Recurrent Laryngeal Nerve Identification in Thyroidectomy: Limitations of Anatomical Landmarks and the Gamboa-Hoil Principle.

Recurrent laryngeal nerve (RLN) injury remains one of the most clinically significant complications of thyroidectomy, with potential consequences for voice, airway protection, and overall quality of life. Despite advances in surgical technique, the reliable identification and preservation of the RLN remain challenging because of its anatomical variability. This narrative review analyzes the anatomical course of the RLN and its relationship with commonly used surgical landmarks, including Berry's ligament (BL), the Zuckerkandl tubercle (ZT), the tracheoesophageal groove (TEG), and the inferior thyroid artery (ITA). The limitations of these landmarks are examined, alongside variations in nerve branching patterns, mechanisms of injury, and factors related to patient characteristics and surgical experience. In addition, differences between proximal and distal approaches for nerve identification are discussed. Current strategies rely primarily on direct visualization and, in selected cases, intraoperative nerve monitoring (IONM). However, these approaches are influenced by anatomical variability and do not consistently prevent RLN injury. Available evidence suggests that no single anatomical landmark provides a universally reliable method for nerve identification. Based on these findings, we propose a surgical concept focused on identifying the RLN at its point of entry into the larynx, where the nerve typically follows a posteromedial course relative to the thyroid lobe and maintains a consistent relationship with the lateral aspect of the trachea, a region that appears more anatomically consistent and less affected by extralaryngeal variability. This approach, termed the Gamboa-Hoil principle, incorporates standard nerve identification, followed by a deliberate pause at the distal extralaryngeal segment, particularly within the final 2 cm before entry into the larynx, where the division of Berry's ligament is deferred until the exact site of nerve entry is confirmed. This concept may provide a more consistent and reproducible framework for RLN identification. Further prospective and comparative studies are required to validate its clinical applicability and impact on surgical outcomes.