| Objective:The paper is going to compare the RLN injury in endoscopic thyroidectomy via bilateral areola approach(ETBAA)and open thyroidectomy approach(OTA)with intraoperative neuromonitoring(IONM)to explore the value of IONM in ETBAA,which can improve the safety of ETBAA surgery.method:A total of 343 patients undergoing thyroid surgery were selected as study subjects From January 2015 to December 2017.According to the different inclusion criterias and exclusion criterias,they were divided into three groups:(1)suitable for endoscopic and select endoscopic thyroidectomy(ETBAA);(2)suitable for endoscopic and unselect endoscopic thyroidectomy(OTA-L);(3)not suitable for endoscopic and misfit endoscopic thyroidectomy(OTA-H).Statistics of patient's age,gender,surgical data,intraoperative electromyogram(EMG)signal,laryngoscope data,drainage volume,drainage tube indwelling time,length of stay and other aspects of clinical data were compared between groups.Results:A total of 343 patients were included in this study,including 149 in the ETBAA group,114 in the OTA-L group,and 80 in the OTA-H group.The number of R1 EMG signal descends over 50% in the ETBAA group,OTA-H group,and OTA-L group was 11(12.36%),2(1.43%),and 5(3.38%),respectively.After 30 minutes the injury was lifted,the rate of decrease in amplitude of R1 recovered to more than 50% was 4 cases,2 cases,and 1 case,respectively.The temporary RLN injury rates in the ETBAA group,OTA-L group,and OTA-H group were 5.03%,0.71%,and 3.38%,respectively.Postoperative laryngoscope showed vocal cord were weakened or fixed.No permanent RLN injury occurred in the three groups.The temporary injury rate of RLN in ETBAA group was significantly higher than the other two groups,and the difference was statistically significant(ETBAA vs.OTA-L,P<0.01;ETBAA vs.OTA-H,P<0.05).In the ETBAA group,there was a strong negative correlation between the amount of surgery and the RLN injury rate(r =-0.933,P <0.01).From the second half of 2016 to the second half of 2017,there was no significant difference in the RLN injury rate between the ETABA group and the OTA-L group(P>0.05).The three groups of RLN injuries were mainly type I lesions.The injury mechanism in the ETBAA group was mainly compression(63.64%),including ITA to RLN compression(54.55%),Berry ligament to RLN compression(9.09%),and traction injury(36.37%).In the OTA-L group,the injury was totally caused by traction injury(100%),and the injury site was a point in the middle third of the RLN(Rm point,50%).In the OTA-H group,the injury mechanism was traction injury(60%).The injury point was a point near the proximal third of the RLN,which is below the lower thyroid(Rp point,33.33%),and One point in the distal third of the RLN,mainly the entrance of the RLN(Rd point,33.33%);RLN was compression by the Berry ligament(20%);the Rd spot was damaged for thermal impair(20%).There was no transfer to open surgery in the ETBAA group.In the ETBAA group,OTA-L group,and OTA-H group after unilateral gland resection,the drainage volume on the first postoperative day was 48.92±18.87,17.38±9.45,and 25.58±13.92,respectively,and the difference was statistically significant(P<0.01).At the second postoperative day,the drainage volume was 34.82±14.98,12.44±8.64,and 20.50±9.84,respectively.The difference was statistically significant(P<0.01).Comparing the postoperative drainage of three groups of bilateral lobectomy cases,the difference was not statistically significant(P>0.05).The days of drainage tube placement were: 2.04±0.19,1.83±0.37,2.06±0.29,among which the OTA-L group had the shortest days,and there was a statistically significant difference compared with the other two groups(P<0.05).The postoperative hospital stay was 3.88 ± 0.85,3.87±0.84,and 4.58±1.26,respectively.The OTA-H group had the longest stay in hospital.Compared with the other two groups,the results were statistically significant(P<0.05).Conclusion:With the accumulation of operator experience and IONM application,the injury rate of RLN in ETBAA gradually decreased.During the maturity of operation,there was no significant difference in the RLN functional effect of ETBAA and open thyroid surgery.Using intraoperative EMG amplitude reduction by 50% as the “prewarning value” of RLN injury can promptly indicate dangerous operations,finding damage mechanism,and improving surgical safety.ETBAA has the advantages of good incision healing,good cosmetic results,and rapid postoperative recovery.It will become a classic surgical method for thyroid surgery,and it will be accepted by more and more doctors and patients for promotion and application. |
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