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Surg Endosc. 2018 Jan;32(1):517-525. doi: 10.1007/s00464-017-5656-0. Epub 2017 Jun 22.

Application of transoral continuous intraoperative neuromonitoring in natural orifice transluminal endoscopic surgery for thyroid disease: a preliminary study.

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Department of General Surgery, Chi Mei Medical Center, Tainan, Taiwan.
Department of Surgery, Chi-Mei Hospital Chiali, Tainan, Taiwan.
Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan.
Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.
Superintendent's Office, Chi-Mei Hospital Chiali, Chiali 606, Shin-Hwa Road, Chiali District, Tainan, 722, Taiwan.



The novel concept of continuous intraoperative neuromonitoring (Cont-IONM) through stimulation of the vagal nerve has been used in thyroidectomies to prevent imminent injury of the recurrent laryngeal nerve (RLN). This article reports on this technology and the results of using transoral Cont-IONM in natural orifice transluminal endoscopic surgery for thyroid disease.


Cont-IONM of the RLN was achieved through automatic cyclical stimulation of the vagal nerve using a C2 monitor and delta stimulating electrode. During the operation, three vestibular incisions were made, and the stimulating electrode was transorally inserted, with its cable line lying outside the trocar. The vagal nerve was gently dissected, looped, and then enveloped by the electrode cuff. Electromyography (EMG) of the vocalis muscle was performed, and the alarm was set to activate when the EMG amplitude reduced by 50% and latency was prolonged by 10%. Demographic data and outcome variables, including incremental time required to achieve Cont-IONM, were obtained.


A total of 20 patients (28 nerves at risk) undergoing a transoral endoscopic thyroidectomy vestibular approach were enrolled in this study. All Cont-IONM procedures were successfully completed. In all patients, the stimulation was set at 0.7 milliamps every 1 s, and Cont-IONM use was unassociated with any untoward neural, cardiovascular, or gastrointestinal sequelae. On average, the ipsilateral Cont-IONM procedure required 10.33 ± 2.57 min to complete. Except for one instance, no significant problems occurred with electrode displacement. In one patient, a combined EMG event occurred, which improved after releasing the thyroid retractor, and the patient had no vocal cord paralysis postoperatively.


Cont-IONM is feasible and safe to use during transoral endoscopic thyroidectomies and may assist in the early detection of adverse EMG changes, thereby preventing paralysis of the RLNs.


Continuous neuromonitoring; Intraoperative neuromonitoring; Natural orifice transluminal endoscopic surgery; Recurrent laryngeal nerve; Thyroidectomy; Transoral endoscopic thyroidectomy

[Indexed for MEDLINE]

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