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We read the article written by Demiryas et al. [1] with interest, and we would like to offer some observations about the study based on the current literature. Though the purpose of the study was to determine the effect of intraoperative neuromonitoring (IONM) on thyroid surgery complications, the explanation of the IONM technique given in the Materials and Methods section was very limited. In addition, it would appear that only the recurrent laryngeal nerve (RLN) was stimulated and vagus nerve (VN) stimulation was not performed. The International Neural Monitoring Study Group published guidelines for RLN monitoring during thyroid surgery in 2011. The standardized technique includes VN stimulation both before thyroid dissection (V1) and after complete thyroidectomy (V2) [2]. V1 is used as a reference to verify the function of the IONM system and allows for subsequent dissection and RLN identification. V2 testing is the most appropriate technique to predict postoperative vocal cord function [2]. This protocol must be applied in order to optimize the prognostic value of IONM [2]. We suggest that because this standardized technique was not used, and because this study includes the data of patients from 2014 to 2016, the results regarding the effects of IONM might be misleading. Near-total thyroidectomies in which the RLN is partially visualized and total thyroidectomies in which the RLN is totally visualized were included in both groups. These two different techniques may lead to different RLN paralysis results. Complete dissection is greatly superior to simply localized or partial exposure of the nerve [3]. What were the vocal cord paralysis ratios of the near-total and total thyroidectomies? The preoperative diagnosis and hyperthyroidism ratios for the two groups were not provided. A high-risk thyroidectomy case, such as a substernal goiter, thyroid cancer, or Graves disease, may prolong the operation time. Without evaluating these factors, can the short duration of the operations in Group 1 only be attributed to IONM? Letter to the Editor GENERAL SURGERY

The effects of neuromonitorization in thyroidectomies can be safely evaluated by standardized technique