Safety and Outcomes of Thyroid Surgery: A High-Volume Center Case Series and the Role of Intraoperative Neuromonitoring in Preventing Complications

<b>Background:</b> Thyroidectomy is one of the most performed endocrine operations worldwide; among the most significant and feared complications are hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. The purpose of this study is to analyze clinical outcomes and complication rates in thyroid surgery performed at a single high-volume center, with a specific focus on the impact of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve. <b>Methods:</b> A retrospective observational study was conducted on 1263 patients who underwent thyroid surgery between 2009 and 2024. Data on demographics, surgical procedures, and postoperative complications were collected. Outcomes were compared between the pre-IONM (2009-2017) and post-IONM (2018-2024) periods. Statistical analysis included descriptive measures, chi-square or Fisher's exact tests, and Kaplan-Meier survival analysis with log-rank comparison. <b>Results:</b> Among the 1263 procedures, 76.7% were total thyroidectomies. The overall incidence of transient and permanent hypoparathyroidism was 2.37% and 0.79%, respectively. RLN injuries included 2 bilateral palsies (0.16%, pre-IONM only), 37 transient unilateral palsies (2.93%), and 10 permanent unilateral palsies (0.79%). After IONM introduction, the incidence of RLN injuries significantly decreased (<i>p</i> = 0.03), and no bilateral injuries were observed (<i>p</i> = 0.04). Kaplan-Meier analysis showed that 92% of transient RLN palsies resolved within 4 months, with significantly faster recovery in the post-IONM group (log-rank <i>p</i> = 0.02). <b>Conclusions:</b> Thyroid surgery in high-volume centers is associated with low complication rates. The implementation of IONM, particularly continuous monitoring, has significantly improved RLN preservation and enhanced recovery from transient injuries. These findings support the routine integration of IONM in thyroid surgery to maximize safety and functional outcomes.