Revisión anatómica neurovascular en cirugía tiroidea y paratiroidea. Sistemática quirúrgica para minimizar eventos adversos.
NEUROVASCULAR ANATOMIC REVIEW IN THYROID AND PARATHYROID SURGERY. SURGICAL SYSTEMATICS TO MINIMIZE ADVERSE EVENTS. Introduction Thyroidectomy is one of the most commonly performed surgical procedures worldwide, and its evolution in recent years has been so significant that it has led to notable chan...
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| Tipo de recurso: | tesis doctoral |
| Estado: | Versión publicada |
| Fecha de publicación: | 2026 |
| País: | España |
| Institución: | Universidad de Valladolid |
| Repositorio: | UVaDOC. Repositorio Documental de la Universidad de Valladolid |
| OAI Identifier: | oai:uvadoc.uva.es:10324/83329 |
| Acceso en línea: | https://doi.org/10.35376/10324/83329 https://uvadoc.uva.es/handle/10324/83329 |
| Access Level: | acceso abierto |
| Palabra clave: | Endocrinología Thyroidectomy Tiroidectomía Laryngeal nerve Nervio laringeo Neuromonitoring Neuromonitorización 32 Ciencias Médicas |
| Sumario: | NEUROVASCULAR ANATOMIC REVIEW IN THYROID AND PARATHYROID SURGERY. SURGICAL SYSTEMATICS TO MINIMIZE ADVERSE EVENTS. Introduction Thyroidectomy is one of the most commonly performed surgical procedures worldwide, and its evolution in recent years has been so significant that it has led to notable changes, especially from a technological point of view. Objective To establish a safe and systematic surgical technique for thyroidectomy, based on the identification of the recurrent laryngeal nerve (RLN) at the level of the crossing with the inferior thyroid artery (ITA). Three patterns of neurovascular crossing will be established (pre-arterial, retro-arterial and inter-arterial) and a comparative study will be carried out on both sides, right and left, observing the frequency of crossing on each side. Other objectives are the analysis of other anatomical variables and the application of new technologies: intraoperative neuromonitoring (IONM) and vascular sealing. Material and methods A retrospective clinical study carried out in the Otorhinolaryngology and Head and Neck Surgery service of the University Clinical Hospital of Valladolid. A total of 500 patients underwent thyroidectomy by the same surgeon, involving 773 RLNs (399 right and 374 left) and different variables were analyzed (crossing pattern of inferior thyroid artery and RLN, nerve divisions, IONM, position of parathyroid glands and main complications). Results 1. Result of the crossing pattern of the recurrent laryngeal nerve and inferior thyroid artery: 767 RLN (99.2%) of all the nerves studied were identified. On the right side, the predominant relationship between RLN and ATI was pre-arterial in 51,1% of cases; in 30.5% the nerve was located between the ATI bifurcation and in 15.5% of cases in a retro-arterial position. It was not visualized in 1,5% of cases. On the left side, the retro-arterial position predominated in 70,3%, followed by 18,7% in an inter-arterial position and 10,6% in front of the ATI. Only 0.2% of the left RLNs were not identified. 2. Result of the division of the recurrent laryngeal nerve and comparison on both sides: On the right side, the RLN had one branch in 53.2%, two branches in 44,6% and three or more branches in 2% of cases. On the left side, the single branch also predominated, with 70,2%, followed by the bifurcated nerve in 27% and the presence of 3 or more branches in 2.6%. 3. Result of the position and anatomical distribution of parathyroid glands: In 84,1% of cases, the superior parathyroid glands were located at an upper level and the inferior ones in 71% of cases at a lower level. 4. Results of thyroidectomy with and without intraoperative neuromonitoring: Of the 500 patients who underwent surgery, 372 (74,4%) were neuromonitored and 128 (25,6%) were not. IONM had a negative predictive value (NPV) and positive predictive value (PPV) of 100% and 28%, respectively. The sensitivity was 100% and the specificity was 87%. 5. Study and analysis of complications according to the different variables: Temporary and permanent RLN paralysis was 1.2% and 0.7% respectively, while temporary and permanent hypoparathyroidism was 14% and 3.75% respectively. CONCLUSIONS 1. The relationship of the RLN with the ATI is a safe and consistent reference point in thyroid surgery. 2. There is a statistically significant relationship between the operated side and neurovascular crossing (p <0.01). 3. RLN divisions are more frequent on the right side, with a statistically significant relationship between laterality and nerve division (p <0.01). 4. IONM had a sensitivity and specificity of 100% and 87% respectively and facilitated RLN dissection, but did not reduce the rate of paralysis (p = 0.56). 5. The use of vascular sealing devices reduced the bleeding rate. |
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