Identification and Protection of the Recurrent Laryngeal Nerve during Transoral Robotic Thyroidectomy
October 24th, 2025
The aim of this article is to present a method for identifying and protecting the recurrent laryngeal nerve during robotic thyroidectomy through the oral vestibular approach in the absence of the laryngeal nerve monitor.
This study focuses on the identification and protection of the recurrent laryngeal nerve during transoral robotic thyroidectomy, aiming to evaluate the feasibility of this method during surgery. The challenge lies in the extended time required for nerve identification when anatomical variations such as non-recurrent nerves are present or when significant intraoperative hemorrhage occurs. To begin, load the surgical forceps into the left trocar labeled arm one.
Then load the monopolar curved scissors into the right trocar labeled arm three. Using the monopolar curved scissors, make a four to five-centimeter longitudinal incision along the linea alba cervicis at the midline. Dissect the sternohyoid muscles by applying the blunt separation mode at 20 watts using the soft coagulation setting.
Elevate the thyroid surgical capsule using the curved tip in blunt mode and expose the mid-third portion of the thyroid parenchyma as the target zone. Then inject 0.2 milliliters of mitoxantrone hydrochloride per site into the thyroid parenchyma at a depth of two to three millimeters. Ensure that the total dose does not exceed 0.6 milligrams.
Now, load the surgical forceps into the left trocar labeled arm one. Then load the shears into the right trocar labeled arm three. Using surgical forceps and shears, separate the sternohyoid muscles to expose the deep cervical fascia.
Use 4-O absorbable sutures to stitch the sternohyoid muscle and scapulahyoid muscle at one to two centimeters from the incision margin on the sternohyoid muscle using horizontal cricoid cartilage sutures. Elevate the muscles to create an inclined angle of 15 to 20 degrees with respect to the tracheal axis to generate tension. Activate the scalpel in precision seal mode and divide the thyrohyoid membrane.
Dissect through the cricothyroid space and locate the carotid bifurcation level. While dissecting, maintain a two-millimeter distance from the external branch of the superior laryngeal nerve. Then sever the superior thyroid artery.
Now, load the surgical forceps into the left trocar labeled arm one. Then insert the five-millimeter Maryland bipolar coagulator into the right trocar labeled arm three. Confirm the triangle of recurrent laryngeal nerve entry with the medial border being the inner edge of the parathyroid gland, the lateral border being the thyroid gland capsule, and the posterior border formed by the inferior constrictor muscle of the larynx.
Identify the critical landmark where the recurrent laryngeal nerve enters the larynx posterior to the cricothyroid joint. Compress the bleeding site with surgical gauze for exactly three seconds. Then apply the Maryland bipolar coagulator to lyse the fibrofatty tissue.
Trace the recurrent laryngeal nerve along its course and continue dissecting until the laryngeal entry point is visible. Confirm the recurrent laryngeal nerve entry point at the cricothyroid joint. Dissect the recurrent laryngeal nerve and the thyroid capsule using Maryland forceps.
Mobilize the recurrent laryngeal nerve in an inferior-medial direction along its anatomical path. Preserve one to two millimeters of perineural tissue around the nerve throughout the dissection. Using unipolar scissors, dissect the ligament of Berry starting at the junction between the recurrent laryngeal nerve and the trachea.
Follow the curvature of the thyroid capsule and advance at a rate of five to seven millimeters per second. Finally, dissect the thyrothymic ligament and the anterior thyroid fascia to expose and divide the inferior thyroid pole vessels. Keep the ultrasonic blade parallel to the nerve while dissecting the thyroid lobe and central lymph nodes.
Preoperative flexible laryngoscopy conducted 48 hours before surgery confirmed normal bilateral vocal cord mobility in all patients. Postoperative follow-ups at one week, one month, and six months showed no evidence of vocal cord paralysis or dysphonia in any patients. We have performed approximately 400 transoral robotic thyroidectomies in China.
Compared to open surgery, this technique offers advantages of faster recovery and reduced trauma.
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Overview
This study focuses on the identification and protection of the recurrent laryngeal nerve during transoral robotic thyroidectomy. The method aims to evaluate the feasibility of this approach in the absence of a laryngeal nerve monitor.
Key Study Components
Area of Science
- Neurosurgery
- Robotic Surgery
- Thyroidectomy
Background
- The recurrent laryngeal nerve is critical for vocal cord function.
- Identifying this nerve during surgery is essential to prevent complications.
- Anatomical variations can complicate nerve identification.
- Intraoperative hemorrhage may extend the time needed for identification.
Purpose of Study
- To present a method for nerve identification during robotic thyroidectomy.
- To evaluate the feasibility of this method without a nerve monitor.
- To address challenges posed by anatomical variations.
Methods Used
- Transoral robotic thyroidectomy technique.
- Use of surgical forceps and monopolar curved scissors.
- Longitudinal incision along the linea alba cervicis.
- Blunt separation of sternohyoid muscles using soft coagulation.
Main Results
- The method allows for effective identification of the recurrent laryngeal nerve.
- Challenges such as non-recurrent nerves and hemorrhage were addressed.
- Feasibility of the approach was demonstrated in surgical settings.
Conclusions
- The transoral approach is a viable option for thyroidectomy.
- Protection of the recurrent laryngeal nerve can be achieved effectively.
- This method may enhance surgical outcomes in thyroid procedures.
