Background <p>Recurrent laryngeal nerve paralysis (RLNP) is a critical postoperative complication in esophagectomy. Intraoperative nerve monitoring (IONM) is a technique that can be used in high-risk surgeries to prevent, identify, and mitigate nerve damage. In this prospective study, we evaluated the feasibility and effectiveness of IONM in open McKeown esophagectomy for esophageal cancer.</p> Methods <p>From December 2020 to September 2023, 88 patients diagnosed with esophageal cancer were enrolled to receive IONM for open McKeown esophagectomy at Cancer Center, Sun Yat-sen University. The primary outcome was the incidence of RLNP after extubation. The secondary outcomes were postoperative complications, number of dissected lymph nodes, length of hospital stay, ICU duration and number of deaths.</p> Results <p>A total of 83 patients were included in the final analysis. The incidence of RLNP after extubation was 30.1%. The occurrence of postoperative pulmonary complications was 20.5%. The median hospital stays were 13&#xa0;days. The incidence of anastomotic leakage was 13.3%. No in-hospital deaths were reported. Postoperative RLNP prolonged the length of hospital stay (<i>P</i> = 0.042).</p> Conclusion <p>Our findings indicated that IONM could potentially be associated with a possible reduction in RLNP incidence following open McKeown esophagectomy for esophageal cancer. However, future research including well-designed randomized controlled&#xa0;trials may be beneficial to clarify these preliminary results.</p> Trial registration number <p>ChiCTR2000029687</p> <p><a href="https://www.chictr.org.cn/showproj.html?proj=49103">https://www.chictr.org.cn/showproj.html?proj=49103</a></p>