title: IONM-guided goiter surgery leading to two-stage thyroidectomy--indication and results.
abstract: OBJECTIVE
  Intraoperative neuromonitoring (IONM) in thyroid surgery allows for changing the operative strategy during bilateral procedures to avoid bilateral recurrent laryngeal nerve palsy (RLNP). While this strategy is comprehendible for the surgeon, the question remains, whether it is always necessary.
  
  
  METHODS
  Two thousand five hundred forty-six patients underwent surgery with IONM between January 2008 and October 2010 (4,012 nerves at risk). We performed a retrospective review of all patients after thyroid surgery. In 98 cases, signal loss occurred on the primary side. Of these patients, 64 required bilateral surgery. We proceeded with the contralateral surgery in 24 cases. Forty operations were ended unilaterally. The second operation was performed on 18 patients in total, 16 after confirmation of primarily intact (n = 8) or recovered vocal cord function (n = 8) and twice under persisting dysfunction. Patient satisfaction was evaluated using a five-point scale.
  
  
  RESULTS
  We have shown a significant difference (p = 0.017) in the rate of bilateral RLNP when signal loss on the primary side resulted in termination of the procedure compared to continuation. Our evaluation of patient satisfaction did not show a significant difference when comparing the two-stage operation to other procedures.
  
  
  CONCLUSIONS
  We have shown a significant difference in the rate of bilateral RLNP when comparing termination and continuation of a bilateral procedure after primary IONM signal loss. We strongly recommend a two-stage thyroidectomy after signal loss on the primary side of resection in benign bilateral goiter surgery.
authors.affiliation: Department of General Surgery, Endocrine Surgery, Abdominal Surgery, Thorax Surgery, Vascular Surgery, Colorectal and Hernia Surgery, Lukaskrankenhaus GmbH, Preußenstraße 84, 41464 Neuss, Germany. mmelin@lukasneuss.de
authors.forename: Magnus
authors.initials: M
authors.lastname: Melin
authors.forename: Katharina
authors.initials: K
authors.lastname: Schwarz
authors.forename: Bernhard J
authors.initials: BJ
authors.lastname: Lammers
authors.forename: Peter E
authors.initials: PE
authors.lastname: Goretzki
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006044:Goiter, Nodular / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D009431:Neural Conduction; D011237:Predictive Value of Tests; D061226:Recurrent Laryngeal Nerve Injuries / Q000517:prevention & control*; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013965:Thyroidectomy / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult