A comparison of the outcome using Ligasure™ small jaw and clamp-and-tie technique in thyroidectomy: a randomized single center study

Efficacy and Safety Evaluation of Energy Devices in Bench Surgery for Pancreas Transplantation

INTRODUCTION

Bench surgery for the preparation of deceased donor pancreatic grafts is labor-intensive and time-consuming. We hypothesized that energy devices could be used during bench surgery to decrease the bench surgery time. However, because bench surgery has two unique characteristics, wet conditions and no blood flow in the vessels, it is necessary to verify the safety and efficacy under such conditions.

METHODS

In an animal tissue model, we validated both ultrasonic and bipolar energy devices: Harmonic Shears and the LigaSure (LS) vessel-sealing device by evaluating heat spread and pressure resistance under bench surgery conditions. In a clinical evaluation of the LS, we compared the outcomes of 22 patients in two different bench surgery groups: with and without the use of the LS.

RESULTS

Clinically, the bench surgery time was significantly shorter in the LS group than that in the conventional group (P < 0.001). In the animal tissue experiments, the highest temperature in bench surgery conditions was 60.4°C after 1 s at a 5-mm distance in the LS group. Pressure resistance of ≥ 750 mmHg was achieved in almost all trials in both veins and arteries, with no difference between Harmonic Shears and LS. There was more surgical smoke visually in bench conditions versus in dry conditions and under half bite versus full bite conditions.

CONCLUSIONS

The encouraging results of our exploratory clinical and animal studies of the energy devices suggest that they may be useful in the setting of bench surgery.

Comparing Two Approaches for Thyroidectomy: A Health Technology Assessment through DMAIC Cycle

Total thyroidectomy is very common in endocrine surgery and the haemostasis can be obtained in different ways across surgery; recently, some devices have been developed to support this surgical phase. In this paper, a health technology assessment is conducted through the define, measure, analyse, improve, and control cycle of the Six Sigma methodology to compare traditional total thyroidectomy with the surgical operation performed through a new device in an overall population of 104 patients. Length of hospital stay, drain output, and time for surgery were considered the critical to qualities in order to compare the surgical approaches which can be considered equal regarding the organizational, ethical, and security impact. Statistical tests (Kolmogorov–Smirnov, t test, ANOVA, Mann–Whitney, and Kruskal–Wallis tests) and visual management diagrams were employed to compare the approaches, but no statistically significant difference was found between them. Considering these results, this study shows that the introduction of the device to perform total thyroidectomy does not guarantee appreciable clinical advantages. A cost analysis to quantify the economic impact of the device into the practice could be a future development. Healthy policy leaders and clinicians who are requested to make decisions regarding the supply of biomedical technologies could benefit from this research.

Effect of energy-based devices on post-operative parathyroid function and blood calcium levels after total thyroidectomy

Introduction: Energy-based devices are widely used in thyroid surgery in order to achieve optimal hemostasis, while their role in the incidence of hypocalcemia and hypoparathyroidism comprises a topic evaluated in numerous studies.Areas covered: The aim of this systematic review is to investigate the potential benefit of Ultrasonic Shears and Electrothermal Bipolar (Radiofrequency) System in thyroid surgery regarding the incidence of post-operative hypocalcemia and hypoparathyroidism. A systematic review of the literature in PubMed/Medline and Scopus databases was conducted. Forty-nine studies met the inclusion criteria and were analyzed. A statistically decreased rate of transient hypocalcemia and hypoparathyroidism was reported in 15 studies and 4 studies, respectively, when using energy-based devices. However, 18 and 13 surveys examined transient hypocalcemia and hypoparathyroidism, respectively, and demonstrated no statistical difference between energy-based devices and conventional hemostasis. No difference was observed between the groups concerning permanent hypocalcemia. Out of 13 studies, only 2 showed a significant reduction in the occurrence of permanent hypoparathyroidism in the energy-based device group.Expert opinion: Energy-based devices reduced the rate of transient hypocalcemia and hypoparathyroidism after thyroid surgeries in 42.8% and 23.5% of the included studies, respectively. Further studies are needed to evaluate their impact on permanent post-operative hypocalcemia and hypoparathyroidism.

Intra- and postoperative complications using LigaSure™ Small Jaw in patients undergoing thyroidectomy: a register-based study

PURPOSE

LigaSure™ Small Jaw (LSJ) reduces operation duration and intraoperative blood loss in patients undergoing thyroidectomy. However, the evidence is sparse regarding postoperative complications and among relevant patients subgroups. In a large cohort of patients including relevant patient subgroups, we evaluated intra- and postoperative complications using LSJ.

METHODS

Single-centre register-based study evaluating 3346 patients undergoing hemi- or total thyroidectomy. We compared differences in intra- and postoperative complications using LSJ compared to conventional technique. Multivariate analyses were conducted to adjust for potential confounders.

RESULTS

Compared to the conventional technique, LSJ was associated with less postoperative drainage (OR 0.4, p = 0.02) and postoperative haemorrhage (OR 0.3, p = 0.02) among patients undergoing hemi- and total thyroidectomy with benign histology, respectively, but with increased risk of postoperative infection [3 (6.4%) vs. 0 (0.0%) patients, p = 0.04] among patients undergoing total thyroidectomy with malignant histology. LSJ was associated with reduced operation duration (- 12.2 min, p < 0.001, - 7.9 min, p < 0.001 and - 13.2 min, p = 0.002) and intraoperative blood loss (- 52.1 ml, p < 0.001, - 13.6 ml, p < 0.001 and - 12.9 ml, p = 0.02) compared to conventional technique among patients undergoing total and hemithyroidectomy with benign histology and hemithyroidectomy with malignant histology, respectively.

CONCLUSION

LSJ was associated with a reduced risk of postoperative haemorrhage and less postoperative drainage but increased risk of postoperative infection depending on the type of thyroidectomy and histology of the thyroid gland. LSJ was associated with only a small reduction in operation duration and intraoperative blood loss.

TRIAL REGISTRATION

The study was based on data prospectively registered in the Danish national database THYKIR.

Energy Based Vessel Sealing Devices in Thyroid Surgery: A Systematic Review to Clarify the Relationship with Recurrent Laryngeal Nerve Injuries

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future.

Comparing Hematoma Incidence between Hemostatic Devices in Total Thyroidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Alternative energy devices have become a popular alternative to conventional hemostasis in thyroid surgery. These devices have been shown to reduce operative time and thermal nerve injury. As hemostasis is paramount in thyroid surgery, we sought to examine the relative efficacy of 2 alternate energy devices compared to conventional hemostasis in preventing postoperative hematoma following total thyroidectomy.

DATA SOURCES

Ovid MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials.

REVIEW METHODS

A systematic literature search was performed for all relevant English-language studies published between 1946 and July 2018. Two authors independently extracted data and analyzed articles for quality using the National Institute of Health Quality Assessment Scale. Our primary outcome of interest was hematoma requiring reoperation.

RESULTS

A total of 348 studies were screened, with 23 meeting the inclusion criteria. We found no significant difference in postoperative hematoma rates using alternate energy devices compared to conventional hemostasis (P = .370, .317). Network meta-analysis echoed the results of conventional meta-analysis, demonstrating no significant difference in hematoma rates.

CONCLUSIONS

We found no significant difference in postoperative hematoma rates following total thyroidectomy for any indication with the use of alternate energy devices compared to conventional hemostatic techniques. This suggests that hematoma occurrence does not necessarily need to be considered when choosing between these hemostatic devices. This information may help guide surgeons' decisions regarding choice of hemostatic technique during thyroid surgery.

The impact of the ultrasonic, bipolar and integrated energy devices in the adrenal gland surgery: literature review and our experience

Background

The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery.

The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others.

Methods

A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas < 6 cm, myelolipomas < 13 cm, adrenal metastases < 7 cm and ASA score ≤ III were the main surgical inclusion criteria. All involved patients were divided into three group, one for each energy device: group 1 - Harmonic Scalpel, group 2 - Ligasure vessel sealing system and group 3 - Thunderbeat. In each group only one device was applied for dissection and haemostasis during the whole operation. Each group consisted of 25 patients, well matched for histology, tumor size and site, gender and age. The following parameters were collected: age, gender, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, hospitalization time, complication and conversion rate.

Results

There was no significant statistical difference between groups regarding the relationship between male/female, right site/left site, the mean age, hospitalization time and the tumor size (p > 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p < 0,001). The second faster device resulted Harmonic Scalpel, which meanly reduced the operation time compared to Ligasure (p = 0.048). intraoperative blood losses are reduced using Thunderbeat (p < 0,001) and HS (p = 0.006) compared to Ligasure, but between Thunderbeat and Harmonic Scalpel there isn’t significant statistical difference (p = 0.178).

Conclusions

Analyzing the results, laparoscopic adrenalectomy carried out using Thunderbeat appeared to show a statistically significant decrease in operation time and intraoperative blood losses compared with laparoscopic adrenalectomy performed using Harmonic Scalpel and Ligasure, while hospitalization time was superimposable in all groups. According to our data, a responsible use of advanced energy devices can improve surgical outcomes guarantying a cost savings and patient’s satisfaction.

Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review

PURPOSE

The reported incidence of post surgical hypoparathyroidism (HypoPT) varies greatly. Previous research suggests that the definition of HypoPT is not consistent in the literature. We therefore conducted a systematic review to investigate how HypoPT is defined and whether this definition, as well as the selected threshold for hypocalcemia affects the incidence.

METHODS

Using a predefined search string we identified all articles in PubMed reporting on the incidence of postsurgical HypoPT from 1st January 2010 to January 2017.

RESULTS

We identified 89 articles that employed 20 different definition of HypoPT. The incidence of HypoPT varied from 0.0% to 20.2%. The definitions were not associated with incidence of HypoPT. Use of prophylactic post-operative calcium supplements, however decreased the risk of HypoPT (p = 0.03), and there was a trend towards a lower risk of HypoPT when using a definition of hypocalcemia below lower limit of the reference range (p = 0.09).

CONCLUSION

The large number of definitions of HypoPT, as well as the huge variation in incidence point to a problem suggests that the awareness of HypoPT should be raised. Use of prophylactic post-operative calcium supplements may decrease risk of HypoPT. This, however, may be due to reverse causality as awareness of the risk of HypoPT may promote the use of calcium supplementation.

Early Experience with LigaSure Thyroidectomy in a Nigeria Teaching Hospital

BACKGROUND

The principles of safe and efficient thyroid surgery had been established and the technique has remained the same for over the century without any major significant changes. The introductions of electrosurgical devices constitute a major shift in the technique of thyroid surgery.

OBJECTIVE

We present our early experience with the use of LIGASURE vessel sealing system for the procedure of thyroidectomy.

MATERIALS AND METHODS

This was a quasi-experimental study comparing outcome of LigaSure thyroidectomy in a prospective nonrandomized cohort with another retrospective cohort of preintervention clamp-and-tie thyroidectomy.

RESULTS

A total of 30 patients with a clinical diagnosis of goiter were recruited into the study. There were two males and 28 females with a mean age of 42.6 years. Diagnosis was simple multinodular goiter 24 (80%), controlled toxic nodular goiter 3 (10%), grave disease 1 (3.3%), and multinodular goiter with retrosternal extension 2 (6.7%). The mean thyroid weight was 121.0 g. The mean duration of surgery was 59 min compared to 128 min for traditional technique (P < 0.01). The mean blood loss of 116 ml was significantly less than 328 ml following the traditional technique (P < 0.01). Mean duration of hospital stay was 1.9 days, compared to 3.55 days in the traditional technique group (P = 0.02). Troubling postoperative complications of change in voice quality occurred in only one patient (3.3%).

CONCLUSION

LigaSure thyroidectomy was found to be easier and faster to carry out with no learning curve and easy to learn and adapt.

Comparing postoperative complication of LigaSure Small Jaw instrument with clamp and tie method in thyroidectomy patients: a randomized controlled trial [IRCT2014010516077N1]

Background

LigaSure® Small Jaw (LSJ) has been recently introduced as an energy-based vessel sealing device, which has provided better intraoperative and postoperative outcomes in thyroidectomies, compared to conventional technique. In the current study, we aimed to examine the efficiency of hand-sewn and LSJ thyroidectomy, based on operation time and perioperative complications.

Methods

All patients with the diagnosis of multinodular goiter, thyroid cancers, retrosternal goiter and other indications for thyroid surgeries, enrolled. Of 550 patients, 261 patients randomly assigned to the conventional group (A) and 274 patients to LigaSure Small Jaw group (B). Study groups compared concerning operative time, recurrent laryngeal nerve (RLN) injury, hypocalcemia, and postoperative complications.

Results

There was no significant difference regarding demographic data between groups A and B. During total thyroidectomy, intraoperative blood loss was 64.42 ± 20.72 ml and 49.64 ± 17.92 ml in groups A and B, respectively (P 0.043). Operative time was significantly lower in LSJ group compared to the conventional group in total and subtotal thyroidectomy (P 0.002; P 0.001). Three patients who underwent conventional total thyroidectomy had RLN palsy. However, there was no significant difference between techniques regarding RLN injury (P 0.134).

Postoperative total and ionized serum calcium levels decreased compared to preoperative levels in both conventional and LSJ technique; however, changes in total and ionized serum calcium were more severe in patients with conventional thyroidectomy (total calcium, P < 0.0001) (ionized calcium, P 0.005).

Conclusion

The LigaSure Small Jaw device decreases operative time and intraoperative bleeding compared to conventional technique. Besides, changes in total and ionized calcium levels in patients with LSJ thyroidectomy are subtle compared to HS technique.

Trial registration

Registered in Iranian Registry of Clinical Trials (www.irct.com), trial registration: IRCT2014010516077N1, Registered: 23 May 2014).

Efficacy and safety of a vessel sealing system in oral cancer resection and reconstructive surgery

OBJECTIVE

Currently, many studies are being performed that focus on the efficacy and safety of the vessel sealing system (VSS) in various fields of surgery. However, in the field of oral cancer surgery, the efficacy and safety of VSS use have not been clarified.

METHODS

One hundred and fifty-one patients underwent oral cancer resection and reconstructive surgery. They were divided into two groups: Ligasure vessel sealing system (LVSS) group and conventional surgery (CS) as control. Intra-operative blood loss, operating time, and incidence of post-operative complications and recurrence were analyzed.

RESULTS

LVSS use significantly reduced intra-operative blood loss. The operating time was shortened only in mandibular gingiva cancer surgery. There were no differences between the two groups with regard to the incidence of post-operative complications and recurrence.

CONCLUSIONS

LVSS use was found to be effective and proved to be efficient and safe, and may be useful in oral cancer surgery.

Randomized clinical trial of platysma muscle suture versus no suture for wound closure after thyroid surgery

Background

Suturing the platysma muscle during wound closure after thyroid surgery is frequently described in the literature. There is no prospective evidence to support its use or benefit. The aim of this study was to evaluate how a platysma muscle suture influences initial postoperative pain following thyroid surgery.

Methods

Patients were assigned randomly to receive a platysma suture or no platysma suture in this prospective, patient-blinded trial. The duration of follow-up was 6 months. The primary endpoint was wound-specific pain 24 h after thyroid resection. Secondary endpoints were intraoperative and perioperative analgesia requirement, postoperative pain and complications until postoperative day 14, and Patient and Observer Scar Assessment Score (POSAS) 6 months after surgery.

Results

Forty-one patients were randomized to each group. Visual analogue scale scores for wound-specific pain were lower in patients without a platysma suture 24 h after surgery (mean(s.d.) 3·15(1·46) versus 2·17(1·41) in groups with and without suture respectively; P = 0·002). There were no differences in the perioperative and postoperative need for analgesics, postoperative wound complications or cervical scar cosmesis 6 months after surgery (mean(s.d.) POSAS 23·99(9·53) versus 26·51(8·69); P = 0·148).

Conclusion

Omitting the platysma muscle suture after thyroid surgery resulted in less wound-specific pain initially, with no difference in postoperative wound complications or cosmetic results. Registration number: NCT02951000 (http://www.clinicaltrials.gov).

Thyroidectomy in elderly patients aged ≥70 years

Worldwide, the indications for thyroid surgery have been continuously extended among elderly patients in the last 20 years. The balance between treatment indication and surgical risk is certainly an interesting topic for every thyroid surgeon. This paper is a review of recent literature from January 2005 up to April 2017. We analyzed three principal subjects: indications for surgical treatment, medical complications and surgical complications. We can summarize the conclusions of our analysis, stating that age could not be considered as an absolute factor, but in relation to the comorbidities and the general clinical condition of the patient. Special risk indices dedicated to geriatric patients could be very useful in order to facilitate the decision-making process; however, relying on the current knowledge, we could state that there is value in providing surgery to geriatric patients in highly specialized and high-volume centers, where access to technology and its systematic use, coupled with surgeons' experience, could certainly avail the geriatric patient management.

Predisposing factors for seroma formation in patients undergoing thyroidectomy: Cross-sectional study

Introduction

Seroma is defined as collection of fluid within the surgical site during postoperative period that causes several complications. Recognition of predisposing risk factors can lead to avoid seroma formation after thyroidectomy.

Materials and methods

A cross-sectional study was carried out during a 3-year period and 678 patients were enrolled the study. We recorded demographic data, past medical history and the type of thyroidectomy were for all patients. We measured total and ionized serum calcium and albumin level in all patients before surgery and a day after it. All patients underwent total or subtotal thyroidectomy and if needed central neck dissection was performed subsequently. Patients underwent serial aspiration If they had seroma formation.

Results

The overall post-thyroidectomy seroma incidence was 2.2%. There was no statistically significant correlation while evaluating gender, age and body mass index with post-operative seroma formation. However, seroma formation was significantly higher in patients underwent total thyroidectomy (P = 0.041). The results of postoperative laboratory tests showed a significant lower level of ionized calcium in patients with seroma formation (P < 0.0001). Logistic regression showed statistically significant value for variables including age, BMI and decreased ionized calcium level, in developing of seroma.

Conclusion

We showed that Seroma formation was lower during thyroidectomy via electrical vessel sealing system in comparison with previous studies. In our study, older age, greater body mass index and decreased ionized calcium level were predictors of seroma formation.

Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model

BACKGROUND

Advanced bipolar and ultrasonic energy have demonstrated reduction of operating time and blood loss in thyroidectomy. However, these devices generate heat and thermal dispersion that may damage adjacent structures such as the recurrent laryngeal nerve (RLN). This study was designed to evaluate the safety profile of the Harmonic Focus+^® (HF+) device through the evaluation of thermal injury to the RLN using different algorithms of distance and time with state of the art technology.

METHODS

25 Vietnamese pigs underwent activation of HF+ in the proximity of their RLN. They were divided into 4 groups according to activation distance (3 mm, 2 mm, 1 mm and on the RLN). Time of activation, time between tones of the ultrasonic generator, changes in the electromyographic signal using continuous nerve neuromonitoring, vocal fold mobility assessed by direct laryngoscopy and histological thermal damaged were evaluated.

RESULTS

None of the pigs had loss of signal in the electromyography during the procedure; only one pig had isolated transient decrease in amplitude and one increase in latency. One pig had transient vocal fold paresis in the group with activation on the nerve. Evaluation of the nerves by histology and immunohistochemistry did not show significant changes attributed to thermal injury.

CONCLUSIONS

The use of ultrasonic energy close to the RLN is safe, provided that activation time does not exceed the necessary time to safely transect the tissue.

A meta-analysis comparing the outcomes of LigaSure Small Jaw versus clamp-and-tie technique or Harmonic Focus Scalpel in thyroidectomy

BACKGROUND

LigaSure (LS) Small Jaw is a surgical hemostasis equipment that is newly introduced in thyroid surgery. The objective of this study is to assess the short-term efficacy and safety outcomes of LS Small Jaw compared with clamp-and-tie technique or Harmonic Focus Scalpel in thyroidectomy.

METHODS

A literature search was performed in the PubMed and Embase databases (until June 12, 2016) that reported the comparisons between LS Small Jaw and other techniques in thyroidectomy. Quality assessments were performed according to The Cochrane Collaboration's risk of bias tool and a modification of the Newcastle-Ottawa Scale in randomized controlled trials (RCTs) and non-RCTs, respectively. All statistical analyses were conducted using RevMan 5.3.

RESULTS

Finally, 7 studies with 813 patients were included into the meta-analysis, and all included studies were comparable with moderate-to-high quality. There was significant reduced operative time in LS Small Jaw, compared with clamp-and-tie (mean difference [MD] = -17.49, 95% confidence interval [CI]: -22.20 to 12.77, P < 0.00001) or Harmonic Focus Scalpel (MD = -2.29, 95% CI: -3.19 to 1.39, P < 0.00001). Besides, other perioperative outcomes including intraoperative blood loss and postoperative blood loss favored LS Small Jaw compared with clamp-and-tie. In terms of complications, less-temporary hypocalcemia rate was observed in LS Small Jaw compared with clamp-and-tie (odds ratio [OR] = 0.49, 95% CI: 0.27-0.90, P = 0.02), although no significant difference was detected compared with Harmonic Focus Scalpel (OR = 0.47, 95% CI: 0.14-1.56, P = 0.22). Other complications such as length of hospital stay, permanent hypocalcemia, temporary or permanent recurrent laryngeal nerve palsy, and hematomas were not significant.

CONCLUSION

In conclusion, LS Small Jaw is more favorable than clamp-and-tie technique or Harmonic Focus Scalpel in thyroidectomy.

Safety of LigaSure in recurrent laryngeal nerve dissection-porcine model using continuous monitoring

OBJECTIVES/HYPOTHESIS

This study investigated recurrent laryngeal nerve (RLN) real-time electromyography (EMG) data to define optimal safety parameters of the LigaSure Small Jaw (LSJ) instrument during thyroidectomy.

STUDY DESIGN

Prospective animal model.

METHODS

Dynamic EMG tracings were recorded from 32 RLNs (16 piglets) during various applications of LSJ around using continuous electrophysiologic monitoring. At varying distances from the RLN, the LSJ was activated (activation study). The LSJ was also applied to the RLN at timed intervals after activation and after a cooling maneuver through placement on the sternocleidomastoid muscle (cooling study).

RESULTS

In the activation study, there was no adverse EMG event at 2 to 5 mm distance (16 RLNs, 96 tests). In the cooling study, there was no adverse EMG event after 2-second cooling time (16 RLNs, 96 tests) or after the LSJ cooling maneuver on the surrounding muscle before reaching the RLNs (8 RLNs, 24 tests).

CONCLUSION

Based on EMG functional assessment, the safe distance for LSJ activation was 2 mm. Further LSJ-RLN contact was safe if the LSJ was cooled for more than 2 seconds or cooled by touch muscle maneuver. The LSJ should be used with these distance and time parameters in mind to avoid RLN injury.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 127:1724-1729, 2017.

A randomized controlled study comparing a vessel sealing system with the conventional technique in axillary lymph node dissection for primary breast cancer

Objective

This study aimed to compare the efficacy and safety of the newest bipolar vessel sealing system (BVSS; LigaSure™ Small Jaw) to that of conventional technique in axillary dissection.

Methods

Sixty-one patients with breast cancer were randomized to a conventional dissection surgical technique (CONV group; n = 30) by scalpel and monopolar cautery or that using a vessel sealing system (BVSS group; n = 31).

Results

There was a significant difference between both groups in the mean number of days until drain removal (6.4 ± 2.9 vs. 8.2 ± 3.8 days; P value = 0.033), and the mean total volume of drainage fluid (365.3 ± 242.2 vs. 625.1 ± 446.6 mL; P value = 0.009). The incidence of seroma was similar in both groups (43.3 vs. 37.9 %; P value = 0.673). There was no statistically significant difference in axillary dissection operating time (66 vs. 70 min; P value = 0.371), or the mean volume of blood loss (18.2 ± 31.1 vs. 20.6 ± 26.3 mL; P value = 0.663).

Conclusions

Our results suggest that BVSS is a more effective device when compared to the conventional techniques in axillary dissection.

Ultrasonic, bipolar, and integrated energy devices: comparing heat spread in collateral tissues

BACKGROUND

Integrated devices incorporating ultrasonic and bipolar technology have been used in laparoscopic surgery, however, are not yet incorporated into open operations. Here, we compare thermal spread and recurrent laryngeal nerve (RLN) functional data of the integrated THUNDERBEAT Open Fine Jaw device, the bipolar Ligasure Small Jaw, and the ultrasonic Harmonic Focus for open thyroidectomy.

MATERIALS AND METHODS

The three energy devices were compared in a live porcine model using three tissue types including liver, muscle, and thyroid. The devices were fired three times on each energy setting, and the thermal spread was measured by thermocouples that were inserted in surrounding tissues at 1-mm intervals. To determine RLN injury, devices were fired at successive 1-mm increments from the RLN until the monitor signal was lost.

RESULTS

When comparing heat generated across these devices at 1 mm, the peak temperature (Celsius) reached in liver tissue was observed with the ultrasonic device (115.4 ± 86.7), in muscle tissue with the integrated device (104.2 ± 82.1), and in thyroid with the bipolar device (81.4 ± 41.3). Temperatures generated at individual settings on each device were similar (P = 0.11-0.81). RLN injury occurred after firing on manually approximated tissue 1-mm away from the RLN for all devices; however, there was no signal loss at ≥2 mm.

CONCLUSIONS

Heat transfer was similar among all devices with the exception of the ultrasonic device when used in the liver, which showed higher temperatures. Liver tissue showed the most consistent results. RLN injury did not occur if the devices were fired on manually approximated tissue ≥2 mm from the nerve.

Antiplatelet and Anticoagulant Medications Significantly Increase the Risk of Postoperative Hematoma: Review of over 4500 Thyroid and Parathyroid Procedures

PURPOSE

Antiplatelet and/or anticoagulant medication use is common. Abstinence a week before surgery may still result in altered hemostasis. The study aim was to report on perioperative antiplatelet and anticoagulant use in thyroidectomy and parathyroidectomy patients, and to determine the association with postoperative hematoma (POH) rates.

METHODS

Retrospective review of a prospective endocrine surgery database was performed. Procedure extent was defined as unilateral, bilateral, or extensive. Antiplatelets were categorized as none, 325 mg aspirin (ASA), <325 mg ASA, clopidogrel, or other. Anticoagulants were categorized as none, oral, or injectable.

RESULTS

A total of 4514 patients were identified. POH developed in 22 patients (0.5 %). Rates were similar between age, gender, and reoperative status. POH were seven times more common after thyroidectomy (0.8 vs. 0.1 %, p < 0.01). Unilateral procedures had lower POH rates than bilateral or extensive (0.1 vs. 0.9 vs. 0.8 %, p < 0.01). POH rates in patients receiving 325 mg ASA (0.8 %) or clopidogrel (2.2 %) were much higher than patients not receiving antiplatelets (0.5 %) or receiving <325 mg ASA (0.1 %, p = 0.04). Oral anticoagulants (2.2 %) and injectable anticoagulants (10.7 %) had much higher POH rates than patients not receiving anticoagulants (0.4 %, p < 0.01). Target organ, patient gender, procedure extent, antiplatelet use, and anticoagulant use were included on logistic regression to determine association with POH. Bilateral procedures, thyroidectomy, clopidogrel, oral, and injectable anticoagulants were all independently associated with POH.

CONCLUSIONS

POH occur more frequently after thyroidectomy and during bilateral procedures. Patients requiring clopidogrel or any anticoagulant coverage are at much higher risk for POH. These higher-risk patients should be considered for observation to ensure prompt POH recognition and intervention.

A comparison of electrothermal bipolar vessel sealing system and electrocautery in selective neck dissection

The use of LigaSure™ vessel sealing system in head and neck surgery was reported to be reliable and safe, providing sufficient hemostasis and reducing operating time. The aim of this study was to evaluate efficacy of this technique in patients undergoing selective neck dissections. This study was carried out as a prospective controlled study at an otolaryngology department of a tertiary medical center between July 2013 and July 2015. Twenty-five patients older than 18 years who underwent unilateral selective neck dissection for head and neck cancer were included in the study. In the control group (group 2, 10 patients) only monopolar and bipolar diathermy was used; in the Ligasure group (group 1, 15 patients) Ligasure was used for hemostasis and dissection in addition to the conventional techniques. Cervical lymphadenectomy time, operation time, preoperative hemoglobin levels, preoperative hematocrit levels, postoperative hemoglobin levels, postoperative hematocrit levels, total neck drainage and drain removal time were analyzed and compared between the groups. Median operation time in group 1 and 2 were 95 min (IQR = 35) and 142.5 min (IQR = 63), respectively. Median cervical lymphadenectomy time in group 1 and 2 were 55 min (IQR = 23) and 102.5 min (IQR = 49), respectively. Median operation time and cervical operation time were significantly lower in group 1 (p < 0.05). In conclusion, LigaSure™ vessel sealing system is a safe, efficacious technique and significantly lowers cervical lymphadenectomy and operation time in selective neck dissections compared to controls. Given the superb hemostatic properties, this technique should be in the surgeon's armamentarium when possible.

Electrophysiologic monitoring correlates of recurrent laryngeal nerve heat thermal injury in a porcine model

OBJECTIVES/HYPOTHESIS

Thermal injury to the recurrent laryngeal nerve (RLN) may not be visually apparent and may go unrecognized intraoperatively. This study aimed to investigate the heat thermal tolerance of RLN and evaluate the electrophysiologic correlates of electromyographic (EMG) signal change during an acute RLN heat damage.

STUDY DESIGN

Prospective porcine model with continuous intraoperative neuromonitoring (CIONM).

METHODS

Ten pigs (20 RLNs) undergoing CIONM had their EMG tracings recorded and correlated with heated normal saline (NS) irrigation of varying temperature and duration.

RESULTS

In the initial pilot study, the EMG was without change during incremental heated NS irrigation (40/45/50/55 °C for 60 seconds), but adverse EMG combined events (CE) (amplitude decrease with a concordant latency increase) occurred and degraded to loss of signal (LOS) (by 17.5 ± 1.3 seconds) when the temperature was elevated to 60 °C (n = 4). Another 16 RLNs were evaluated to further compare the EMG pattern after various degrees of thermal stress (60/70 °C for 30/20 seconds). Electromyographic recordings showed CEs and LOS in all RLNs, and only six of eight RLNs with 60 °C exposure showed slight EMG amplitude recovery (16%-35%) after 20 minutes. None of the injured nerve segments were visually apparent, but all were detectable by IONM.

CONCLUSION

Sixty degrees Celsius is a critical temperature to cause RLN thermal injury. Continuous intraoperative neuromonitoring can be used as a tool for the early detection of acute thermal stress and may guide use of energy-based devices during thyroid procedures.

LEVEL OF EVIDENCE

N/A.