Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, Changchun, 130000, People's Republic of China.
Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital "G. Martino", University of Messina, Messina, Italy.
Surg Endosc. 2021 Aug;35(8):4865-4872. doi: 10.1007/s00464-021-08421-1. Epub 2021 Mar 15.
The aim of this report was to summarize observations, evaluate the feasibility, provide detailed information concerning proper techniques, and address limitations for non-recurrent laryngeal nerve (NRLN) dissection and release during the robotic bilateral axillo-breast approach (BABA) for thyroidectomy.
The BABA approach was used in two cases of thyroidectomy in the setting of NRLN. Preoperative CT imaging findings suggesting the aberrant anatomy are reviewed and technical planning, inclusive of intraoperative nerve monitoring, was employed. Intraoperative videos with narrative discussion of technique for safe dissection are provided, along with supplementary video of additional technical guidance.
In both cases, the NRLNs were identified, dissected, and preserved. We dissected the proximal segment of each NRLN to its origin. We determined that the use of only the NRLN proximal to distal robotic dissection jeopardized the nerve. The BABA approach with the Type I NRLN is similar to the dissection of the recurrent laryngeal nerve (RLN) in transoral thyroidectomy. Due to interference with endoscopic viewing caused by the thyroid cartilage, the Type I NRLN is more challenging to manage both at the laryngeal entry point and its origin from the vagus nerve (VN). For the Type II NRLN, it is essential to identify its point of origin and the reflection of the nerve from the VN. Therefore, modification of nerve dissection to mirror open surgery with bidirectional nerve dissection assisted in avoidance of traction injury to the nerve.
We presented a video, a detailed description of methods, and discussed limits for NRLN management in robotic BABA. This report included (i) a description of the aberrant anatomy and CT scans to inform surgeons of the possible NRLN locations, (ii) a description of a technique for using the nerve monitor in the robotic surgeries, and (iii) a description of the techniques used to isolate and protect the NRLN during the robotic surgery. In robotic BABA, our NRLN-sparing technique and degree included mainly a multi-directional nerve dissection (i.e., medial-grade, later-grade approach together with proximal to/from distal) using athermal technique. The NRLN-sparing technique is predominantly carried out in an anterior dissection plane.
本报告旨在总结观察结果，评估可行性，提供关于非重现性喉返神经（NRLN）解剖和释放的详细信息，并探讨机器人双侧腋窝乳房入路（BABA）在甲状腺切除术时进行 NRLN 解剖的局限性。
在 NRLN 情况下，我们在两例甲状腺切除术患者中使用了 BABA 方法。我们回顾了术前 CT 成像发现提示异常解剖结构，并进行了技术规划，包括术中神经监测。提供了安全解剖技术的术中视频，并附有额外技术指导的补充视频。
在这两个病例中，我们都成功识别、解剖和保留了 NRLN。我们将每个 NRLN 的近端部分解剖至其起源处。我们发现，仅使用从近端到远端的机器人 NRLN 解剖会危及神经。使用 BABA 方法和 I 型 NRLN 类似于经口甲状腺切除术的 RLN 解剖。由于甲状软骨干扰内镜视野，I 型 NRLN 在喉入口和起源于迷走神经（VN）处的管理更为困难。对于 II 型 NRLN，识别其起源点和神经从 VN 反射至关重要。因此，通过双向神经解剖来模拟开放性手术的神经解剖有助于避免对神经的牵拉损伤。
我们提供了一个视频、详细的方法描述，并讨论了在机器人 BABA 中 NRLN 管理的局限性。本报告包括（i）描述异常解剖结构和 CT 扫描，使外科医生了解可能的 NRLN 位置，（ii）描述在机器人手术中使用神经监测器的技术，以及（iii）描述在机器人手术中隔离和保护 NRLN 时使用的技术。在机器人 BABA 中，我们的 NRLN 保留技术主要包括使用非热技术进行多方向神经解剖（即内侧级、外侧级以及近端到/远端）。NRLN 保留技术主要在前方解剖平面进行。
