Intraoperative neuromonitoring versus optical magnification in the prevention of recurrent laryngeal nerve injury in thyroid surgery: a prospective randomized study

Background Although a standardized technique in thyroid surgery, still a certain percentage of both early and late complications is reported and undoubtedly the recurrent laryngeal nerve (RLN) paralysis remains the most fearful. Thus, different technological innovations have been introduced over the last decades with the aim to guarantee major accuracy and decrease the risk of severe complications. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate dissection and increase the surgeon’s precision. The aim of our study is to compare these two techniques in terms of complications rate especially in the incidence of RLN paralysis during thyroid surgery. Materials and Methods In our prospective randomized longitudinal study, from October 2018 to February 2020 total thyroidectomy was performed in a population of 100 consecutive patients that was divided into 2 groups of 50 patients. In the first group (OM - Optical Magnification), only surgical binocular loupes (2.5x-4.5x) were used as an aid in the RLN identification and dissection, while in the second group (IONM – Intraoperative Neuromonitoring) was adopted only the NIM in intermittent modality. The preoperative assessment included either indirect laryngoscopy or fibrolaringoscopy and all the patients had normal vocal cord motility. Written informed consent was obtained and thyroid surgery was performed by the same experienced surgeons of the team. Exclusion criteria were previous thyroid surgery, lobectomy, neck irradiation, concomitant parathyroidectomy, lymph node dissection, minimally invasive procedures such as MIVAT, TOETVA. The follow-up period was 6 months. No cases of mortality were reported in our series. Results The two groups were homogeneous in distribution of age, sex and type of thyroid disease at the admission. No statistically significant differences in the presence of hyperfunction or thyroiditis was shown. In the IONM group, the most relevant data was the presence of 2 cases of bilateral RLN paralysis that needed immediate airway management and intensive care unit transfer of the patients. However, the two transients bilateral RLN paralysis in the IONM Group (4%) versus none in the OM Group (0%) were not statistically significant (p>0.05). Furthermore, statistically relevant data was found regarding the duration of the operation, transient hypocalcemia and the length of hospitalization (p<0.05). The duration of the operation seemed to be significantly shorter in the OM Group (median 80 vs 100 minutes, p<0.05). With regard in the length of hospital staying, there was a statistically significant difference in favor of the OM Group (median 2 vs 4 days, p<0.05). Nevertheless, the OM group reported a 4-fold higher risk developing transient hypocalcemia than the IONM group (OR 3.78, Adj OR 4.11, p=0.01). In addition, the multivariate analysis adjusted by group and gender documented a relevant difference regarding the transient postoperative dysphonia with the males having a 5-fold higher risk developing transient dysphonia than the females (Adj OR 5.19, 95% IC 0.99-27.18, p=0.05). A collateral data of our study was the finding of occult carcinomas in relation to the histological report and cytological examination for each group (90% and 80% of incidence rate in OM and IONM group respectively) and the presence of overall histological carcinomas in the OM group was statistically significant (p<0,05). Finally, no significant difference was found regarding definitive hypoparathyroidism and in the follow-up at six months after surgery all patients were found with preserved vocal cord motility and no cases of hypocalcemia or hypoparathyroidism were detected. Conclusion To our knowledge, this is the first study in the literature that directly compares the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications in both methods remains comparable and the 2 cases of RLN paralysis in the IONM group of our series are not statistically significant. While the OM is advantageous for the accurate identification, isolation and dissection of the RLN, the IONM allows intraoperative assessment of the nerve integrity and functionality and can add greater confidence to the surgeon, especially if less experienced. In our opinion the two techniques can be considered a valid alternative in thyroid surgery, at least in highly specialized endocrine-surgical centers, and their simultaneous application provides better outcomes. A new multicenter study with a larger cohort of patients and using the IONM in continuous modality could certainly provide us further information

Pelvic floor anatomy

The pelvis is a complex structure made up of bones, muscles, ligaments, and fascia and con- tains organs such as the bladder, urethra, uterus, prostate, and rectum. The pelvic floor is separated into three compartments (anterior, middle, and posterior) and consists of muscles and connective tissue that work as a coordinated system to sup- port the organs and to prevent dysfunctions. This chapter attempts to provide an essential description of those structures and organs of pel- vic floor that contribute to the complex mecha- nism of anal continence. The pelvic cavity, the anterior and middle compartment of the pelvic floor, and the ischioanal fossae are anatomic structures beyond the scope of this section. Fecal incontinence is described mostly as a disorder of the posterior compartment of pelvic floor, managed traditionally by colorectal sur- geons. Therefore, in order to make easier to understand the physiology of continence mecha- nism, we concentrated our attention to the ana- tomical aspects regarding the muscles of pelvic floor and the structure of the anorectum

Traumatic cloaca; surgical treatment of a disabling deformity

Traumatic cloaca is a disabling deformity of the anus and vagina caused by the severe damage of the sphincter apparatus and of the perineal body, resulting in a common aperture for the rectum and vagina, as in congenital cloaca. The most common cause is major obstetric injury occurred by median episiotomies that lead to third and fourth degree perineal lacerations, unrecognized or not repaired properly. The incidence is approximately 0.3% of all complicated vaginal deliveries. The resulting deformity is characterized by three-dimensional destruction of the perineal body, anterior disruption of the sphincter complex and loss of the distal rectovaginal septum of varying length. [1-4,7, 9] Other rare causes of traumatic cloaca may be severe injuries in women victims of sexual violence or by grave accidents in sports like cycling

[Treatment of obstructive defecation syndrome related to hedrocele. Our experience]

Hedrocele represents an unusual variant of the rare posterior perineal hernia and results from a defect in the rectogenital septum. We report two cases of obstructive defecation syndrome (ODS) related to presence of hedrocele successfully treated by laparoscopy-assisted transanal surgery

Intraoperative Neuromonitoring and Optical Magnification in the Prevention of Recurrent Laryngeal Nerve Injuries during Total Thyroidectomy

Background and Objectives: Recurrent laryngeal nerve (RLN) paralysis is a fearful complication during thyroidectomy. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate RLN identification and dissection. The purpose of our study was to evaluate the influence of the two techniques on the incidence of RLN paralysis and determine correlations regarding common outcomes in thyroid surgery. Materials and Methods: Two equally sized groups of 50 patients who underwent total thyroidectomies were examined. In the first group (OM), only surgical binocular loupes (2.5×–4.5×) were used during surgery, while in the second group (IONM), the intermittent NIM was applied. Results: Both the operative time and the length of hospitalization were shorter in the OM group than in the IONM group (median 80 versus 100 min and median 2 versus 4 days, respectively) (p p = 0.05). The OM group reported a four-fold higher risk of developing transient hypocalcemia than the IONM group (OR 3.78, adjusted OR 4.11, p = 0.01). Despite two cases of temporary bilateral RLN paralysis in the IONM group versus none in the OM group, no statistically significant difference was found (p > 0.05). No permanent RLN paralysis or hypoparathyroidism have been reported. Conclusions: Despite some limitations, our study is the first to compare the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications remains comparable and both techniques can be considered valid instruments, especially if applied simultaneously by surgeons

May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score

Abstract Background Although thyroidectomy is one of the most common surgical procedures performed worldwide, some permanent complications, despite the considerably reducing incidence, may affect dramatically the patients quality of life. The purpose of this study is to evaluate whether factors identified preoperatively and expressed in a score could be predictors of major surgical difficulty during total thyroidectomy and influence the incidence of complications. Methods A total of 164 patients who underwent total thyroidectomy were examined. For each patient we calculated a preoperative score, including seven parameters, which we evaluated to be predictors of difficulty in thyroid surgery, that is, sex, body mass index (BMI), neck length, neck extension, thyroid gland volume, thyroiditis, and increased parenchymal vascularization. The overall score was also compared with peri- and post-operative factors describing objectively the difficulty in thyroid surgery. These factors are the duration of the operation, the length of hospitalization, the incidence of complications such as hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve injuries. Results There was no statistically significant association between our score and either the percentage of postoperative complications or the length of hospitalization. The operative time was the only variable remarkably associated with the score value (p < 0.00001). Comparing the duration of the operation with each of the preoperative predictive factors, we found that none of the factors reached the value of statistical significance, but a close association could be noted with the thyroid volume and the BMI. Conclusions In our study, predictors of difficulty in thyroidectomy did not affect morbidity rates, as suggested by previous studies, but only operative times, which were significantly increased in patients with higher score. Although our results have limited statistical significance, they allow us to confirm the fundamental role of a systematic use of optical magnification and microsurgical technique in thyroidectomy. Further studies, with a larger cohort of patients, are needed to validate our results and to formulate a universally accepted predictive score of difficulty in thyroidectomy preoperatively

Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study

The large perineal defect, with impaired wound healing and delayed start of the adjuvant chemotherapy, can make the reconstructive phase of abdominoperineal resection for low rectal cancer extremely challenging. Using biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure is a poorly investigated technique, which, in our series, resulted in safe, reproducible results affected by limited complications. Moreover, for improved perineal wound healing, it guaranteed a faster start of the adjuvant therapy with clear reduction in oncological outcomes (i.e., recurrences and death).Background: Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure. Methods: From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152). Conclusions: In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results

Fine needle aspiration cytology of 650 thyroid nodules operated for multinodular goiter: a cyto-histological correlation based on the new Italian cytological classification (siapec 2014)

The new italian cytological classification (SIAPEC 2014) of thyroid nodules, in line with the Bethesda and BTA-RCPath ones, replaces the previous TIR3 class with two new classes (TIR3A and TIR3B), to which correspond different risks of malignancy and clinical actions required. The present study was conducted to evaluate the diagnostic accuracy of the new SIAPEC classification as opposed to its previous version (SIAPEC 2007). Preoperative cytology was compared with the final histology obtained from 650 consecutive patients submitted to total thyroidectomy for multinodular goiter. Of these 434 patients (group A) had their cytological diagnosis based on the old SIAPEC 2007 classification and 216 patients (group B) had their cytological diagnosis based on the SIAPEC 2014 classification. In group A 111 patients (25.6%) had a TIR3 diagnosis, while in group B 52 patients (24.1%) received a TIR3 diagnosis, of which 30 had TIR3A and 22 had TIR3B. In group A, 46 (41.4%) out of the 111 patients with TIR3 diagnosis had, based on histology, a thyroid carcinoma. In group B, only 2 (6.7%) out of 30 patients with TIR3A diagnosis had a thyroid carcinoma. This rate of malignancy was significantly lower (p<0.001) of that observed in patients with TIR3B diagnosis, in which 12 (54.5%) out of 22 patients had a carcinoma. The observations here reported show that, with respect to its previous version, the new italian cytological classification provides greater diagnostic accuracy for detecting thyroid nodule malignancy