A safe and reliable technique for visualization of the laryngeal recurrent nerves in the neck

doi:10.1016/j.amjsurg.2004.08.064

The American Journal of Surgery

Volume 189, Issue 2, February 2005, Pages 200-202

https://doi.org/10.1016/j.amjsurg.2004.08.064 Get rights and content

Abstract

Background

The risk of an injury of the laryngeal recurrent nerve is an important issue during any surgical procedure in the lower neck.

Methods

Based on our experience with the transcervical-subxiphoid bilateral videothoracoscopic maximal thymectomies, we developed an original technique of visualization for both of these nerves. The key point of the presented technique is the dissection in the lower part of the neck, beneath the level of the thyroid gland. The central step is the division of the deep cervical fascial layers covering and obscuring the recurrent nerves. Preservation of the deepest layer protects the nerves from an injury.

Results

We used this technique in 100 consecutive transcervical-subxiphoid bilateral videothoracoscopic maximal thymectomies without any case of permanent recurrent nerve palsy.

Conclusion

The presented technique is safe, reliable, and relatively simple. It may be used during an extended thymectomy, as well as during a thyroid resection and other operations in the lower neck.

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Visualization and protection of the laryngeal recurrent nerves bilaterally is a priority. The technique of visualization of the laryngeal recurrent nerves is described elsewhere.16 In brief, to reach the nerve below the level of the thyroid gland, divide the deep cervical fascial layers covering the carotid arteries until the clean wall of the artery is reached.
Technical Pitfalls of Transcervical Extended Mediastinal Lymphadenectomy-How to Avoid Them and to Manage Intraoperative Complications
2010, Seminars in Thoracic and Cardiovascular Surgery
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As the result, the nerves are easily dissected with a peanut. During visualization of the recurrent nerves, it is recommended to preserve the last, deepest fascial membrane covering the nerve to avoid its injury.3 Circumferential dissection of any nerve is not advised.
Transcervical extended mediastinal lymphadenectomy (TEMLA), introduced by our team in 2004, is a new technique for the preoperative staging of non-small cell lung cancer (NSCLC). The aim of TEMLA is to maximally accurately stage and possibly to improve late results of treatment of NSCLC. Operative techniques include a collar incision in the neck, elevation of the sternal manubrium with a special retractor, bilateral visualization of the laryngeal recurrent and vagus nerves, and dissection of all mediastinal nodal stations except for the pulmonary ligaments nodes (station 9, according to the Mountain-Dresler map). Generally, the mediastinal pleura are not violated, and no drain is left in the mediastinum. In this article, some important steps the facilitating safe and straightforward performance of TEMLA are presented, and methods of managing intraoperative complications is discussed.
Technique and application of transcervical extended mediastinal lymphadenectomy in thoracic surgery
2009, Operative Techniques in Thoracic and Cardiovascular Surgery
Citation Excerpt :
Bilateral visualization and protection of the laryngeal recurrent nerves are priorities. The technique used for visualization of the laryngeal recurrent nerves is described elsewhere in the article.3 In short, to reach the nerve below the level of the thyroid gland, one must divide the deep cervical fascial layers covering the carotid arteries until the clean wall of the artery is reached.
Transcervical extended mediastinal lymphadenectomy: Results of staging in two hundred fifty-six patients with non-small cell lung cancer
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TEMLA was performed for patients with a negative result of TBNA. The operative technique included a 5- to 8-cm collar incision in the neck, elevation of the sternal manubrium with a special retractor, bilateral visualization of the laryngeal recurrent and vagus nerves, and dissection of all mediastinal nodal stations except for the pulmonary ligament nodes (station 9) and the most distal left paratracheal nodes (station 4L).1–4 Most of the procedure is open, with the subcarinal and the periesophageal nodes (stations 7 and 8) removed with mediastinoscopy-assisted technique and the para-aortic and the pulmonary-window nodes (stations 6 and 5) removed with videothoracoscopy-assisted technique, with the videothoracoscope inserted through the transcervical incision.
Transcervical extended mediastinal lymphadenectomy (TEMLA) is a new surgical procedure for staging of the mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC). The operation is performed through the 5- to 8-cm collar incision in the neck and enables complete removal of all mediastinal nodal stations except for the pulmonary ligament nodes (station 9) and the most distal left paratracheal nodes (station 4L). Generally, TEMLA is an open procedure performed partly with mediastinoscopy-assisted and videothoracoscopy-assisted techniques. Operative technique of TEMLA includes elevation of the sternal manubrium with a special retractor and bilateral visualization of the laryngeal recurrent and vagus nerves.
From January 1, 2004 to November 15, 2005, TEMLA was performed in 256 patients. Length of operation was 80 to 330 minutes (mean, 161 minutes). Complication of TEMLA occurred in 11.3% of patients with temporary laryngeal nerve palsy in 6 of 256 patients (2.3%) and permanent nerve palsy in 2 of 256 patients (0.8%). The number of dissected nodes during TEMLA was 15 to 85 (mean, 38.9). N2-3 nodes were found in 80 patients (31.3%). During subsequent thoracotomy, omitted N2 nodes were found in 5 of 138 patients, and omitted normal mediastinal nodes were found in 13 of 138 patients (9.4%). Sensitivity of TEMLA in discovery of N2-3 nodes was 94.1%, specificity was 100%, accuracy was 98%, negative predictive value was 97.2%, and positive predictive value was 100%. Preliminary results may suggest some therapeutic impact for patients who underwent TEMLA and subsequent R0 resection, with a 77.2% survival rate after the mean 24-month follow-up period.
Comparison of complete remission rates after 5 year follow-up of three different techniques of thymectomy for myasthenia gravis
2010, European Journal of Cardio-thoracic Surgery
Effect of bilateral mediastinal lymphadenectomy on short-term pulmonary function
2007, European Journal of Cardio-thoracic Surgery

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How I do itA safe and reliable technique for visualization of the laryngeal recurrent nerves in the neck

Abstract

Background

Methods

Results

Conclusion

Surg Clin North Am

Ann Thorac Surg

Am J Surg

How I do it
A safe and reliable technique for visualization of the laryngeal recurrent nerves in the neck