Neural monitoring in transoral endoscopic thyroidectomy

Transoral endoscopic thyroidectomy (TOET) is now a common procedure worldwide. Although prospective data for the use of intraoperative neural monitoring (IONM) in TOET are still limited, the literature agree that IONM should be routinely used in TOET because it helps to elucidate the mechanism of recurrent laryngeal nerve (RLN) injury and helps to avoid further nerve injury. However, specialized training is needed for effective use of IONM in TOET. The surgeon and anesthesiologist must work as a team and must have knowledge and experience in the standard procedures, equipment, trouble-shooting algorithms, and limitations of IONM. Specifically, IONM should be used in TOET only if the surgeon has adequate nerve monitoring experience, and guidelines for IONM must be modified for use in TOET. Without proper troubleshooting algorithms, IONM can be burdensome and even dangerous. Nevertheless, applications of IONM have great potential for further development. As its limitations are addressed, IONM is expected to contribute to increased safety of TOET.