A nonrecurrent laryngeal nerve is a rare anomaly and estimated to be present in 0.25 to 0.99% of patients.1 The identification and preservation of the recurrent laryngeal nerve is an essential part of thyroid surgery. It is now well-known that the recurrent laryngeal nerve is not only a single nerve but also a complex branching network of innervation. Thyroid surgery demands a precise understanding of the anatomical intimacy between the gland and surrounding structures, including the parathyroid glands and neurovascular tissue. The morbidity associated with thyroid surgery, in the short-term, generally relates to hematoma collection and hypocalcemia. Long-term morbidity is more commonly seen with dysphonia and vocal cord dysfunction due to superior laryngeal nerve damage and its role in explosive sound formation, the recurrent laryngeal nerve, its tortuous anatomical course, and its role in laryngeal musculature innervation.
We review the literature on this subject and report three cases of the rare nonrecurrent anomaly, firstly a 75-year-old lady with a large retrosternal goiter. During her initial work-up which included a CT scan of the thorax, an ‘arteria lusoria' was identified in the retroesophageal plane. Intraoperatively, a right-sided nonrecurrent inferior laryngeal nerve (NRILN) was identified. The second case is of a 63-year-old lady with a right-sided type 1 nonrecurrent laryngeal nerve which we identified and photographed when medially retracting the gland off the central compartment and ligament of Berry. The third case is that of a 45-year-old lady with a right-sided thyroid nodule and a right-sided NRILN identified intraoperatively.
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PRK B, A K, R N, V A. What is the Ideal CO2 Insufflation Pressure for Endoscopic Thyroidectomy? Personal Experience with Five Cases of Goiter. World J Endoc Surg 2011; 3 (1):3-6.
The endoscopic thyroidectomy (ET) using high CO2 insufflation pressures (CIP) are prone to complications, such as hypercarbia, acidosis, pneumomediastinum and cardiac arrhythmias. The purpose of this study was to analyse the perioperative events and CO2 related morbidity in five cases of endoscopic thyroidectomy in our experience.
Between Febraury 2010 and August 2010 (6 months), five cases of benign goiters operated with extracervical ET technique in endocrine surgery department of a teritiary care hospital of southern India were studied. Clinicopathological, operative and morbidity data were documented and analyzed.
All the five patients were women and mean age was 37.2 years (25-46). CIP of 12 to 14 mm Hg was used for creation of working space and CIP of 8 to 10 mm Hg for its maintainence. Average operative time was 135 minutes (65-212). Two cases had to be converted into open procedure due to gas related complications, such as hypercarbia, acidosis and ventricular tachycardia.
CO2 insufflation pressure (CIP) of 10 to 12 mm Hg for creation of working space and 6 to 8 mm Hg for maintainence of space is optimal. A protocol based on CIP, monitoring and intermittent desufflation is recommended for safe ET with minimum complications.
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Fernando R, Chandrasinghe P, Bandara M. Hypocalcemia and Hoarseness Following Total Thyroidectomy for Benign Disease: Relationship of Incidence to the Size of the Gland. World J Endoc Surg 2011; 3 (1):7-9.
Total thyroidectomy is considered as the standard surgical procedure for most malignancies and benign disease involving both lobes of the thyroid gland. Postoperative complications are likely to be commoner when the thyroid gland is large in size due to the alteration of structural anatomy.
Postoperative complications of 102 patients who underwent total thyroidectomy for benign disease, by the same surgeon, were analyzed. Patients were prospectively followed up and presence of hoarseness and hypocalcemia, both transient and temporary, were compared with the weight of the gland.
Fourteen patients developed hypocalcemia of which 12 (11.7%) had transient and 2 (1.96%) had permanent deficiencies. Eight patients developed hoarseness following surgery of which seven (6.86%) had transient and only one (0.98%) had permanent hoarseness. A mean thyroid weight of 91.78 gm was observed in the uncomplicated group. Those who developed postoperative hypocalcemia and transient hoarseness had a mean thyroid weight over 100 gm. One patient, who had a thyroid weighing 195 gm developed permanent hoarseness due to RLN injury.
There is no statistically significant difference in the incidence of transient RLN and transient or permanent hypocalcemia. With increased size of the thyroid gland increased rate of complications was observed with a mean thyroid weight above 100 gm. There may be a significant risk of permanent RLN injury when the thyroid gland is enlarged over 10 times (closer to 200 gm) its normal size.