1. The Modern Thyroid Operation
Slide 1.
Setup of a functional neuromonitoring in thyroid surgery in Department of Otolaryngology- Head and Neck Surgery, Kaohsiung Medical University, Taiwan
Feng-Yu Chiang, MD
Department of Otolaryngology Kaohsiung Medical University, Taiwan

7. The modern thyroid operation
Eradicate thyroid disease
A safe thyroid operation
Intra-operative evidence

8. Eradicate thyroid disease
Total lobectomy
Total thyroidectomy
Neck dissection (Central or Lateral)
Resection of upper aerodigestive tract
I-131 therapy

9. A safe thyroid operation
Preserve RLN and EBSLN
Preserve parathyroid function

10. Intra-operative evidence
Anatomic integrity
- High-resolution photographs
Functional integrity
- IONM of RLN
- Intact blood supply to parathyroid

11. Preservation of RLN

12. Recurrent laryngeal nerve palsy
Most common and serious complication
The leading reason for medicolegal
litigation

13. Routine identification of RLN
Lower rates of RLN palsy
Gold standard of RLN treatment

14. Intra-Operative NeuroMonitoring (IONM)

15. Applications of IONM Prevent RLN injury Localize and identify RLN
Predict vocal function
Elucidate mechanism of RLN injury
Help preserve parathyroid

16. ET tube
KMU ENT

17. After intubation and neck fully positioned, we routinely check the electrodes position with laryngofiberoscopy from the nose. 17 17 17

18. Video of RLN approach

19. IONM is useful and helpful for
Anatomic variants of RLN
Difficult thyroid operation

20. Anatomic variants of RLN
(Extralaryngeal branches, Non-RLN, Distorted RLN…etc)
- important factors:
RLN injury
False results of IONM

21. Extralaryngeal branches of RLN
Branch to trachea
Branch to esophagus
Branch to inferior constrictor muscle
Anterior branch
Posterior branch

22. Bifurcated RLN

24. Non-recurrent RLN

25. Video of detecting
Non-RLN

26. Video of mapping
Non-RLN

27. Video of Non-RLN

28. Difficult thyroid operation
(Recurrent, substernal or large goiter , Thyroid cancer)
Early localization & Definite identification
An important step to prevent RLN injury

29. Localization

30. Reoperation

31. RLN can be displaced to any direction in this circumstance.

32. Substernal or large goiter

35. Palsy rates in 3 operation periods
IONM - +
NAR
852
173
612
Palsy rate
Temporary
Permanent
5.7%
5.0%
0.7%
6.4%
5.8%
0.6%
0.65% 0%
This slide show the palsy rates of my series at 3 different op period. So, During learning of IONM, the palsy rates will not change.
In period 3, the palsy rate was significantly reduced to less than 1% after understanding the mechanism of nerve injury and improving the surgical technique.

36. Preservation of EB-SLN

37. The path of EB-SLN can be divided into type 1, 2a and 2b
The path of EB-SLN can be divided into type 1, 2a and 2b. Type 2a and 2b have higher risk of injury during clamping the sup pole vessels.

38. Video of EB-SLN
We can identify the nerve by watching the twitch of CT muscle.

39. Preservation of parathyroid function
Preserve parathyroid with intact
blood supply
Auto-transplantation for devascularized parathyroid

40. Parathyroid with intact blood supply
(1)