Hermann Michael, Alk Gunter, Roka Rudolf, Glaser Karl, Freissmuth Michael
Department of Surgery, Kaiserin-Elisabeth-Spital, University of Vienna, Vienna, Austria.
Ann Surg. 2002 Feb;235(2):261-8. doi: 10.1097/00000658-200202000-00015.
To evaluate the effect of recurrent nerve dissection on the incidence of recurrent laryngeal nerve injury (RLNI) and to analyze the performance of individual surgeons.
Dissection of the recurrent nerve is mandatory in total thyroidectomy, but its relative merit in less extensive resections is not clear. The reported rates of RLNI differ widely; this may reflect a variation in the performance of individual surgeons.
The authors studied the incidence of RLNI in primary surgery for benign thyroid disease during three periods in a single center. In period 1 (1979-1990; 9,385 consecutive patients, 15,865 nerves at risk), the recurrent nerve was not exposed. In period 2 (1991-1998; 6,128 patients, 10,548 nerves at risk), dissection of the recurrent nerve was the standard procedure. Global outcome and individual performance in these two periods were compared and presented to the surgeons. The effect of this quality control procedure was tested in 1999 (period 3; 930 patients, 1,561 nerves at risk).
Exposure of the recurrent nerve significantly reduced the global rate of postoperative and permanent RLNI. Some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent RLNI rates ranged from 0% to 1.1%). The documented significant differences in individual performances did not affect the outcome in period 3. The extent of nerve dissection was a source of variability; the rate of permanent RLNI averaged 0.9%, 0.3%, and 0.1% for surgeons who only localized, partially exposed, and completely dissected the recurrent nerve, respectively.
Recurrent nerve dissection significantly reduces the risk of RLNI. Extensive dissection facilitates visual control of nerve integrity during resection and is therefore superior to a more limited exposure of the nerve. Quality control can improve the global outcome and identify the variability in individual performance. This cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes.
评估喉返神经解剖对喉返神经损伤（RLNI）发生率的影响，并分析个体外科医生的手术表现。
在全甲状腺切除术中，喉返神经解剖是必要的，但在范围较小的切除术中其相对优势尚不清楚。报道的RLNI发生率差异很大；这可能反映了个体外科医生手术表现的差异。
作者研究了单一中心三个时期内原发性甲状腺良性疾病手术中RLNI的发生率。在第1期（1979 - 1990年；9385例连续患者，15865条神经有风险），未暴露喉返神经。在第2期（1991 - 1998年；6128例患者，10548条神经有风险），喉返神经解剖是标准手术步骤。比较了这两个时期的总体结果和个体表现，并向外科医生展示。在1999年（第3期；930例患者，1561条神经有风险）测试了这种质量控制程序的效果。
暴露喉返神经显著降低了术后和永久性RLNI的总体发生率。一些但并非所有外科医生通过喉返神经解剖改善了结果（例如，永久性RLNI发生率范围为0%至1.1%）。记录的个体表现的显著差异在第3期并未影响结果。神经解剖范围是变异性的一个来源；仅定位、部分暴露和完全解剖喉返神经的外科医生，其永久性RLNI发生率分别平均为0.9%、0.3%和0.1%。
喉返神经解剖显著降低了RLNI的风险。广泛解剖有助于在切除过程中视觉控制神经完整性，因此优于对神经更有限的暴露。质量控制可以改善总体结果并识别个体表现的变异性。仅通过向外科医生提供比较数据无法消除这种变异性；因此，寻找潜在原因很重要。
