Hindawi Publishing CorporationJournal of yroid ResearchVolume 2013, Article ID 539274, 3 pageshttp://dx.doi.org/10.1155/2013/539274
Clinical StudyThe Identi�cation of �ecurrent Laryngeal �erve by In�ection ofBlue Dye into the Inferior Thyroid Artery in Elusive Locations
Gulcin Hepgul,1 MeltemKucukyilmaz,2 Oguz Koc,2 Yigit Duzkoylu,2
Yavuz Selim Sari,2 and Yesim Erbil3
1 General Surgery Department, Bagcilar Training and Research Hospital, 34021 Istanbul, Turkey2General Surgery Department, Istanbul Training and Research Hospital, 34098 Istanbul, Turkey3General Surgery Department, Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
Introduction. yroidectomy creates a potential risk for all parathyroid glands and the recurrent laryngeal nerve (RLN). eidenti�cation and dissection of the RLN is the gold standard for preserving its function. In some cases, it may be quite difficultto identify the nerve localization. In such elusive locations, we aimed to identify RLNs using peroperative injection of a blue dyeinto the inferior thyroid artery.Materials andMethods. is study included 10 selected patients whose RLN identi�cation had beendifficult peroperatively during the period fromApril 2008 to June 2009.When the RLNs became elusive in location, the branches ofthe inferior thyroid artery (ITA) on the capsule of the thyroid lobe were isolated, and then 0.5mL isosulphan blue dye was injectedinto the artery. Results. RLN was carefully dissected in the tracheoesophageal groove. RLN was clearly visualized, in all patients. AllRLNs were identi�ed along their course in the dyed surrounding tissue. No RLN palsy was encountered. Conclusion. e injectionof blue dye into the ITA branches can be used as an alternate method in case of difficulty in identi�cation of RLNs.
1. Introduction
yroidectomy is one of the most frequent operations per-formed in iodine-de�cient regions. e main postoperativecomplications are recurrent laryngeal nerve (RLN) palsy andhypoparathyroidism [1–3]. Although the overall incidence ofnerve palsy is low, when it occurs, it becomes a devastatinglife-long handicap. e incidence of nerve palsy varies from0% to 14%. Several factors in�uence the likelihood of injuryto the nerve, including the underlying disease (substernalgoiter, malignancy, Graves disease, etc.), the extent of resec-tion, and the experience of the surgeon.e standardmethodfor RLN preservation during thyroidectomy is routine visualidenti�cation of the nerve [1–3].ere are several approachesto identify the RLNs depending on the surgeon preference(distal or proximal to cricothyroid). But in some cases itmay be still quite difficult to localize the RLNs, and in thesesituations, blue dye injection into the inferior thyroid arteryor its branches may be useful to identify the RLN. To ourbest knowledge this is the �rst report of using peroperative
injection of a blue dye into the inferior thyroid artery toidentify the RLN.
2. Materials andMethods
is study included 10 patients (8 women and 2 men) whowere selected during the period from April 2008 to June2009. e median age of the patients was 64 years (range51–76 years). e indication for surgery was a large goiterwith compressive effects in all patients. e study plan wasreviewed and approved by our institutional ethics committee,and informed consent was obtained from all patients. Undergeneral endotracheal anesthesia, the patients were placed in asupine position with the neck extended. A low collar incisionwas made and carried down through the subcutaneous tissueand platysma muscle. Superior and inferior subplatysmal�aps were developed, and the strap muscles were dividedvertically in the midline and retracted laterally. e thyroidlobe was bluntly dissected free from its investing fascia and
2 Journal of yroid Research
F 1: e injection of blue dye.
rotated medially. e middle thyroid vein was ligated. esuperior pole vessels were ligated adjacent to the thyroid lobe.e RLNs were tried to identify in the tracheoesophagealgroove. When decision made as an elusive location of RLN,the branches of the inferior thyroid artery (ITA) on thecapsule of the thyroid lobe were isolated, and 0.5mL ofisosulphan blue dye was injected (Figure 1).
3. Results
RLN was carefully dissected in the tracheoesophageal grooveand clearly visualized in all the patients aer injection ofdye. All RLNs were identi�ed along their course in the dyedsurrounding tissue (Figures 2(a), 2(b), and 2(c)). e nervewas gently separated from its surrounding tissue. Once thenerve and parathyroid glands were identi�ed and dissected,the thyroid lobe was removed from its tracheal attachmentsby dividing the ligament of Berry. e contralateral thyroidlobe was removed in a similar method. ere was no oper-ative mortality. Persistent or transient vocal cord paralysiswas not encountered in any patients. In one (10%) patient,serum calcium level was found to be less than 8mg/dL atthe postoperative 24 hour. Papillary microcarcinoma wasdetected in 2 patients.ere were no difficulties related to theblue dye injection during histopathological examination.
4. Discussion
yroidectomy creates a potential risk for the parathyroidglands and for the laryngeal nerves. Causes of RLN palsyinclude damage to the anatomic integrity of the nerve.ermal lesions, difficulties in tracheal intubation leading toaxon damage through excessive strain, edema or hematoma,and neuritis caused by scar tissue are some of the factorscausing damage to the nerve structure. Neuritis as a resultof viral infection may also damage the nerve. Galeno ofPergamo was the �rst anatomist to describe the RLN as abranch of a cranial nerve. In 1923, Lahey emphasized theimportance of RLN and developed a standard technique for
A
(a)
B
(b)
C
(c)
F 2: e nerve in the dyed surrounded tissue.
its identi�cation and exposure during thyroidectomy [4, 5].�ince Lahey, identi�cation and dissection of RLN is the goldstandard of preserving its function. Identi�cation of RLNhas decreased the rates of transient or permanent nerveinjury during thyroid operations [2, 3]. Many surgeons userelationships with the ITA, tracheoesophageal groove, andligament of Berry as anatomical landmarks to identify thenerve. e �rst routine pattern for identifying the nerve is to�nd the inferior thyroid artery and to use it as an anatomicmarker. However, because of the numerous variations ofthis neurovascular relationship altered also by the pathologiccondition of the gland, identi�cation of the artery doesnot assure consequent identi�cation and preservation of therecurrent laryngeal nerve. If the nerve has not been foundinferiorly, it is justi�able to search for it in the upper part ofthe gland using the posterior suspensory ligament of Berryas a landmark [6, 7]. Nevertheless, in some complicated casesor complementary thyroid surgery it may be very difficult tolocate the RLNs; if you do not have another nerve identifyingoption such as neuromonitorization, you can easily use the
Journal of yroid Research 3
dye method, and the RLN tract will be more de�nite. Inconclusion, we propose that injection of blue dye into theinferior thyroid artery or its branches can be used as amethodfor the identi�cation of the RLN. However, this techni�ueshould not be considered as a substitute for conventionalvisual identi�cation of the nerve.
References
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