Abstract
A BSTRACT This narrative review summarizes contemporary surgical strategies used to prevent injury to the recurrent laryngeal nerve (RLN) during thyroid surgery. RLN damage remains one of the most clinically important complications of thyroidectomy, leading to transient or permanent dysphonia, aspiration risk and, in rare cases, airway compromise. We reviewed the literature on key preventive approaches, including meticulous capsular dissection and routine identification/visualization of the RLN, use of intraoperative neuromonitoring, selection of energy devices and safe thermal techniques, and management of high-risk anatomical settings such as large goiters, retrosternal extension, reoperative surgery and inflammation. Evidence consistently supports that direct RLN visualization is the cornerstone of prevention, while neuromonitoring improves nerve identification, provides functional feedback, and may be particularly valuable in complex cases. Modern energy-based devices (e.g., ultrasonic and bipolar sealing systems) can reduce operative time and blood loss when used with appropriate safety margins from the nerve and controlled activation times; however, improper use can increase thermal injury risk. Additional adjuncts include careful handling of Berry’s ligament, preservation of parathyroid glands, and structured postoperative laryngeal assessment. Overall, RLN protection is best achieved through a standardized surgical algorithm combining anatomic knowledge, deliberate dissection with RLN visualization, selective use of neuromonitoring, and safe application of energy devices. Further prospective studies with uniform outcome definitions are needed to compare techniques across different risk profiles and surgeon experience.