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Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). Methods: A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. Results: A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Conclusions: Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.

Introduction: The aim of our study was to investigate the contributions made to thyroid surgery by outstanding Russian surgeons;' (Pirogov N.I., Bujalskiy I.V., Velyaminov N.A., Bobrov A.A., Lezhnev N.F., Fyodorov S.P., Opel V.A. and others) MATERIALS AND METHODS: Research was done on thyroid surgery in Russia in the period from the early 19th century to the early 20th century and the achievements of Russian surgeons were assessed in relation to progress in the field worldwide, including the difficulties that prevented Russian surgeons from gaining extensive attention at an international level and the steps taken by Russia in the 21st century to share expertise in thyroid surgery with other countries. Data was gathered from 178 documents. Books, manuals, and other scientific publications, as well as doctors reports and patient records were analyzed. Research was done on 15 surgical instruments and 10 photographs., Results: The first description of thyroid surgery in Russia dates back to 1804. In 1831 Nikolaiy Ivanovich Pirogov described the anatomy, topography, syntopy and the main principals of thyroid surgery. In 1847 he performed the first "strumectomy" in the world under general anesthesia. For bleeding control he used 30 - 40 ligatures and vascular forceps with locks. The next operation on the thyroid under anesthesia was carried out 13 years later by Eugene S. Cooper (USA). Ilya V. Bujalskiy (Russia), consultant at St.-Petersburg Mariinsky hospital, used an ether narcosis in May, 1847 and chloroform in August 1848 when operating on the thyroid. One other description of the use of chloroform narcosis , by Paul von Sick (Germany) in 1867. In 1886 Nicolay A. Velyaminov performed thyroid resection in the Mariinsky hospital. In 1904 Russian surgeon Nikolai F. Lezhnev reported on 106 thyroid operations performed with visual control of the recurrent laryngeal nerves in Bobrov's clinic in Moscow, where those techniques had been introduced in 1893. He also dealt with the problem of ectopic goiter, and at sessions of the Pirogov Surgical Society gave case presentations of patients with lingual goiter (1908, 1926). Sergey P. Fedorov was well-known in Europe. That is why William Mayo came to observe his operations. He called Fedorov a "master surgeon"., Conclusion: The contribution of famous Russian surgeons to the field of thyroid surgery is important and should be appreciated at its true value., Key Words: History, Thyroid surgery.

Aim: To define surgical approaches which provide surgical adequacy, preservation of function and aesthetic results., Material and Methods: Analysis included 191 emergency interventions for various neck injuries and more than 35.000 elective operations for thyroid diseases., Results: The study showed that collar-like incisions have the best aesthetic effect on the neck; an approach along anterior margin of the sternocleidomastoid muscle is advisable for emergency assessment of cervical organs; W.F. MacFee access is optimal for lateral cervical lymphadenectomy in asthenic patients while serpentine incision - in hypersthenic ones.

A search of residual tissues is complicated in recurrent operations on the thyroid gland. The Saint-Petersburg Centre of Surgery of the Endocrine System and Oncology developed the method of detection of residual tissues of the thyroid gland with the aim of preoperative chromothyroidolymphography under control of ultrasound. The method consisted of US performance during 15-20 minutes before the operation and an introduction of 1% sterile water solution of methylene blue in revealed residual tissues of the thyroid gland. The volume of injected coloring agent was 0.5-2 ml in the residual tissue volume smaller than 9 cm3 and 2-3 ml injected in case of more than 9 cm3. The residual tissues of the thyroid gland accurately visualized during the following operation. Described method gives the possibility to detect all regions of residual tissues which should be removed and at the same time it shortens a revision and surgery trauma.

An analysis of 169 palliative surgical interventions out of 581 patients with "neglected" papillary, follicular and medullary thyroid cancer was made for the period from 1975 to 2010.The majority of the patients was older than 60 years, 40 of them had hematogenic dissemination. In 10 (6.2%) cases palliative operations were completed with a permanent tracheostomy through the perforation in the lower flap of that wound that decreased postoperative purulence up to 12.5%. Five years later 48 (40.3%) patients were alive from 119 patients with papillary and follicular thyroid cancer and only 10 (26.3%) with medullary cancer. Longer than 10 years 36 (28.9%) patients with papillary and follicular thyroid cancer survived that supports the validity of palliative interventions.

Anasplastic carcinoma of the thyroid gland (243 cases), polinodous goiter of cervical retrosternal localization (25 cases), acute purulent strumitis or thyroiditis (9 cases) induced disturbance of aero-digestive organs of the neck and resulted in the necessary urgent surgical care. The most dangerous complications after 23777 operations on the TG requiring repeated surgical intervention were bilateral lesion of the recurrent nerves (1% of observations), hemorrhages in the TG bed (0.38% of observations). Timely surgical treatment as well as exact knowledge of the neck anatomy, visual control of the recurrent laryngeal nerves, cover of the nerves and lessening the TG bed volume with a part of the parietal leaf of the 4th fascia of the neck in each thyroid operation considerably decreased the danger of asphyxia and the appearance of life threatening complications at the early postoperative period.

An analysis of observations of 81 patients has shown that inadequate operations might be followed by the appearance of continuing growth of the tumor in 24.7% of cases. Reoperations made for clinical-laboratory indications are followed by residual tumors in 61.29%. After inadequate operations the patients must be under active observation.

The results of using improved methods of prophylactics of postoperative bleedings in operations on the thyroid gland are described. It was shown that a hypertonic test from 0.5 ml of 1.0% solution of Mezaton made before the end of operation as well a decrease of the volume of the ablated gland bed using an original fascio-tracheopexy allowed reduction of frequency of bleedings in the thyroid gland bed from 0.36% per 2750 operations in 2005-2007 to 0.16% per 826 surgical procedures at the period 2008-2010. The symptoms of bleedings in the thyroid gland bed are enumerated and efficient actions of the personnel and surgeons for prevention of asphyxia and cardiac arrest.

The article presents a comparison and analysis of clinical and morphological data obtained in surgical treatment of 743 thyrotoxicosis patients operated in clinical bases of the Saint Petersburg Center of surgery of organs of the endocrine system at the period from 2005 through 2010. Causes of disagreement of the clinical diagnosis and morphological conclusion in patients with different diseases of the thyroid gland resulting in thyrotoxicosis are considered. Great clinical material (743 observations) was used by the authors to demonstrate the diagnostic value of special methods of investigation of the thyroid gland in patients with the toxic goiter. Advantages of subtotal resection of the thyroid gland by the P.Dunhill--E.S.Drachinsky method are stressed for surgical treatment of patients with nodular transformation of the thyroid tissue against the background of diffuse toxic goiter.

Direct and long-term results of surgical interventions for differentiated cancer of the thyroid gland supplemented with lymphadenectomy on the tumor side were studied on the material of 1136 patients. As a group of comparison there was a group of 303 patients with similar histological diagnoses, gender and age and distribution of carcinomas by stages in which the ablation of para- and pretracheal lymph nodes was not fulfilled by any reasons. The investigation gives proofs of the necessity to perform central lymphadenectomy simultaneously in all primary operations for differentiated cancer of the thyroid gland.

On the basis of studying clinical symptoms of thyrotoxicosis in elderly patients and an analysis of results of investigation of the heart the authors marked out additional indications to surgical treatment of this category of patients. Results of surgical treatment of elderly and senile patients suffering from thyrotoxicosis are also described.

The epidemiological picture and clinical course of thyroid carcinoma in children in the Russian Federation (St.Petersburg, Chelyabinsk, Arkhangelsk) and the nearest abroad (Belarus, Ukraine) are compared. The influence of the radiation pollution is determined after the Chernobyl accident on the appearance and aggressiveness of the course of thyroid carcinoma in children and adolescents living in St. Petersburg. Epidemiology and results of treatment of 105 patients of this age having thyroid carcinoma are analyzed who were treated from 1986 till 2007 in the St. Petersburg center of surgery and oncology of organs of the endocrine system. A reliable relationship was noted between the time of the appearance and aggressiveness of the course of thyroid carcinoma in patients in St. Petersburg with the data obtained from the regions exposed to radiation pollution after the Chernobyl accident. Good results of surgical treatment are shown as well as of survival of radio-induced and sporadic thyroid carcinoma in children and adolescents.

An analysis of results of surgical treatment of 50 patients aged from 16 to 75 years with different diseases of the thyroid has shown that the frequency of decrease of the level of calcium and parathormone becomes less in the row: diffuse toxic goiter, cancer of the thyroid gland, polynodous euthyroid goiter. Decrease of the calcium and parathormone level is associated with deterioration of blood circulation and functional activity of parathyroid glands after operation on the thyroid gland. The patients after operation on the thyroid gland need prophylactic administration of calcium preparations.

Age is one of the most significant risk factors of the development of diseases of the thyroid gland. Hyperthyroidism is much more difficult for diagnosing in elderly patients since its symptoms might be rubbed off and somewhat atypical. Rather often the cardial symptoms in elderly and senile patients are brought to the forefront when there are no other external manifestations of the disease. One of the most difficult questions in decision on the strategy of treatment of toxic goiter in elderly people having thyrotoxicosis is the question of indications to surgery. The article describes clinical symptoms and exact indications to surgical treatment in elderly people with thyrotoxicosis and assesses long-term results.

On the basis of anatomical (30 observations) and clinical material (160 patients with different diseases of the thyroid gland) the topography of connective-tissue fixing apparatus of the thyroid gland was defined more precisely. Its classification is proposed and the relationship with the surrounding structures is described. The character of changes in the connective-tissue fixing elements is shown in different variants of its pathology. The best places for dissection of the connective-tissue structures are well-founded with special reference to the topography of the thyroid vessel branches, recurrent and superior laryngeal nerves. The sequence of surgeon's actions in mobilization of the thyroid gland lobe is proposed and substantiated.

Under analysis were results of genetic investigations of 105 patients with thyroid cancer (TC) treated from 2004 through 2007 in the St. Petersburg City Center of surgery and oncology of the endocrine system organs. The patients' age was from 17 to 80 years (mean age 51.6 +/- 1.9 years). The influence of functional variants of matrix metalloproteinase genes in TC was determined. A reliable correlation was noted between certain gene markers and TC patients' age. An association was revealed between matrix metalloproteinase-3 5A (more active allele) and size of the tumor. A reliably decreased frequency of hyperactive genotype MMP-1 2G was detected in a group of women with metastatic forms of papillary cancer as compared with patients without metastases. It was shown that MMP genes could be a substantial factor of slowing down the rate of malignant growth and invasive properties of cancer of the thyroid gland.

On the basis of an anatomical (60 observations) and clinical material (160 patients with different diseases of the thyroid gland) the authors specified topography of the external branch of the superior laryngeal nerve, proposed supplements to the classification of variants of its passage, estimated the risk of traumatizing this structure during operation, determined the zone of most probable injury. Anatomical substantiation is given to the places of most convenient ligation of the main branches of the superior thyroid vessels.

Carcinoma of the thyroid gland in children and adolescents is high biological aggression with frequent involvement of the regional lymph vessels, the presence of distant metastases and invasion to the gland capsule. Surgical treatment followed by radio-iodine therapy, and if necessary with TTH-suppressive therapy allows survival of absolute majority of the patients. The application of (131)1 therapy in the postoperative period suggests the necessity of permanent observation of the patients for the early diagnosis of possible neoplasms of other localizations.

Results of surgical treatment of 192 patients aged from 19 through 72 years were analyzed, they had euthyroid goiter, compensated and subcompensated forms of toxic goiter. A comparative assessment is given of sodium thiopental, propophol and sibazon for induction of general anesthesia according to their effects on the indices of central hemodynamics, thyroid status and subjective patient's comfort, as well as propranolol, thalinolol and esmolol as medicines for intraoperative correction of hemodynamic manifestations of thyrotoxicosis. The influence of surgical manipulations was assessed on main hemodynamic indices and the level of thyroid glands hormones. Attention is called to the main tasks of anesthesiologists responsible for anesthesiological maintenance of operation under conditions of compensated and subcompensated thyrotoxicosis.

The article presents an analysis of results of surgical treatment of 90 patients aged older than 75 years (mean age 78.0+/-2.8 years) with nodular diseases of the thyroid gland. The influence of a concomitant pathology in other organs on the course of diseases of the thyroid gland was established. It was noted that in senile patients malignant tumors appeared three times more often against the background of a benign pathology of the thyroid gland than in young patients. Main indications for surgical treatment were compression syndrome and cancer of the thyroid gland. The results of treatment of malignant tumors of the thyroid gland in senile patients and causes of postoperative complications were studied. Unfavorable results of treatment were due to prolonged observations at the pre-admission stage, predominance of patients (63.0%) with the 4th stage of disease, almost half of them had anaplastic cancer.

The work presents an analysis of specific features of surgical anatomy of recurrent laryngeal nerves in 676 patients operated in the City Center of endocrine surgery and oncology of St. Petersburg for different diseases of the thyroid gland (TG) during the period from 01.01.2005 to 15.07.2006 mainly by one and the same surgeon. In the course of 696 operations 718 recurrent laryngeal nerves were detected, verified, separated in the neck from the subclavian area to the place of entering into the larynx, and photo-video documented. In 656 cases the disease of TG was primary, and in 40 cases--recurrent. The investigation performed allowed the development and use of reliable methods of prophylactics and treatment of recurrent laryngeal nerves injured in patients during operations for different diseases of TG, carcinoma of this organ included. The optimal places of detection and identification were determined as well as the ways of separation of these nerves from the surrounding tissues. The surgical anatomy of the recurrent laryngeal nerves in the neck was studied. The role, place and effectiveness of electrophysiological monitoring were established. The corrections introduced in the technique of thyroidectomies in 4110 patients resulted in lowered incidence of postoperative pareses of the laryngeal muscles from 0.91% to 0.56% during the period from 2001 to 2006.

Prevalence of secondary hyperparathyroidism (SHPT) was studied in 235 patients treated by program hemodialysis. SHPT was diagnosed according to recommendations of K/DOQI Clinical Practice Guidelines with the parathyroid hormone (PTH) level higher than 300 pg/ml. In the beginning of replacement renal therapy with hemodialysis the secondary hyperparathyroidism of different degree was found in 145 patients (61.7%): mild form (PTH from 300 to 450 pg/ml) in 37.8%, medium (PTH from 450 to 1000 pg/ml) in 40.5%, severe (PTH more than 1000 pg/ml) in 21.7%. Normal indices of PTH were determined in 70 patients. In 20 patients the parathyroid hormone was less than 120 pg/ml and they had symptoms of adynamic disease of the bones. In the group of patients observed for 4 years (n = 80) the incidence of SHPT became less against the background of treatment from 60.0% to 37.0%. Relatively satisfactory results of conservative treatment can be explained by predominance of patients with less than 5 years of CRF. The therapy was more effective in patients with mild and medium forms of SHPT. In patients with severe SHPT (PTH more than 1000 pg/ml) the effect was partial and 77.0% of these patients needed surgical treatment.

The authors give an analysis of preoperative diagnostics of nodular tumors of the thyroid gland in 105 children and adolescents. It was shown that there are no special techniques allowing an absolute exclusion of malignant growth in the thyroid nodule before operation. The most accurate method of investigation in differential diagnostics of thyroid carcinoma in children and adolescents is thought to be fine-needle aspiration biopsy under USI control. The sensitivity of the method was 83.3%, the specificity - 98%.

The authors present 27 cases of intrathyroid adenomas of the parathyroid glands that made up 22.68% of 119 patients operated on for parathyroid tumors. Clinical manifestations of primary hyperparathyrosis were diagnosed in 10 out of 27 patients. In 17 of these patients the hormonal-inactive parathyroid adenomas, detected accidentally during operations for different diseased of the thyroid gland, were ablated. The authors stress a careful revision of the thyroid to be necessary in order to exclude an intrathyroid localization of parathyroid neoplasms which can result in persistence of the disease if not ablated.

The article presents an analysis of results of surgical treatment of 2092 patients with cancer of the thyroid gland (CTG) using different kinds of lymphadenectomies. During 30 years 1076 different operations on the lymph nodes of the neck and mediastinum have been made by the same collective of surgeons. The improved strategy and technique of surgical treatment of patients with differentiated CTG, electrophysiological monitoring of the nerves resulted in less postoperative lethality (from 0.89% to 0%), less number of unilateral damages of the inferior laryngeal nerves (from 4.4% to 0.33%), bilateral pareses (from 2.1% to 0%), accessory nerves (from 2.7% to 0.1%). Surgical diagnostics of the regional metastases of cancer at the preclinical stage by means of intraoperative biopsy of not involved cervical lymph nodes of the 3-4 groups and the division of traumatic operations into 2 stages improved the immediate results and did not deteriorate the long-term results of treatment of CTG patients.

The authors have analyzed the cases of diagnosis of asymptomatic tumors of the parathyroid gland made during 8814 operations on the thyroid in the period from 1995 through 2004. The probability of detecting parathyroid incidentalomas in different forms of goiter was calculated which reaches 0.4%. A precision technique of operating allows the parathyroid tumors to be detected at the preclinical stage in all patients apart from a removal of the necessary volume of the thyroid tissue, guaranteed preservation of the laryngeal nerves and parathyroid glands.

The work is based on an analysis of immediate and long-term results of treatment of 138 patients. It was shown that organ-sparing operations in combination with central lymphadenectomy were good for patients with intrathyroid carcinomas. Regional metastases observed by the moment of surgical treatment were a bad prognostic sign. The survival of patients without metastases was similar to that of patients with papillary and follicular cancer of the thyroid gland.

Three groups of patients with different degrees of primary hyperparathyroidism were compared: 36 patients with asymptomatic tumors (incidentalomas) of the parathyroid glands, 20 patients with parathyreoadenomas of medium size and mild signs of hyperparathyroidism and 26 patients with large adenomas and severe manifestations of the disease. It was shown that asymptomatic tumors of the parathyroid glands (incidentalomas) might turn into clinically marked hyperparathyroidism as the size of the parathyroid tumors was growing.

The authors have analyzed the results of treatment of 147 patients with diffuse toxic goiter (DTG) operated upon in the St. Petersburg Center of the surgery of the endocrine system organs. Questions of surgical strategy are considered when DTG is combined with nodular forms. The diagnostic potentialities of the methods used are assessed. The incidence of carcinomas in patients with nodular formations and DTG was determined. It was shown that the presence of nodules in the thyroid gland did not influence the nearest and distant results when using the corresponding surgical strategy.

In the clinic of hospital surgery of the St. Petersburg state PMA operations on 19 000 patients with diseases of the thoracic gland were performed during 30 years. More than 1000 of these patients were operated on for recurrences. In most patients the recurrence repeated the primary disease of the thyroid gland. It is necessary to single out new diseases of the thyroid residue which make up 11% of the total number of observations. The causes of appearance of the postoperative recurrent goiter are different, the correct diagnosis can be made but after complex examination of the patients which allows to choose rational medical strategy.