Suturless Thyroidectomy

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Aim: Our purpose, Harmonic Scalpel (HS) and Conventional thyroidectomy in this clinical study was to compare in terms of universal parameters. Material and Method: This prospective randomized trial study was performed on these 929 consecutive patients given total thyroidectomy. Patients were randomly assigned to either the Focus group (in which the operation was performed entirely using the Harmonic Focus and no other hemostatic tool; 468 patients) or the classic group (in which the operation was performed using conventional clamp-and-tie technique and mono-polar electric scalpel; 461 patients). Results: The operation time was significantly longer in Group II (49±11min.) than Group I (32±8 min). The mean blood loss was not significantly in patients both groups. There was no statistically significant difference in specimen size. The two groups were similar when transient/permanent hypocalcaemia rates were compared. Permanent RLN palsy was seen in five patient in Group I. There was no statistically significant difference in drain usege. Postoperative bleeding, seroma, infection rates, hospitalisation time were not different between the two groups. Discussion: In conclusion, usage of the UHS in thyroid surgery decreases operation time when it is compared to conventional methods. On the other hand there is no difference in postoperative complications. The UHS is an effective, reliable and feasible technique in thyroid surgery.

Introduction

The technique of total thyroidectomy has been well described and involves capsular dissection of the thyroid gland, encountering the recurrent laryngeal nerve in the region of the ligament of Berry and preservation or autotransplantation of the parathyroid glands [1,2]. The most recent development in thyroid surgery is the use of vessel sealing technology as an alternative to traditional ligatures and titanium clips [3]. Two devices designed specifically for thyroid surgery are available; the Harmonic Scalpel FOCUS (Johnson& Johnson,EthiconEndo-surgery,Cincinnati,OH,USA) and the Ligasure Precise (Covidien, Boulder, CO, USA). The Harmonic Scalpel FOCUS has an active blade that oscillates at 55 kHz, simultaneously sealing and cutting tissue. This vibration denatures hydrogen bonds, leading to formation of a protein coagulum [5,6]. Thermal spread from either instrument is reported to be 0.5–2 mm and is related to vessel size and hence he corresponding energy required for proper vessel sealing. The coagulation of smaller vessels is associated with lower thermal spread [4,5]. The aim of this prospective study was to compare the usage of the ultrasonic harmonic scalpel (UHS) with conventional procedures, in total thyroidectomies, for operation time, blood loss, usage of drain, length of hospitalisation and complications.

Material and Method

Study Design

The study involved 115 men and 814 women from January 2007 to July 2012. 929 patients underwent total thyroidectomy in the General Surgery Depertment of Bartın State Hospıtal. These patients thought to be benign in the preoperative period. (After the pathological examination of 32 patients were found to be malignant). Approval was obtained from the ethical committee of the hospital before initiating the study and informed consent was obtained from the patients. All patients were blinded to the surgical technique used and signed an informed written consent before enrollment to the trial. This prospective randomized trial study was performed on these 929 consecutive patients total thyroidectomy. Patients were randomly assigned to either the Focus group (in which the operation was performed entirely using the Harmonic Focus and no other hemostatic tool; 468 patients) or the classic group (in which the operation was performed using conventional clamp-and-tie technique and mono-polar electric scalpel; 461 patients). The method of randomization was performed by drawing lots. The patients all underwent similar treatment following the same protocol, except for the Harmonic Focus used. Total thyroidectomy were performed by the same experienced thyroid surgical team (four adept surgeons) in all cases. This team was stable during the study period. The two groups did not display statistically significant differences in term of age, gender, BMI, and pathology classification A complete preoperative assessment (serum thyrotropin levels, parathyroid hormone, serum Ca and P, nodule size by ultrasonography) was obtained in all patients. Preoperative laryngeal nerve status was determined by indirect laryngoscopy, performed by the same otolaryngologist from the Department of Otolaryngology.

Surgical Technique

Four adept surgeons can use both techniques. Total thyroidectomy was performed in all patients. Under general anesthesia and with endotracheal intubation, the patients were placed on the operating table in the supine position with the neck extended. A 5 cm low-collar incision was made above the sternal notch. After skin incision with the conventional scalpel, flaps were raised using the mono-polar electric scalpel. In the Focus group, we used the Harmonic Focus for vascular control of the thyroid gland (Harmonic Focus, Ethicon Endo-Surgery, Inc, Cincinnati, OH. For better hemostasis, the middle vein, the superior and inferior thyroidal arteries and veins were controlled using. Other small vessels and surrounding connective tissues were controlled using easy cutting. For patients in the classic group, mono-polar electric scalpel was used to control the small vessels of the gland and conventional “clip, cut and tie” routines was adapted for the superior and inferior thyroidal arteries, as well as the superior, middle and inferior veins. Total thyroidectomy was first performed. In all patients, we identified recurrent laryngeal nerve routinely. The parathyroid glands were identified macroscopically, and a meticulous dissection from the thyroid gland was performed. Every effort was made to identify and preserve all parathyroid glands. Parathyroid glands were transplanted in the sternocleidomastoid muscle, if the blood supply to the glands was compromised. Hypocalcemia not developed in these patients. Outcomes of the study included operating time, fluid content in the suction balloon (drainage volume), and incidence of complications (rate of hypocalcemia and laryngeal nerve injury). The operative time was measured from initiation of the incision to conclusion of the skin closure. We placed a vacuum drain where large dead spaces remained after thyroidectomy or in cases where we were unsure of haemostasis. The drainage was measured and the drain was removed on postoperative day 1. Serum calcium, phosphate and total protein levels were recorded preoperatively. Vocal cord mobilities of all patients were evaluated laryngoscopically. Operation time, blood loss, intra-operative complications, weight of the specimen and necessity of drain was noted. Blood loss was calculated from the increase in weight of the blooded gauzes. Postoperative seroma, bleeding, infection, transient or permanent hypocalcaemia, permanent RLN palsy and length of hospitalisation were recorded.

Statistical Analysis

Statistical analysis of the differences between groups was performed using the 2-sample t test and χ2test. Statistical analysis was made by SPSS 13. P < 0.05 was considered statistically significant.

Operating time was significantly shorter in Focus group (P < 0.05) by allowing a one third time saving vs classic hemostasis. Postoperative transient biochemical hypoparathyroidism occurred less frequently Focus group (43 patients) in than in the the classic group (48 patients) but no obvious distinction. 9 patient injury to recurrent laryngeal nerve occurred. (Both group) 5 patient (in Focus group) presented permenant recurrent laryngeal nerve paralysis. Intraoperative bleeding was not significant in any patient, and no neck hematoma, seroma, wound infection, or postoperative bleeding was observed. There were neither blood transfusions nor postoperative definitive sequelae. The mean postoperative hospital stay was no statistically difference (P > 0.05).

Results

The results of our study are shown in Table 1. We did not find any difference between the two gruops in pre-operative demographic and laryngoscopic data and both groups had a similar mean age. The operation time was significantly longer in Group II (49±11 min. ) than Group I (32±8 min). The mean blood loss was not significantly in patients both groups. There was no statistically significant difference in specimen size (Table 1). The two groups were similar when transient/permanent hypocalcaemia rates were compared. The mean transient hypocalcaemia rate % 0.9 of Group I, was similar to the in % 1 Group II. Permanent hypocalcaemia rate was in Group I and in Group II. Permanent RLN palsy was seen in only one patient in Group I. There was no statistically significant difference in drain usege (Table 1). The two groups were similar when transient/permanent hypocalcaemia rates were compared.. Postoperative bleeding, seroma, infection rates, hospitalisation time were not different between the two groups. Among all of the cases, no death was seen.

Discussion

The thyroid has a rich blood supply,haemostsis is very important thyroid surgery. Electrocautery used in conventional techniques may harm the surrounding vital tissues due to high rates of lateral tissue damage. Also, the patient is subjected to electricity when electrocoagulation is used. On the other hand, UHS allows haemostasis to occur in low temparatures, lateral tissue damage is less, and electricity is not used. The main advantage of using the UHS in thyroid surgery is the reduction in operation time. In conventional methods, dissection, tying and cutting the vessels takes time. The UHS allows simultaneous dissection, cutting and coagulation so the operation time is shorter. The studies published by Siperstein et al.11 (29 minutes), Voutilainen et al.8 (35 minutes) and Defechereux et al.9 (26 minutes) show that the operation time shortens with the UHS. In our study, we observed a significant reduction in operation time by 32±8. Blood loss is minimal when thyroidectomy is performed by experienced surgeons. We calculated blood loss from the increase in weight of the blooded gauzes. Some authors have reported that the amount of bleeding did not differ between the two methods [7,12,13]. Also Defechereux et al.5 reported a reduction in intra-operative bleeding. Drains were used in operations where large dead space remained after thyroidectomy or when the surgeon had concerns about haemostasis. Bleeding was less and so the space was drier in the UHS group, therefore drain usage was significantly less in the UHS group. The major local complications of thyroidectomy are RLN palsy and hypocalcaemia. The permanent RLN paralysis range is 0%–14% in various studies. In experienced hands the rate of this complication is lower than 2% [10]. In line with previous studies, the use of a UHS did not increase the RLN palsy risk in our study [7,10,12]. The rate of transient hypocalceamia has been reported as %5-%15 and permanent hypocalcemia rates have been reported as %5 in total thyroidectomoies [12]. The rates of transient and permanent hypocalcaemia were 9.1% and 0.8%, respectively, in our UHS grouop.

Conclusion

In conclusion, usage of the UHS in thyroid surgery decreases operation time when it is compared to conventional methods. On the other hand there is no difference in postoperative complications. The UHS is an effective, reliable and feasible technique in thyroid surgery.

Competing interests

The authors declare that they have no competing interests.

References

1. Delbridge L, Reeve TS, Khadra M, Poole AG. Total thyroidectomy: the technique of capsular dissection. ANZ J Surg 1992;62:96–9.

2. Serpell JW, Grodski S, Yeung M, Swann J, Kemp S, Johnson W. Hemithyroidectomy: a heuristics perspective. ANZ J Surg 2008;78:1122–7.

3. Manouras A, Markogiannakis HE, Kekis PB, Lagoudianakis EE, Fleming B. Novel hemostatic devices in thyroid surgery: electrothermal bipolar vessel sealing system and harmonic scalpel. Expert Rev Med Devices 2008;5:447–66.

4. Cipolla C, Graceffa G, Sandonato L, Fricano S, Vieni S, Latteri MA. LigaSure in total thyroidectomy. Surg Today 2008;38: 495–8.

5. Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF, Heniford BT. Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small, medium, and large sized arteries. Surg Endosc 2003;17:1228–30.

6. Lombardi CP, Raffaelli M, Cicchetti A, Marchetti M, De Crea C, Di Bidino R, Oragano L, et al. The use of ‘harmonic scalpel’ versus ‘knot tying’ for conventional ‘open’ thyroidectomy: results of a prospective randomized study. Langenbecks Arch Surg 2008;393: 627–31.

7. Karvounaris DC, Antonopoulos V, Psarras K, Sakadamis A. Efficacy and safety of ultrasonically activated shears in thyroid surgery. Head Neck. 2006;28:1028–31.

8. Voutilainen PE, Haglund CH. Ultrasonically activated shears in thyroidectomies: a randomized trial. Ann Surg 2000;231:322–8.

9. Defechereux T, Rinken F, Maweja S, Hamoir E, Meurisse M. Evaluation of the ultrasonic dissector in thyroid surgery. A prospective randomised study. Acta Chir Belg 2003;103:274–7.

10. Koutsoumanis K, Koutras AS, Drimousis PG, Stamou KM, Theodorou D, Katsaragakis S, et al. The use of a harmonic scalpel in thyroid surgery: report of a 3-year experience. Am J Surg 2007;193:693–6.

11. Siperstein AE, Berber E, Morkoyun E. The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery. Arch Surg 2002;137:137–42.

12. Cordón C, Fajardo R, Ramírez J, Herrera MF. A randomized, prospective, paralel group study comparing the harmonic scalpel to electrocautery in thyroidectomy. Surgery 2005;137:337–41.

13. Terris DJ, Seybt MW, Gourin CG, Chin E. Ultrasonic technology facilitates minimal access thyroid surgery. Laryngoscope 2006;116:851–4.

Additional Info

  • Recieved: 06.06.2013
  • Accepted: 19.06.2013
  • Published Online: 19.06.2013
  • Printed: 01.03.2015
  • DOI: 10.4328/JCAM.1935
  • Author: Ahmet Serdar Karaca, Ridvan Ali, Muzaffer Capar, Mesut Dede, Sezar Karaca
  • Identifier: J Clin Anal Med. 2015;6(2):180-182
  • Index Page: 180-182
  • How to Cite: Ahmet Serdar Karaca, Ridvan Ali, Muzaffer Capar, Mesut Dede, Sezar Karaca. Suturless Thyroidectomy. J Clin Anal Med. 2015;6(2):180-182
  • Running Title: Suturless Thyroidectomy
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