LAUSR

The first anatomical description of the recurrent laryngeal nerve (RLN) is due to Galen in the 2nd century AD, but only in the last century its importance has been understood by endocrine surgeons. RLN injury is a major complication of thyroid surgery and leads to vocal cord paralysis (VCP). RLN’s visualization is the gold standard for integrity preservation. However, an anatomical intact nerve does not represent its functionality. Reviews of large case series have shown a unilateral VCP in 9.5%, while bilateral VCP in 1.3%. Instead, the permanent VCP rate is 1% –2%. Unilateral VCP can cause hoarseness, while bilateral VCP is associated with severe respiratory distress and requires a tracheostomy. However, both are associated with a significant impact on the patient’s quality of life, on the cost for the National Sanitary System and may have medico-legal consequences. Intraoperative neuromonitoring (IONM) has been developed on the principle of RLN and superior laryngeal nerve (SLN) identification. IONM helps the surgeon in nerves identification in order to reduce paralysis rates. In addition, it is used in the identification of clamping, ligation, compression, traction, thermal injury, or ischemia injuries, in which the RLN appears anatomically intact, but functionally damaged. Intermittent (I-IONM) and continuous (C-IONM) intraoperative neuromonitoring can be considered an additional technique to the routine practice of visual identification of the RLN and SLN during thyroid surgery. Many surgical societies and guidelines recommend the use of IONM, especially in surgery for recurrent cancer, locally advanced cancer or large goiters. However, Literature shows discordant results. In C-IONM, nerve stimulation occurs throughout the endocrine procedure which provides a constant evaluation of nerve and vocal cord functional integrity. The probe can be applied directly