point as well as the distance from the esophageal wall. The data obtained were measured in 10 histologic serial cross-sections, that is, in normal position undistorted by preparatory manipulation. Reference (0) is the lower margin of the cricoid cartilage. The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)

Fig 5 The course of the left recurrent laryngeal nerve (3) between the turning point (5∗) from the vagus nerve (5) and the entry into the larynx (3∗) is photographed from the lateral aspect after removal from the peritracheal tissues. The attachments of the thyroid gland (6) are removed, the gland is shifted posteriorly to display the recurrent laryngeal nerve (3) and the vascular arrangement underneath. Esophagus (1), trachea (2), inferior constrictor muscle of the pharynx wall (11), that is, the lower esophageal sphincter (12). Note the Zenker’s diverticulum on the right (arrow). The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)

Fig 6 Posterior aspect of the muscular wall of the esophagus (1) and pharynx (11). The right recurrent laryngeal nerve (3) largely removed from its peritracheal tissue bed is pulled down laterally by tweezers behind its turning point (5∗) around the subclavian artery (9). This shows that the ramifications of the recurrent laryngeal nerve enter the lateral wall of the esophagus (1) and trachea (2), by alternating, which was typical. The left cricoid gland (6) is in natural position, the right one (6) is displaced toward posterior. Underneath the lower lobe, the thyroid artery and its vessels (6a) encircle the recurrent laryngeal nerves. The turning point of the left recurrent laryngeal nerve (5∗) is seen under the aortic arch (10). Esophagus (1), common carotic artery (7), brachiocephalic trunk (8). Note the venous network on top of the pharyngeal muscle (11), the lower esophageal sphincter (12), and the phrenic nerve (13). The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)

Fig 7 The posterior wall of the pharynx (11) and hypopharynx has been cut open and the pharynx musculature (11) is pulled aside with tweezers to show the lumen. On the right, the mucosa (20) has been partly removed and the terminal recurrent laryngeal nerve (3) is seen passing upward to the epiglottis (14). The recurrent laryngeal nerve branches that supply the laryngeal muscles and the mucosa (20) are exposed. The cricoesophageal membrane (19), which is the tendon of origin of the longitudinal esophageal muscle, is displayed. Inferior thyroid artery (6). The Annals of Thoracic Surgery 1999 67, 217-223DOI: (10.1016/S0003-4975(98)01131-X)