Harmonic Scalpel Compared to Conventional Hemostasis in Thyroid Surgery

Introduction

Thyroid surgery has evolved in the last century since Theodore Kocher and Theodore Billroth first developed acceptable and efficient operative techniques.
During the last decade, alternative techniques for reducing operation time, improving, safety and effectiveness have been proposed, including video-assisted, and endoscopic surgery, nerve monitoring, and less invasive forms of anesthesia.
Bleeding remains one of the major postoperative complications of thyroid surgery, with the potential to cause life-threatening airway obstruction.
Given the significant vascularity of the thyroid gland and the relatively small operative field, meticulous hemostasis has and will always be an important prerequisite for a successful outcome in thyroid surgery.
Effective vessel hemostasis can be achieved by using the conventional clamp-and-tie technique. Several studies have reported the successful use of bipolar vessel sealing systems or the HS in shortening the length of thyroid surgery and reducing blood loss.
The harmonic scalpel use mechanical vibrations at 55.5 kHz. This device is able to cut and coagulate tissue simultaneously. The proposed advantages of using this device include less lateral thermal tissue injury, a lack of neuromuscular stimulation, and the avoidance of electrical energy transmission either to or through the patient.
The harmonic scalpel has a different effect on the tissue due to the mechanism of energy generation. The primary results are protein denaturation, as well as increased viscosity, and the adhesion properties on the cutting edges of the blades provide closure of the vessels and bleeding control.
The aim of this study was to determine whether conventional hemostasis (CH) or the harmonic scalpel (HS) results in shorter operative times for thyroidectomy and to evaluate the incidence of postoperative complication with each approach.

Method

In this study, 85 consecutive patients undergone open thyroidectomy were randomized into two groups: group CH (conventional hemostasis with classic technique of tying and knots, resorbable ligature, bipolar diathermy) and group HS (harmonic scalpel).
Outcomes of the study included operative time, fluid content in the suction balloon (drainage volume) during the first 24 h after surgery, postoperative pain, hospital stay, and incidence of complications (rate of hypocalcemia and RLN injury).
Suction drainage was used to evaluate the overall amount of blood loss after the procedure and to assess the actual difference between the groups.

Discussion

There was no difference between the two techniques regarding the amount of blood loss for different procedures. No significant differences were found between the two group concerning mean thyroid weight and mean hospital stay (2.2 day in HS vs. 3.7 in CH p>0.05). The mean operative time was significantly shorter in the HS group (47.2 min vs. 79.2 min p<0.001). Two (4.7%) transient recurrent laryngeal nerve palsies were observed in the CH group and no one (0 %) in the HS group. Postoperative transient hypocalcemia occurred more frequently in the CH group (21/43, 48 % vs. 7/42, 16 %).

Conclusion

In patients undergoing thyroidectomy, HS is a reliable and safe tool. Comparing with CH techniques, its use reduces operative times, postoperative pain, drainage volume, and transient hypocalcemia.

Harmonic Scalpel

Conventional Hemostasis

References

[1]. O. Yener, M. Demir, A. Yılmaz, et al., “Harmonic Scalpel Compared to Conventional Hemostasis in Thyroid Surgery”, Indian J Surg., 2012.

[2]. P. Hallgrimsson, L. Lovén, J. Westerdahl, et al., “Use of the harmonic scalpel versus conventional hemostatic techniques in patients with Grave disease undergoing total thyroidectomy: a prospective randomised controlled trial”, Langenbecks Arch Surg., Vol. 393, pp. 675-680, 2008.