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Zhou D, Zhang Z, Dou X, Xia F, Li X. Advances in the assessment of cosmetic outcomes, sensory alteration in surgical areas, and health-related quality of life of endoscopic thyroidectomy. World J Surg Oncol 2024; 22:52. [PMID: 38347606 PMCID: PMC10863152 DOI: 10.1186/s12957-024-03307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/13/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Endoscopic thyroidectomy has been preliminarily proven effective and safe for thyroid diseases. The cosmetic outcomes and life quality are critical contents of postoperative assessment. This review will primarily focus on the assessment methods and results related to cosmetic outcomes, sensory alteration of surgical area, and quality of life following endoscopic thyroidectomy. METHODS A comprehensive search of published articles within the last decade was conducted using the terms "endoscopic/robotic thyroidectomy," "patient satisfaction scores," "questionnaire," "quality of life," and "cosmetic" in PubMed. RESULTS Assessment methods for postoperative cosmetic satisfaction and sensory alterations encompassed verbal/visual analog scales, scar evaluations, Semmes-Weinstein monofilament tests, and more. The evaluation of postoperative quality of life in endoscopic thyroidectomy involved tools such as SF-36, SF-12, thyroid-specific questionnaires, thyroid cancer-specific quality of life questionnaires (THYCA-QOL), as well as assessments related to voice and swallow function. The cosmetic results of endoscopic thyroidectomy generally surpassed those of open thyroidectomy, while the quality of life in endoscopic procedures was either superior or equivalent to that in open thyroidectomy, especially with respect to general health, role emotion, and vitality. CONCLUSIONS Assessments of cosmetic outcomes and sensory alterations following endoscopic thyroidectomy predominantly relied on patients' subjective feelings. The objective and subjective perspectives of scar assessments remain underutilized. In addition, postoperative laryngoscopy and voice function assessments in endoscopic thyroidectomy procedures require more attention.
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Affiliation(s)
- Di Zhou
- Division of Thyroid Surgery, Department of General Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Zeyu Zhang
- Division of Thyroid Surgery, Department of General Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Xiaolin Dou
- Division of Thyroid Surgery, Department of General Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Fada Xia
- Division of Thyroid Surgery, Department of General Surgery, Xiangya Hospital of Central South University, Changsha, China.
| | - Xinying Li
- Division of Thyroid Surgery, Department of General Surgery, Xiangya Hospital of Central South University, Changsha, China
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Cozzi AT, Ottavi A, Lozza P, Maccari A, Borloni R, Nitro L, Felisati EG, Alliata A, Martino B, Cacioppo G, Fuccillo M, Rosso C, Pipolo C, Felisati G, De Pasquale L, Saibene AM. Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk. J Pers Med 2023; 13:1429. [PMID: 37888040 PMCID: PMC10607766 DOI: 10.3390/jpm13101429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. METHODS In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). RESULTS We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. CONCLUSIONS Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.
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Affiliation(s)
- Anna Teresa Cozzi
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Alice Ottavi
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Paolo Lozza
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Alberto Maccari
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Roberto Borloni
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Letizia Nitro
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Elena Giulia Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Andrea Alliata
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Barbara Martino
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Giancarlo Cacioppo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Manuela Fuccillo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Cecilia Rosso
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Carlotta Pipolo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Giovanni Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Loredana De Pasquale
- Thyroid and Parathyroid Surgery Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy;
| | - Alberto Maria Saibene
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
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Kloosterman R, Wright GWJ, Salvo-Halloran EM, Ferko NC, Mennone JZ, Clymer JW, Ricketts CD, Tommaselli GA. An umbrella review of the surgical performance of Harmonic ultrasonic devices and impact on patient outcomes. BMC Surg 2023; 23:180. [PMID: 37386399 PMCID: PMC10308659 DOI: 10.1186/s12893-023-02057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/25/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND For thirty years, the Harmonic scalpel has been used for precise dissection, sealing and transection. There are numerous meta-analyses on individual surgical procedures with Harmonic, but no overarching review covering all the areas. This umbrella review seeks to summarize the clinical results from the use of Harmonic across surgical fields and broadly quantify its effects on patient outcomes. METHODS MEDLINE, EMBASE, and Cochrane Databases were searched for meta-analyses (MAs) of randomized controlled trials (RCTs) comparing Harmonic devices to conventional techniques or advanced bipolar (ABP) devices. For each procedure type, the most comprehensive MAs were evaluated. RCTs not already analysed in a MA were also included. Operating time, length of stay, intraoperative blood loss, drainage volume, pain, and overall complications were evaluated, and the methodological quality and certainty of evidence were assessed. RESULTS Twenty-four systematic literature reviews were identified on colectomy, hemorrhoidectomy, gastrectomy, mastectomy, flap harvesting, cholecystectomy, thyroidectomy, tonsillectomy, and neck dissection. There were also 83 RCTs included. In every MA evaluated, Harmonic devices were associated with either statistically significant or numerical improvements in every outcome compared with conventional techniques; most MAs reported a reduction in operating time of ≥ 25 min. Harmonic versus ABP device MAs in colectomy and thyroidectomy showed no significant differences in outcomes. CONCLUSION Across surgical procedures, Harmonic devices demonstrated improved patient outcomes for operating time, length of stay, intraoperative bleeding, drainage volume, pain, and overall complications compared to conventional techniques. Additional studies are required to assess differences between Harmonic and ABP devices.
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Affiliation(s)
| | | | | | - Nicole C. Ferko
- EVERSANA, 113-3228 South Service Rd., Burlington, ON L7N 3H8 Canada
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Vossler JD, Karasaki KM, Mahoney RC, Woodruff SL, Murayama KM. The Effect of Energy Devices, Nerve Monitors, and Drains on Thyroidectomy Outcomes: An American College of Surgeons National Surgical Quality Improvement Project Database Analysis. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2021; 80:16-26. [PMID: 34820631 PMCID: PMC8609195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The effect of energy devices, nerve monitors, and drains on thyroidectomy outcomes has been examined for each tool independently. Current literature supports the routine use of energy devices and nerve monitors and does not support the routine use of drains. The effect of these operative tools is interrelated and should be examined concurrently. The aim of this study was to describe the risk-adjusted effect of each of these tools on thyroidectomy outcomes. A retrospective analysis of 17 985 open thyroidectomy procedures was conducted using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) 2016-2018 thyroidectomy targeted procedure database. All open thyroidectomies were included. The risk-adjusted effect of energy devices, nerve monitors, and drains on 30-day outcomes was calculated by multiple logistic regression. Energy devices were associated with a decreased risk of hematoma and decreased extended length of stay without increased risk of hypocalcemia or recurrent laryngeal nerve injury. Nerve monitors were associated with a decreased risk of overall morbidity, decreased recurrent laryngeal nerve injury, and decreased extended length of stay without an increased risk of adverse outcomes. Drains were associated with an increased risk of bleeding, reoperation, and extended length of stay without decreasing hematoma. Our results support the routine use of energy devices and nerve monitors for thyroidectomy and do not support the routine use of drains for thyroidectomy.
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Affiliation(s)
- John D. Vossler
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Kameko M. Karasaki
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Reid C. Mahoney
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Stacey L. Woodruff
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Kenric M. Murayama
- Department of Surgery, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
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Sorensen JR, Printz T, Iwarsson J, Grøntved ÅM, Døssing H, Hegedüs L, Bonnema SJ, Godballe C, Mehlum CS. The Impact of Post-thyroidectomy Paresis on Quality of Life in Patients with Nodular Thyroid Disease. Otolaryngol Head Neck Surg 2019; 161:589-597. [DOI: 10.1177/0194599819855379] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective To investigate the impact of postoperative paresis on disease-specific quality of life (DSQoL) after thyroidectomy in patients with benign nodular thyroid disease. Study Design Observational study. Setting University hospital. Subjects and Methods Patients were evaluated before and 3 weeks and 6 months after surgery in an individual prospective cohort study using videolaryngostroboscopy (VLS), voice range profile, voice handicap index (VHI), multidimensional voice program, maximum phonation time (MPT), and auditory perceptual evaluation. Changes in DSQoL were assessed by the Thyroid-specific Patient-Reported Outcome measure. Cohen’s effect size was used to evaluate changes. Results Sixty-two patients were included, 55 of whom completed all examinations. Three weeks after surgery, a blinded VLS examination showed signs of paresis of either the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve (RLN/EBSLN) in 13 patients (24%). A paresis corresponded to a 12 ± 28 point increase in VHI ( P = .002) and was associated with a significant 4.3 ± 7.5 semitone decrease in the maximum fundamental frequency ( P < .001) and a 5.3 ± 8.2 dB reduction in maximum intensity. Further, it was associated with a 4.5 ± 11.2 second reduction in MPT ( P = .001) and an increase of 0.40 ± 1.19 in grade, 0.42 ± 1.41 in roughness, and 0.36 ± 1.11 in breathiness. Signs of postoperative RLN/EBSLN paresis correlated with an 11.0-point ( P = .02) poorer improvement in goiter symptoms at both 3 weeks and 6 months after surgery. Conclusion Signs of RLN/EBSLN paresis after thyroidectomy were associated with less pronounced improvement in goiter symptoms in patients with thyroid nodular disease. However, thyroidectomy was associated with an overall improved DSQoL by 6 months after surgery.
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Affiliation(s)
- Jesper Roed Sorensen
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense C, Denmark
| | - Trine Printz
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense C, Denmark
| | - Jenny Iwarsson
- Department of Scandinavian Studies and Linguistics, Copenhagen University, Copenhagen, Denmark
| | - Ågot Møller Grøntved
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense C, Denmark
| | - Helle Døssing
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense C, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense C, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense C, Denmark
| | - Christian Godballe
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense C, Denmark
| | - Camilla Slot Mehlum
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense C, Denmark
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Aires FT, Matos LLD, Dedivitis RA, Cernea CR. Effectiveness of harmonic scalpel in patients submitted to total thyroidectomy: systematic review with meta-analysis. Rev Assoc Med Bras (1992) 2018; 64:649-657. [DOI: 10.1590/1806-9282.64.07.649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 11/22/2022] Open
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Park MW, Baek SK, Park EH, Jung KY. Long-term voice outcome after thyroidectomy using energy based devices. Auris Nasus Larynx 2018; 45:527-532. [DOI: 10.1016/j.anl.2017.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/31/2017] [Accepted: 08/09/2017] [Indexed: 12/12/2022]
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Ruggiero R, Docimo G, Bosco A, Lanza Volpe M, Terracciano G, Gubitosi A, Docimo L. Update on sutureless thyroidectomy. G Chir 2018; 39:45-50. [PMID: 29549681 DOI: 10.11138/gchir/2018.39.1.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay. PATIENTS AND METHODS 250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used. RESULTS The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study. CONCLUSIONS We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.
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Vizzielli G, Conte C, Romano M, Fagotti A, Costantini B, Lodoli C, Gueli Alletti S, Gaballah K, Pacelli F, Ercoli A, Scambia G, Gallotta V. Clinical Impact of a Surgical Energy Device in Advanced Ovarian Cancer Surgery Including Bowel Resection. In Vivo 2018; 32:359-364. [PMID: 29475921 PMCID: PMC5905206 DOI: 10.21873/invivo.11246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/17/2017] [Accepted: 12/20/2017] [Indexed: 12/18/2022]
Abstract
AIM To evaluate the clinical impact of the use of the Caiman® articulating energy device in advanced ovarian cancer (AOC) including rectosigmoid resection [e.g. modified posterior exenteration (MPE)]. PATIENTS AND METHODS This was a prospective single-institution observational study with women undergoing MPE where all soft-tissue dissections and vessel ligations were performed using the Caiman® device. Intraoperative and postoperative surgical data were collected. Bladder function after nerve-sparing surgery was analyzed before and 6 months after surgery. RESULTS Forty patients were registered in the study. The median time for specimen removal using Caiman® was 86 min (range=70-120 min). Major vessel ligation was successful in all patients with a median of a single (range=1-4) Caiman® application to seal major vessels. No intraoperative or postoperative complications or bladder dysfunctions associated with the use of Caiman® were noted. CONCLUSION Caiman® can be safely used in AOC surgery and may save time through faster dissection. However, comparative studies with other energy devices are needed to confirm this finding.
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Affiliation(s)
- Giuseppe Vizzielli
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Carmine Conte
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Massimo Romano
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Anna Fagotti
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Barbara Costantini
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Claudio Lodoli
- Department of General Surgery, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Khaled Gaballah
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Fabio Pacelli
- Department of General Surgery, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Alfredo Ercoli
- Department of Obstetrics and Gynecology, University of Eastern Piedmont, Novara, Italy
| | - Giovanni Scambia
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
| | - Valerio Gallotta
- Department of Women's and Children's Health, Agostino Gemelli University Hospital, Catholic University, Rome, Italy
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