How is the recurrent laryngeal nerve identified and preserved in thyroid surgery?

Updated: Feb 27, 2020
  • Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Several approaches are used to identify and preserve the RLN. The authors' preferred approach involves finding the nerve at its point of laryngeal entry, which is approximately 0.5 cm below the inferior cornu of the thyroid cartilage. Thyroid tissue in the region of the ligament of Berry is meticulously dissected from the trachea by carefully ligating traversing vessels. This technique exposes the RLN as it enters the larynx. It also minimizes the compromise of blood supply to the parathyroids and limits the extent of dissection involving the nerve.

Thick connective tissue called the Berry ligament attaches the thyroid to the trachea at the level of the second or third tracheal ring. This is the most common site of injury to the RLN The nerve may run deep to the ligament, pass through it, or even penetrate the gland a short distance at this level. Be extremely careful in this area during surgery. Retraction of the thyroid lobe may result in traction injury and make the nerve susceptible to transection. The path of the nerve must be clearly identified.

Continuous electrophysiologic monitoring of the RLN during thyroid surgery is easily performed. Two EMG devices include an endotracheal-tube electrode (Xomed-Treace, Jacksonville, FL) and an RLN-postcricoid-laryngeal surface electrode. Both provide useful EMG information and help to reveal the location of the RLN.

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