Immediate repair of the recurrent laryngeal nerve during thyroid surgery via a tension-free end-to-side anastomosis with the Vagus.

Abstract

The unprecedented technical and technological evolution in thyroid surgery has labelled it as an extremely safe and efficient procedure, and indeed "typifies perhaps better than any other operation the supreme triumph of the surgeon's art."-William Halsted, 1852-1922. Surgeon's experience reflected by annual case load is the most important denominator in thyroid surgery. Nevertheless, even high-volume thyroid surgeons in high-volume centres are not immune to its complications. Despite the advances in surgical technology and techniques, recurrent laryngeal nerve (RLN) injury is still a wellknown complication of thyroid surgery. The considerable postoperative morbidity associated with it and its impact on the patient's overall quality of life make it a dreadful complication of thyroid surgery and a common cause of malpractice accusations. Intraoperative RLN reconstruction is not widely used in clinical practice, but the evidence so far makes it a viable and safe alternative to traditional techniques with better long-term results, as it prevents the occurrence of atrophy of the vocal cord and should be considered in the operating room if possible. Furthermore, immediate reconstruction of an intraoperatively detected RLN injury has been strongly recommended by the 2020 American Association of Endocrine Surgeons guidelines. After neurorrhaphy, RLN regeneration occurs but in a random, misdirected fashion resulting in simultaneous contraction of abductors and adductors. Therefore, normal vocal fold function/mobility is typically not restored. The objective of this technical note is to describe a novel immediate RLN repair technique that has a strong propensity to regenerate and reinnervate laryngeal muscles and potentially restore laryngeal mobility.