Association between recurrent laryngeal nerve diameter and postoperative palsy following robot-assisted minimally invasive esophagectomy

Recurrent laryngeal nerve palsy (RLNP) is a significant complication following upper mediastinal lymphadenectomy during esophagectomy. In this retrospective study, we investigated the association between recurrent laryngeal nerve (RLN) diameter and the risk of RLNP following robot-assisted minimally invasive esophagectomy (RAMIE). We analyzed consecutive patients with esophageal cancer who underwent RAMIE between January 2015 and March 2024. The left RLN diameter was measured from intraoperative digital recordings using validated image processing software. Patients were categorized into thick and thin nerve groups based on the median RLN diameter. Rates of immediate and permanent RLNP (defined as persisting beyond 6 months) were compared between groups. Multivariable analysis was performed to adjust for potential confounders. Among 149 patients, the median left RLN diameter was 1.5 mm. Immediate RLNP rates did not differ significantly between thick (n = 67) and thin (n = 82) nerve groups (19.5% vs. 11.9%, P = 0.265). However, recovery of vocal cord function was significantly more frequent in patients with thick nerves compared with those with thin nerves (87.5% vs. 43.8%, respectively), resulting in a higher permanent RLNP rate in the thin nerve group (11% vs. 1.5%, P = 0.023). Multivariable analysis identified thin RLN as the sole independent risk factor for permanent RLNP (odds ratio: 9.22, 95% confidence interval: 1.09-78.1, P = 0.041). Patients with thin left RLNs exhibit a significantly increased risk of permanent RLNP following RAMIE. Intraoperative RLN diameter assessment may inform surgical decisions and improve postoperative management strategies.