Effects of Patient and Tumor Characteristics on Central Lymph Node Metastasis in Papillary Thyroid Cancer: A Guide for Selective Node Dissection.

BACKGROUND: Prophylactic central lymph node dissection (CLND) in papillary thyroid carcinoma (PTC) is still controversial. This study aimed to analyze the factors related to the patient and tumor characteristics affecting central lymph node metastasis (CLNM) in PTC patients and to evaluate the contribution of the results to shaping the surgical treatment algorithm. METHODS: Two hundred and fifty-five PTC patients who underwent total thyroidectomy and CLND were evaluated retrospectively. Histopathology reports were examined to reveal tumor characteristics. The CLNM ratio and the relationship between CLNM with clinicopathological and demographic characteristics were analyzed. RESULTS: The incidence of CLNM was 54.9% (95 CI%: 49-60.8). Male gender (P=0.027), age<45 years (P=0.016), tumor size≥9.5 mm (P<0.001), lymphovascular invasion (P<0001) and extracapsular invasion (P=0.007) were factors that increased the risk of metastasis. The follicular variant decreased the risk (P=0.010). There was no relationship between CLNM and focality (P=0.054). A low-to-moderate correlation was found between tumor diameter and the metastatic lymph node (MLN) number/total lymph node number ratio (r=0.396, P<0.001). CONCLUSION: A selective prophylactic CLND strategy can be applied in cN0 patients. As the tumor diameter increases in PTC, both the risk of CLNM and the number of MLN increase. Lymphovascular and extracapsular invasion are other factors that increase the risk. The follicular variant is associated with a lower risk of CLNM. Male patients who are under the age of 45 and have a tumor diameter of 9.5 mm or more are definite candidates for prophylactic CLND.

Routine Histopathological Examination of the Specimen After Laparoscopic Cholecystectomy: Can We Be Brave Enough to Give Up?

BACKGROUND: Selective versus routine histopathological examination after cholecystectomy is still in debate. This study aims to investigate the effect of histopathology results on treatment modality and surgery strategy. The validity of the selective histopathology approach was questioned. METHODS: The data of patients undergoing laparoscopic cholecystectomy between January 2009 and December 2019 were retrospectively analyzed. The demographics and histopathology results, whether the operation was emergent or elective, and the reasons for conversion to open surgery were recorded. Malignant and precursor histopathology diagnoses were examined, and their relationship with the surgical strategy was questioned. RESULTS: A total of 2723 patients were included in the study. Of these patients, 2600 (95.5%) were operated under elective, while 123 (4.5%) were operated under emergency conditions. While the surgery was completed laparoscopically in 2685 (98.6%) patients, it was converted to open surgery in 38 (1.4%) patients. Age, gender, the presence of primary gallbladder cancer, acute cholecystitis, and xanthogranulomatous cholecystitis in histopathological examination were found to be independent predictive factors for conversion to open surgery (P < .05). The rate of primary invasive carcinoma in the series was 0.1%. CONCLUSION: Routine histopathological examination of the gallbladder is important for demonstrating a wide spectrum of pathological changes in this organ. Invasive cancer or precursor lesions can be detected even in patients without any macroscopic abnormality. Histopathological examination also plays a role in determining follow-up, further examination, and treatment modality in addition to the diagnosis in these patients.

The effect of pneumoperitoneum on intravascular fibrinolytic activity in rats.

BACKGROUND/AIM: Venous stasis during pneumoperitoneum in laparoscopic surgery is closely related to fibrin synthesis and deposition. The etiologic factors underlying fibrinolysis or hypercoagulability are not clearly defined. This study aimed to determine the effects of pneumoperitoneum time and pressure on coagulation cascade and the fibrinolytic pathway. MATERIALS AND METHODS: After the pneumoperitoneum model was established in rats, PAI-1, tPA, TAFI, D-dimer, and fibrinogen activities were evaluated in different time periods under different pressures in groups including 6 rats. Group 1 did not undergo any procedure. Group 2 received 8 mmHg of pressure for 30 min, Group III 8 mmHg for 60 min, Group IV 12 mmHg for 30 min, and Group V 12 mmHg for 60 min. RESULTS: D-dimer levels had a tendency to decrease with increasing intraabdominal pressures. In both low and high pressure groups, fibrinogen had a tendency to increase with exposure time. There was no statistically significant difference among the study groups in terms of fibrinogen, D-dimer, and PAI-1. The levels of TAFI were significantly decreased with increasing pressure regardless of the exposure time. CONCLUSION: Pneumoperitoneum of the coagulation system can be changed by duration of time and pressure.

Relationship between indoleamine 2,3-dioxygenase activity and lymphatic invasion propensity of colorectal carcinoma.

AIM: To evaluate whether serum and tumor indoleamine 2,3-dioxygenase activities can predict lymphatic invasion (LI) or lymph node metastasis in colorectal carcinoma. METHODS: The study group consisted of 44 colorectal carcinoma patients. The patients were re-grouped according to the presence or absence of LI and lymph node metastasis. Forty-three cancer-free subjects without any metabolic disturbances were included into the control group. Serum neopterin was measured by enzyme linked immunosorbent assay. Urinary neopterin and biopterin, serum tryptophan (Trp) and kynurenine (Kyn) concentrations of all patients were determined by high performance liquid chromatography. Kyn/Trp was calculated and its correlation with serum neopterin was determined to estimate the serum indoleamine 2,3-dioxygenase activity. Tissue sections from the studied tumors were re-examined histopathologically and were stained by immunohistochemistry with indoleamine-2,3-dioxygenase antibodies. RESULTS: Neither serum nor urinary neopterin was significantly different between the patient and control groups (both P > 0.05). However, colorectal carcinoma patients showed a significant positive correlation between the serum neopterin levels and Kyn/Trp (r = 0.450, P < 0.01). Urinary biopterin was significantly higher in cancer cases (P < 0.05). Serum Kyn/Trp was significantly higher in colorectal carcinoma patients (P < 0.01). Lymphatic invasion was present in 23 of 44 patients, of which only 12 patients had lymph node metastasis. Eleven patients with LI had no lymph node metastasis. Indoleamine-2,3-dioxygenase intensity score was significantly higher in LI positive cancer group (44.56% ± 6.11%) than negative colorectal cancer patients (24.04% ± 6.90%), (P < 0.05). Indoleamine 2,3-dioxygenase expression correlated both with the presence of LI and lymph node metastasis (P < 0.01 and P < 0.05, respectively). A significant difference between the accuracy of diagnosis by using either total indoleamine-2,3-dioxygenase immunostaining score or of lymph node metastasis was found during the evaluation of cancer patients. CONCLUSION: Indoleamine-2,3-dioxygenase expression may predict the presence of unrecognized LI and lymph node metastasis and may be included in the histopathological evaluation of colorectal carcinoma cases.

Microscopic hematuria as a marker of blunt abdominal trauma in rats: description of an experimental model.

BACKGROUND: Microscopic hematuria is an extremely important sign in blunt abdominal trauma (BAT) patients. Controversies still exist in the literature on whether microscopic hematuria is a sign of intra-abdominal extrarenal organ injury and is an indication for radiographic assessment of BAT patients. In this study, a new BAT rat model was developed, and we tried to determine the relationships between microscopic hematuria and extrarenal intra-abdominal organ injury. METHODS: After verifying our model, lethal and maximal sublethal intensity of impact energy determined in the rats. Animals allocated into six sublethal impact energy groups. BAT was induced by dropping a standard mass from variable heights. After 2 hours of examining period, macroscopic laparotomy findings, histopathological liver, spleen and renal injury grades, and microscopic hematuria levels were recorded in these six groups. RESULTS: According to our results, while the trauma intensity increase severity of the histopathological injury increases for all organs. Although there was a significant correlation between microscopic hematuria and trauma intensity, we could not show same relationship between microscopic hematuria and histopathological organ injury. On the other hand, microscopic hematuria was correlated with the macroscopic laparotomy findings. CONCLUSIONS: Microscopic hematuria could serve as a predictor of the severity of trauma and intra-abdominal organ injury. This study would support the use of abdominal imaging and attentive assessment for intra-abdominal organ injury in stable BAT patients with hematuria. The laparotomy threshold may be lowered for unstable BAT patients with hematuria.

[Ultrasonographic findings and evaluation of white blood cell counts in patients undergoing laparotomy with the diagnosis of acute appendicitis]. / Akut apandisit tanisiyla laparotomi uygulanan hastalarda ultrasonografi bulgulari ve lökosit sayisinin degerlendirilmesi.

BACKGROUND: Acute appendicitis (AA) is one of the most frequent pathologies among surgical illnesses. Diagnosis is easy in typical cases, but difficult in atypical cases. In this study, ultrasonographic (USG) findings and leukocyte counts of patients were examined to determine their values in the diagnosis of AA. METHODS: Data for 85 patients seen in the first six months of 2006 were examined retrospectively. Histopathological diagnosis together with leukocyte counts and USG findings were compared, and sensitivities in the diagnosis were determined. RESULTS: The average age of the patients was 33.5, and 44.7% were female. In 95.3% of the patients, leukocyte counts were 10000/mm3 and above. In 74.1% of the patients (63 patients), USG was performed, and 58.7% of the cases (37 patients) were compatible with AA. In four (4.7%) of the patients, AA was not found histopathologically (negative laparotomy). The sensitivity of leukocyte counts (> or =10000/mm(3)) was 98.8% and its selectivity was 75%. The sensitivity of USG was 61.0% and its selectivity was 75%. When the areas under the receiver operating characteristics (ROC) curve were compared, leukocyte counts were more sensitive in determining the diagnosis. CONCLUSION: In this study, the sensitivity of USG was lower than the high sensitivity ratios reported in the literature. However, the sensitivity of leukocyte counts was significantly higher than that of USG.

Blunt abdominal trauma: evaluation of diagnostic options and surgical outcomes.

BACKGROUND: In the present study, it is intended to outline the diagnostic tests and their influences on decisions of the surgeon about patients presented with blunt abdominal trauma. METHODS: One hundred forty-four patients (98 males, 46 females; mean age 36; range 17 to 84 years) admitted to Gazi University School of Medicine due to blunt abdominal trauma (BAT) between May 2003-May 2005 were reviewed retrospectively. Age, gender, injury mechanism, Glasgow Coma Scale, revised trauma score, follow-up period, applied diagnostic procedures, and treatment methods were evaluated. RESULTS: The underlying cause was traffic accident in 126 (87.5%) patients, fall from height in 14 (9.7%) patients, and blows in 4 (2.8%) patients. Isolated abdominal trauma was seen in 21 patients and multisystem trauma in 123 patients. The most frequent associated trauma was head injury (66.6%). Abdominal ultrasonography (USG) was applied in 139 (97%) of the patients, and abdominal computed tomography (CT) was performed in 73 (51%). Diagnostic peritoneal lavage (DPL) was applied in 41 (28%) patients, and 15 (37%) of them proved to be positive. While emergency laparotomy was applied in 19 (13.2%) of the patients, 21 hemodynamically stable patients were diagnosed to have free fluid through USG and CT and were followed-up. During the follow-up period, 2 patients were scheduled to be operated, and small intestine perforation was found in these patients. The overall mortality rate for all patients was 16%, and the postoperative mortality rate with respect to the operated patients was 14.3%. CONCLUSION: If USG, CT, and DPL are applied in a complementary manner, a large number of patients with solid organ injuries secondary to blunt trauma can be managed nonoperatively. Thus, unnecessary laparotomies can be avoided and related morbidities and mortalities decreased.

Retrorectal tumors: a case series.

BACKGROUND/AIMS: Retrorectal masses are rarely encountered in surgical practice, and they arise from congenital remnants, and from osteogenic, neurogenic, inflammatory, or metastatic processes. The majority of these masses are benign but many can be malignant, so they need to be treated with aggressive surgical management. METHODS: In this case series, eight patients with retrorectal masses of various etiologies are described, with particular emphasis on diagnosis and surgical treatment. RESULTS: In our series, we noted one duplication cyst, one tailgut cyst, one epidermoid cyst, one teratoma, one gastrointestinal stromal tumor, one epithelial malignant tumor, one inflammatory mass, and one retrorectal mass of as yet unknown origin. In three patients, complete excision via posterior sagittal approach was performed, one underwent abdominoperineal en-block proctectomy, two were only biopsied for neoadjuvant therapy, and two are waiting for operation. CONCLUSIONS: Surgery is the main treatment of choice, and the surgical strategy should be decided according to the localization and nature of the retrorectal mass.

Intermittent pneumatic sequential compression of the lower extremities restores the cerebral oxygen saturation during laparoscopic cholecystectomy.

BACKGROUND: Pneumoperitoneum causes intracranial pressure elevation and blood stasis at lower extremities. This study investigates cerebral oxygen saturation changes during laparoscopy and the effects of intermittent sequential compression (ISC) of the lower extremities in patients during elective laparoscopic cholecystectomy. PATIENTS AND METHOD: Sixty patients were randomly divided into two groups according to the application of ISC to the lower extremities. Group I served as control group whereas ISC was applied to group II. Cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure, and associated changes have been recorded during the operation. RESULTS: Peripheral blood oxygen saturation and mean blood pressure values did not change significantly after pneumoperitoneum. Cerebral oxygen saturation levels of the group II patients were higher in than the group I patients and the difference between the groups was statistically significant (p = 0.0001). The difference became more prominent following the 35(th) minute of the operation. Mean heart rate of the patients in group II was lower than the patients in group I and the difference was also statistically significant (p = 0.0001). CONCLUSION: In this study, it was found that the decrease in cerebral oxygen saturation was recovered with ISC application. This simple and reliable technique helps to restore cerebral oxygen saturation levels while increasing blood return from the lower extremities.

Transperineal rectocele repair with polyglycolic acid mesh: a case series.

PURPOSE: This study was designed to evaluate the outcome of transperineal rectocele repair using polyglycolic acid mesh. METHODS: Eighty-three consecutive females with predominant, symptomatic Stage II or Stage III rectocele underwent transperineal rectocele repair using polyglycolic acid (Soft PGA Felt(R)) mesh and finished their six-month follow-up. No additional interventions, including levatoroplasty or perineorraphy, were performed. The preoperative and postoperative symptom scores and stages of the posterior vaginal wall prolapse were recorded. The end points were reassessed at six months, postoperatively. RESULTS: Preoperatively, 39 patients had Stage II and 44 patients had Stage III rectocele. The mean total symptom score was 9.87 +/- 1.93, which was reduced to 1.62 +/- 0.59 postoperatively (P < 0.0001). Objective evaluation of anatomic repair revealed that 74 patients (89.2 percent) had anatomic cure. Surgical complications were seen in a total of seven patients (8.4 percent), including hemorrhage (3.6 percent) and wound infection (4.8 percent). Mesh erosion, mesh infection, or worsening of sexual function was not noted. CONCLUSIONS: Transperineal repair of rectocele with the polyglycolic acid mesh is an efficient therapy for patients with rectocele. It is highly successful in eliminating symptoms of obstructed defecation, and it is free of significant complications.

Strangulation of a prolapsed rectal cancer in labor: a case report.

BACKGROUND: Colorectal cancer during pregnancy is uncommon. Most patients present in late pregnancy, and the tumor is localized to rectum in up to 85% of cases. Delayed diagnosis due to confusing significant lower gastrointestinal symptoms with pregnancy-associated gastrointestinal changes is a common feature. From the increasing intraabdominal pressure during delivery, a tumor can prolapse throu the anus and develop incarceration and strangulation, but that is seen a extremely rarely, CASE: A 33-year-old woman was found to have a prolapsing rectal cancer through the anus during delivery, and it progressed to incarceration, CONCLUSION: Colorectal cancer during pregnancy is rare and mostly localized to the rectum. To manage a strangulated rectal prolapse that occurs in labor, consideration should be given to perineal rectosigmoidectomy under general anesthesia. The choice of surgical procedure is controversial if the preoperative diagnosis is not clear.

Potential benefit of oral calcium/vitamin D administration for prevention of symptomatic hypocalcemia after total thyroidectomy.

OBJECTIVE: To evaluate routine oral calcium and vitamin D administration for preventing symptoms of hypocalcemia after total thyroidectomy. SUBJECTS AND METHODS: A total of 487 consecutive patients were prospectively randomized into two groups in terms of routine oral calcium and vitamin D supplementation: In the control group (244 patients) the treatment was not routinely started after surgery, whereas the treated group (243 patients) received routine supplementation that started on postoperative day 1. RESULTS: Patients of treated group had only minor hypocalcemia symptoms, whereas 7 patients of control group experienced carpopedal spasm as a major symptom (p<0.001). None of the patients in the treated group required intravenous calcium administration. Average hospital stay of the treated group patients was significantly shorter than that of control group (p<0.001). CONCLUSIONS: Routine postoperative calcium and vitamin D supplementation therapy may be useful for the prevention of symptomatic hypocalcemia after total thyroidectomy and may allow for a safe and early discharge from the hospital.

A prospective comparison of local and spinal anesthesia for inguinal hernia repair.

AIM: Today, in inguinal hernia repair, postoperative pain and costs are regarded as equally important issues as technique and recurrence rates. Postoperative pain is thought to vary according to the applied anesthesia method. As local anesthesia is reported to inflict less pain, its effects on early period post-operative complications should also be evaluated. METHODS: Two hundred patients, on whom Lichtenstein tension free hernia repair had been performed due to unilateral inguinal hernia between March 2004 and July 2005, were prospectively examined. The patients were randomized according to the anesthesia applied. They were divided into two groups: local anesthesia (LA) and spinal anesthesia (SA). The early post-operative complications, post-operative pain scores, and operation durations of the patients, were evaluated. RESULTS: Local anesthesia was found not to increase the post-operative complications; on the contrary, it was shown to prevent the complications of spinal anesthesia. Although visual analogue pain score (VAS) values at 4, 8, 12, and 24 h post-operation were found to be lower than the SA group, the difference between was not significant. Also, it was discovered that LA did not retard the operation duration. CONCLUSION: Local anesthesia reduces post-operative pain and facilitates patients' mobilization and discharge along with decreasing the early post-operative complications. Thus, LA is a safe and advantageous method to be applied in inguinal hernia repair.

Metabolic syndrome and its association with ischemic cerebrovascular disease.

Metabolic syndrome (MS) is the term that encompasses metabolic risk factors that may lead to atherosclerotic cardiovascular disease. This study was undertaken to investigate the prevalence of MS in patients with ischemic cerebrovascular disease (CVD), according to National Cholesterol Education Program/Adult Treatment Panel III (ATP III) criteria. A total of 40 patients who were referred to the emergency department and given a diagnosis of CVD were included in this study. Detailed medical histories, physical examination findings, heights, weights, and waist circumferences of patients were recorded. Fasting blood glucose levels and lipid profiles of patients were evaluated. Those with hypertension, diabetes, or hyperlipidemia were regarded as meeting at least 1 of the ATP III criteria. Study results were compared, especially between females and males. In all, 55% of patients were female, and 70% were older than 65 y. Blood pressure over 130/85 mm Hg was assessed in 60% of patients. Among female patients, 81.8% had a waist circumference greater than 88 cm; 50% of male patients had a waist circumference over 102 cm. A fasting blood glucose level above 110 mg/dL was identified in 57.5% of patients. Serum triglyceride levels in 30% of patients were above 150 mg/L. It was noted that 33.3% of male patients had a high-density lipoprotein (HDL) level below 40 mg/L, and in 68.2% of female patients, an HDL level below 50 mg/dL was recorded. According to these findings, 14 of 22 female patients (64%) and 13 of 18 male patients (72%) were identified as having MS. High rates of stroke associated with MS reveal the importance of forthcoming preventive approaches.

Adult ileal intussusception: an unusual emergency condition.

Adult intussusception occurs infrequently and differs from the childhood condition in its presentation, cause, and treatment. Nonspecific symptoms can delay diagnosis; most cases are diagnosed at emergency laparotomy. Increased use of computed tomographic scanning to evaluate patients with abdominal pain can enhance reliable preoperative diagnosis. Treatment entails simple bowel resection in most cases. Reduction is controversial, especially in cases of colonic intussusception. This report describes the diagnosis and management of a case of adult ileal intussusception caused by an inflammatory fibroid polyp-a rare lesion of the gastrointestinal tract.

Nitric oxide synthase inhibitors appear to improve wound healing in endotoxemic rats: An investigator-blinded, controlled, experimental study.

BACKGROUND: Although inflammation is a normal part of wound healing, if the inflammatory response is excessive the repair process might be prolonged. Nitric oxide (NO) has been implicated in healing inflammation and wounds. OBJECTIVE: Endotoxins and cytokines associated with sepsis induce NO synthesis in the tissues. This study used tensile strength and tissue hydroxyproline levels as proxies for wound healing to determine whether wound healing in the presence of endotoxemia is improved when NO synthase is inhibited by N-nitro-l-arginine methyl ester (L-NAME) or N (5)-(1-Imino-methyl)-l-ornithine (L-NIO). METHODS: In this investigator-blinded, controlled, experimental study, male Wistar albino rats (275-300 g) were divided into 4 groups. The first group received an intraperitoneal (IP) injection of Escherichia coli endotoxin 10 mg/kg and an SC injection of 0.9% sodium cloride (NaCl). The second group received IP E coli 10 mg/kg and SC L-NAME 2 mg/kg. The third group received IP E coli 10 mg/kg and L-NIO 10 mg/kg. The control group was administered an IP and an SC injection of 0.9% NaCl. Each group received both injections at 24 and 16 hours before surgery. All rats underwent a 3-cm dorsal midline incision, which was subsequently closed. Five days after surgery, all rats were euthanized and skin from the healing wound was excised. Hydroxyproline levels and tensile strength were then measured. RESULTS: Forty-four male rats (mean age, 16 weeks; mean [SD] weight, 284 [16] g) were included in the study. Each of the groups receiving endotoxin (endotoxin, L-NAME, and L-NIO groups) had 12 rats; the control group consisted of 8 rats. All the groups that received endotoxin showed significant declines in hydroxyproline levels versus controls (P < 0.001, P = 0.001, and P = 0.002, respectively). Compared with the control group, the endotoxin-only group had a significant reduction in both mean (SD) hydroxyproline levels and mean (SD) wound tensile strength (298.27 [17.66] vs 175.82 [18.73] g/cm2 and 7.16 [0.51] vs 4.01 [0.29] µg/mg wet tissue; both, P < 0.001). Compared with the endotoxin- only group, rats that received L-NIO had significantly greater mean (SD) hydroxyproline levels and mean (SD) wound tensile strength (6.44 [0.34] vs 4.01 [0.29] µg/mg wet tissue and 280.12 [14.38] vs 175.82 [18.73] g/cm(2); both, P < 0.001). Wound tensile strength in the L-NIO group was not significantly different from that in the control group. A significant difference was observed between the L-NIO and L-NAME groups in wound tensile strength (280.12 [14.38] vs 241.38 [20.69] g/cm(2); P = 0.001), but not in tissue hydroxyproline levels. CONCLUSION: Inhibition of NO synthesis might improve wound tensile strength, which suggests a possible role for NO inhibitors in improved wound healing in the presence of endotoxemia.

Recurrent laryngeal nerve injury and preservation in thyroidectomy.

OBJECTIVE: We aim to evaluate the rates of recurrent laryngeal nerve (RLN) injury after thyroidectomy and to put forward the factors influencing the risk of RLN injury during thyroid surgery. METHODS: We retrospectively analyzed the records of 418 patients who underwent thyroid surgery for thyroid disease at the Turkish State Railway Hospital, Ankara and Gazi University Hospital between 1989-2003 for RLN injury and factors affecting this complication. Moreover, we evaluated 6 different types of operations used during surgical practice. Indirect laryngoscopy was performed preoperatively and was repeated postoperatively for all patients. RESULTS: Three hundred and thirty-nine (81.1%) were females and 79 (18.9%) were male. Indications for surgery were multinodular goiter in 253 cases, solitary nodule in 69, hyperthyroidism in 68, thyroid carcinoma in 5 and recurrent goiter in 23 cases. Bilateral subtotal thyroidectomy was performed in 286 cases (68.4%), unilateral subtotal thyroidectomy in 52 (12.4%), unilateral total thyroidectomy in 25 (5.9%), bilateral total thyroidectomy in 22 (5.3%), nodule excision in 10 (2.4%) and completion thyroidectomy for recurrent goiter in 23 (5.5%) cases. Unilateral vocal cord problems occurred, 16 (3.8%) cases and in 6 (1.2%) cases it became permanent. The distribution of permanent RLN paralysis over the cases was 0.04% multinodular goiter, 2.9% hyperthyroidism and 8.7% recurrent goiter (p<0.05). Transient RLN paralysis rate was 2%, while permanent RLN paralysis rate was 0.03% for bilateral subtotal thyroidectomies. In addition, in unilateral total thyroidectomies, transient RLN paralysis was 12% while permanent paralysis was 4%. For bilateral total thyroidectomies, 13.6% was transient and 9% was permanent RLN paralysis and 13% was transient and 8.7% was permanent paralysis for completion cases (p<0.05). CONCLUSION: We can avoid RLN injury during thyroid surgery by identifying the nerve and following its course carefully. Intraparenchymal dissection or subtotal excision can be performed if failure to identify RLN occur, and new operative techniques and medical management of benign thyroid diseases should be considered.