Uen Yih-Huei, Wu Che-Wei, Wen Kuo-Shan, Lin Yi-Feng, Lin Kai-Yuan
Department of Surgery, Asia University Hospital, Taichung, Taiwan.
Department of Biotechnology, Asia University, Taichung, Taiwan.
Surg Endosc. 2025 Sep;39(9):6249-6258. doi: 10.1007/s00464-025-12009-4. Epub 2025 Aug 6.
Continuous intraoperative neuromonitoring (C-IONM) has been developed and used in open thyroidectomy to perceive imminent recurrent laryngeal nerve (RLN) injury, but has scarcely been reported in transoral endoscopic thyroidectomy vestibular approach (TOETVA) due to technical difficulty. This study aims to report the percutaneous C-IONM technology in TOETVA and compare it with the conventional peroral method to confirm its feasibility, safety, and effectiveness.
This prospective study included 102 consecutive patients who received TOETVA and standardized continuous vagal nerve (VN) stimulation via percutaneous insertion of commercially available handheld stimulation probe into the moderately dissected carotid space between carotid artery and internal jugular vein and fixed by an external fixator (PC group, n = 52 with 67 nerves at risk [NAR]) or conventional peroral DELTA electrode (DELTA group, n = 50 with 61 NAR). Demographic data, technical outcome variables, and electromyography (EMG) signals were collected and compared.
C-IONM procedures were successfully set up in all PC group patients but failed in three DELTA group patients. Comparisons of technical characteristics show the PC group demonstrated a shorter electrode positioning time, fewer stimulator displacement events, and more stable EMG responses than the DELTA group. Four NARs (3 in PC, 1 in DELTA group) reported imminent recurrent laryngeal nerve (RLN) traction-related adverse events, all with intraoperative recovery after surgical technique modification, causing no postoperative vocal cord palsy. Severely weakened or loss of EMG signal occurred in 4 NARs (all in DELTA group), either due to stretch injury of VN (3 NAR) or traction injury of RLN (1 NAR), causing two postoperative VCP in 2 NARs.
Percutaneous continuous vagal stimulation was superior to peroral vagal stimulation in a selected cohort of patients undergoing TOETVA to perceive the imminent injury of RLN to start immediate rescue.
术中连续神经监测（C-IONM）已被开发并应用于开放性甲状腺切除术中，以察觉即将发生的喉返神经（RLN）损伤，但由于技术难度，在经口内镜甲状腺手术前庭入路（TOETVA）中鲜有报道。本研究旨在报告TOETVA中的经皮C-IONM技术，并将其与传统经口方法进行比较，以确认其可行性、安全性和有效性。
这项前瞻性研究纳入了102例连续接受TOETVA的患者，通过经皮插入市售手持刺激探头至颈动脉与颈内静脉之间适度解剖的颈动脉间隙，并通过外部固定器固定，对其进行标准化的连续迷走神经（VN）刺激（PC组，n = 52，有67条神经有风险[NAR]）或传统经口DELTA电极（DELTA组，n = 50，有61条NAR）。收集并比较人口统计学数据、技术结果变量和肌电图（EMG）信号。
所有PC组患者的C-IONM程序均成功建立，但DELTA组有3例患者失败。技术特征比较显示，PC组的电极定位时间更短，刺激器移位事件更少，EMG反应比DELTA组更稳定。4条NAR（PC组3条，DELTA组1条）报告了即将发生的喉返神经（RLN）牵拉相关不良事件，所有事件在手术技术改进后术中均恢复，未导致术后声带麻痹。4条NAR（均在DELTA组）出现EMG信号严重减弱或消失，原因是VN拉伸损伤（3条NAR）或RLN牵拉损伤（1条NAR），导致2条NAR术后出现声带麻痹。
在接受TOETVA的特定患者队列中，经皮连续迷走神经刺激在察觉RLN即将发生的损伤以启动立即抢救方面优于经口迷走神经刺激。
