Use of intraoperative neuromonitoring in robotic thyroidectomy: a systematic review of recurrent laryngeal nerve outcomes

Background: Intraoperative neuromonitoring (IONM) is an emerging alternative to visual identification of the recurrent laryngeal nerve (RLN) during surgery. Its goal is to reduce RLN injury and vocal cord paralysis (VCP). However, evidence has been inconsistent concerning its benefits. This study aims to assess IONM’s efficacy in preventing RLN injury during robotic thyroidectomy (RoT). Methods: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was conducted across four electronic databases: PubMed, Web of Science, EMBASE, and Cochrane Library. The inclusion criteria comprised studies published in English that focused on RoT procedures utilizing IONM to assess their effect on RLN injury. Exclusion criteria included non-English publications, studies without full-text availability, reviews, editorials, case reports, animal studies, and studies that did not meet our objectives. After screening, data were extracted and presented qualitatively. Results: An analysis of six studies involving 1006 patients, where the majority evaluated IONM within RoT procedures. Continuous IONM (C-IONM) was feasible and effective for identifying RLN and aiding in its preservation. Outcomes such as success rates, electromyography signal quality, VCP incidence, hypoparathyroidism, hypocalcemia, and bleeding showed comparable trends across groups. Notably, a study found that RoT using IONM, particularly C-IONM, was associated with significantly longer operative times averaging approximately 55.8 minutes longer than open thyroidectomy. Despite this, findings emphasized the protective role of C-IONM in minimizing nerve injury during robotic thyroid procedures, although it did not significantly impact postoperative complications like VCP or length of stay. Conclusion: Our findings suggest that IONM, particularly C-IONM, is feasible during RoT and may support RLN identification and preservation. However, current evidence is limited, and further well-designed studies are needed to clarify its clinical impact and establish criteria for routine use.