title: Experience with intraoperative neuromonitoring of the recurrent laryngeal nerve improves surgical skills and outcomes of non-monitored thyroidectomy.
abstract: OBJECTIVE
  Intraoperative neuromonitoring (IONM) can serve as a tool to increase skills in recurrent laryngeal nerve (RLN) identification and complete removal of thyroid tissue. The aim of this study was to validate this hypothesis.
  
  
  METHODS
  This prospective study involved 632 patients (1161 RLNs at risk) who underwent thyroid surgery in 2011-2014. Although IONM was not used until 2012, this prospective study started on 1 January 2011. The three participating surgeons knew about the study before that date and that the rate of RLN identification would be carefully measured in total and near-total surgery. Solely, visual identification of the RLN was used throughout 2011. IONM was introduced as a training tool in 2012-2014 for the first 3 months of each year. In the remaining months, thyroid operations were performed without IONM. Outcomes of non-monitored thyroid operations were compared before (01-12/2011) vs. after (04-12/2012-2014) 3 months of exposure to IONM yearly (01-03/2012-2014). The rate of RLN identification was assessed in total and near-total thyroidectomies and in totally resected lobes in Dunhill's operation. The prevalence of RLN injury and the utilization of total thyroidectomy were evaluated.
  
  
  RESULTS
  In 2011, the rate of successful RLN visual identification in total and near-total thyroidectomies and in totally resected lobes in Dunhill's operation was 45.71 %. After the introduction of IONM in 2012-2014, in the procedures performed without IONM, the rate was 86.66, 90.81, and 91.3 %. The prevalence of RLN injury in 2011 was 6.8 %, while in the years following the introduction of IONM, it was 3.61, 2.65, and 1.45 %. Utilization of total thyroidectomy increased from 47.9 % in 2011 to 100 % in 2014.
  
  
  CONCLUSIONS
  Experience with IONM led to an increase in RLN identification (p < 0.0001), a decrease of RLN injury (p < 0.05), and an increase in the safe utilization of total thyroidectomy (p < 0.0001) in non-monitored thyroid operations. IONM is a valuable tool for surgical training.
authors.affiliation: Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland. beatawojtczak@wp.pl.
authors.forename: Beata
authors.initials: B
authors.lastname: Wojtczak
authors.affiliation: Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Sutkowski
authors.affiliation: Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Kaliszewski
authors.affiliation: Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland.
authors.forename: Mateusz
authors.initials: M
authors.lastname: Głód
authors.affiliation: Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland.
authors.forename: Marcin
authors.initials: M
authors.lastname: Barczyński
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000453:epidemiology; D064795:Intraoperative Neurophysiological Monitoring; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D061226:Recurrent Laryngeal Nerve Injuries / Q000175:diagnosis* / Q000453:epidemiology; D013959:Thyroid Diseases / Q000503:physiopathology / Q000601:surgery*; D013965:Thyroidectomy / Q000009:adverse effects* / Q000706:statistics & numerical data; D016896:Treatment Outcome
keywords: Intraoperative neuromonitoring; Recurrent laryngeal nerve; Surgical skill; Thyroid surgery