This document discusses the surgical anatomy and identification techniques for the recurrent laryngeal nerve (RLN) during thyroid surgery, highlighting the American Thyroid Association's guidelines and various approaches to RLN identification. A new medial approach is introduced, particularly useful in complex cases including revision surgeries and thyroid cancers with local invasion, yielding successful identification of RLNs in all cases studied. The study conducted on 71 patients demonstrated that this approach does not increase the risk of operative complications, making it a valuable technique for surgeons in specific situations.

1. Received: 30‐11‐2017 Edited by: Yi Cui
Chinese Medical Journal ¦ April 5, 2018 ¦ Volume 131 ¦ Issue 7 871

2. Introduction
2015 American Thyroid Association Guidelines
recommend “Visual identification of the recurrent
laryngeal [RLN] during dissection in all cases”

3. Surgical anatomy
 Right RLN tracheoesophageal groove more horizontal
 LRLN more vertically in the left tracheoesophageal
groove

4. Relationship of RLN and Berry’s ligament
 fibrous structure that anchors the thyroid gland to the first three rings of the tracheal cartilage

5. Relationship of RLN and Inferior Thyroid
Artery
it may cross superficially or
deeply to the inferior
thyroid artery (ITA) or
between its branches
Unilateral or bilateral
absence of the ITA is not a
rare variation, and is
described in 3–6 % of
cases

6. Tubercle of Zuckerkandl
 is the posterior and lateral projection of the thyroid gland.
 described as “an arrow pointing to the recurrent laryngeal nerve
 In patients with an identifiable tubercle of Zuckerkandl, the recurrent laryngeal nerve is located
medial to the tubercle in the vast majority of instances

7. Surgical anatomy
On both sides nerves
enter the larynx at the
cricothyroid articulation
beneath the fibers of the
inferior constrictor
muscles of the pharynx.

8. “non-recurrent” inferior laryngeal nerve
 (0.6%), the right recurrent
laryngeal nerve passes directly
from the vagus in the neck
towards the larynx and does not
recur around subclavian artery.
 Make it susceptible to injury

9. The “false” nonrecurrent nerve
enlarged anastomic branches between
the normal RLN and the cervical
sympathetic chain may mimic a
nonrecurrent laryngeal nerve (NRLN)
in up to 7.5 % of the cases
Another confounding condition is
represented by small branches
connecting an NRLN and the stellate
sympathetic ganglion

10. Extralaryngeal branching
 extralaryngeal bifurcation of the RLN that constitutes a frequent event present in up to 30–40 % of cases

11. Approaches to RLN identification
lateral approach
• routine
• uncomplicated
• Theodor Kocher
Inferior approach
• revision
Superior
• least used
• consistent

12. lateral approach
identifies the RLN at the midpole of the thyroid lobe.
This approach is usually used and applicable to most cases
except those with a very large cervical or substernal goiter or
the presence of a fibrous scar due to previous surgery.
However, injury to the extralaryngeal branching of the RLN may
occur with this approach.

13. inferior approach
finds the RLN at the lower pole of the thyroid lobe around the
tracheoesophageal groove.
advantage is that extralaryngeal branching rarely occurs at this
level
disadvantage is that it involves the dissection of a long
segment, and it may be difficult to find the RLN because of
inferior thyroid artery bleeding.

14. Superior approach
identifies the RLN at the laryngeal entry point, which is above
the ligament of Berry
useful for large cervical or substernal goiters, where the nerve
cannot be found using a lateral or inferior approach.
The advantage of this approach is that the RLN entry point is
relatively constant
The disadvantage is that dissection around the ligament of
Berry is not easy because this region is fibrous and has a rich
vasculature.

15. Therefore, we introduce a new approach to help identify
the RLN in special cases

16. Material and method
 This study was conducted on 71 patients with thyroid cancer.
 Duration : March 2010 and November 2014
 Setting : Furan University Shanghai Cancer center.
 Study type : cohort study

17. The medial approach was performed
1. Revision cases with the presence of a fibrous scar due to previous
surgery
2. Multifocal thyroid cancer with local invasion (RLN, esophagus, and
carotid sheath) and lymph nodes metastasis
3. other cases in which it was difficult to find the RLN using the standard
approaches.

18. Surgical technique
 A collar incision was used, and subplatysmal flaps were elevated.
 The strap muscles were separated in the midline to expose the thyroid gland
 the thyroid isthmus was clamped and transected at its attachment to the
opposite lobe. The lobe was separated internally from the trachea until half
of the lateral side of tracheal rings 2–4 was exposed from the thyroid lobe
 Using the third tracheal ring as a landmark located 0.3 cm from the lateral
surface of the tracheal ring
 the surgeon employed a careful blunt dissection to expose the RLN through
the layers of the fibers

19. • To avoid accidental bleeding of
the inferior thyroid artery caused
by injure, we try to identify the
RLN above the level of the artery.
In the author’s observation, this
level is about the third tracheal
ring.
• The location of the RLN in the
level of third tracheal ring is
relatively stable by its anatomical
characteristic, which is suitable
for both sides.

20. All patients then received a total thyroidectomy and central
lymph nodes dissection (with or without lateral lymph nodes
dissection)
A postoperative laryngoscopy was performed for all patients.
Patients were followed up every 6 months
for 12 to 62 months, with a median of 28 months.

21. Results
 Age : 16 to 68 years
 29 males and 42 females
 in all of the cases, RLNs were successfully identified
 Of the 71 patients, 22 were revision surgeries.
 Among the remaining 49 patients, 81.6% (40 of 49) of the patients were T4

22. Complication rate
Number of case Complication
7 patients had clinical and biochemical
hypocalcaemia, which was corrected
using calcium supplementation.
2 cases showed unilateral vocal cord
paralysis one fully recovered after 6
months, while the other showed
lateral vocal paralysis and were
treated with a tracheotomy.

23. Discussion
 In China, most thyroid procedures are performed by general surgeons even
though most of them are not well trained for thyroid cancer surgeries. Thus,
in our cancer center, reoperative thyroid procedures and those with severe
thyroid cancers are very common.
 In revision cases , the lateral side of the thyroid was difficult to separate
because of scarring and the loss of normal tissue planes; thus, the RLN could
not be identify by regular approaches.
 multifocal thyroid cancers with local invasion (RLN, esophagus, and carotid
sheath) and lymph nodes metastasis also difficult in terms of finding the RLN
with the three common approaches.

24.  Thyroid surgeons should have a number of different techniques available if
identification of the RLN proves troublesome.
 In this case series, we described a new backup approach for the
identification of the RLN. This work represents the largest series of patients
undergoing thyroid surgery using this method and provides valuable safety
data for surgeons wishing to use it as a backup method for RLN
identification in special cases.

25. Most patients in our study were in the late stages of thyroid
cancer, which makes it difficult to identify the RLN.
 However, in all of the cases, the RLNs were successfully
identified by the medial approach. The data also confirm that
identifying the RLN with the medial approach does not increase
the risk of operative complications, including vocal paralysis,
hypocalcaemia, primary hemorrhage, or wound complications.

26. The patient size in this study seems to be small compared to
other studies on thyroid surgery.
However, the purpose of this study was to describe a backup of
the RLN identification approach for special cases, not routine
cases.
Especially in underdeveloped countries which, intraoperative
neuromonitoring of the RLN is expensive and not available in
most cases

27. THANK YOU