Intraoperative neuromonitoring (IONM) is being used during a right thyroid lobectomy. The signal loss in the right recurrent laryngeal nerve (RLN) is detected after division of the superior thyroid vessels but before manipulating the thyroid lobe. What is the most appropriate next step?

• A Proceed immediately to complete the thyroid lobectomy
• B Stop the operation, reassess nerve integrity, and consider abandoning the contralateral side if planned ✓
• C Convert to open technique for better nerve visualisation
• D Inject dexamethasone into the RLN and continue surgery

Explanation

Intraoperative signal loss on IONM indicates RLN injury or traction, and the standardised approach per the International Neural Monitoring Study Group guidelines is to stop, assess the cause (traction, thermal, ischaemia), and attempt signal recovery by releasing traction. If the signal does not recover, proceeding to planned contralateral lobectomy risks bilateral RLN injury, which causes bilateral vocal cord paralysis and acute airway obstruction. In such cases, the contralateral operation should be staged.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.