Training and learning curve of intraoperative neuromonitoring

The early identification of laryngeal nerves has been accepted as the safest technique to reduce recurrent morbidity, but the identification of the nerve alone can not ensure the presence of the function. Moreover, identification may not be easy, as in cases of reoperation, removal of central lymph nodes, thyrotoxicosis and in case of retrosternal goiter, thyroiditis or aberrant anatomy. Therefore it may be very useful to have an instrument that facilitates the safe completion of this important surgical step. For this reason, in recent years intraoperative neuromonitoring (IONM) has been proposed and applied in many centers in thyroid surgery in addition to the standard practice of visual identification of recurrent laryngeal nerve (RLN), with the primary purpose of evaluating its function and facilitating its identification and dissection. This work shows the benefits of the IONM technique, while recognizing that this technique cannot replace the fundamental elements in the performance of thyroidectomy. Moreover it describes that the introduction of IONM system, as a complement to the thyroidectomy procedure, may also have useful implications from medico-legal and training points of view.