ORIGINAL ARTICLE The Use of the Harmonic Scalpel vs Conventional Knot Tying for Vessel Ligation in Thyroid Surgery Allan E. Siperstein, MD; Eren Berber, MD; Ebru Morkoyun Hypothesis: The technique of thyroidectomy has un- and complications using a 2-tailed t test, ␹2 test, and Wil- dergone little change in several decades. The harmonic coxon rank sum test. scalpel, using ultrasonic frictional heating to ligate ves- sels, is widely used in laparoscopic surgery, but there is Results: The 2 groups were similar regarding age and sex. little experience in open thyroidectomy. We hypoth- There were no intraoperative complications. Mean±SD thy- esized that the use of the harmonic scalpel could lead to roid size tended to be larger in the harmonic scalpel group a significant reduction in operative time as compared with for both lobectomy (5.1±2.6 cm vs 4.2±2.2 cm; P=.06) knot tying in thyroid surgery. and total thyroidectomy specimens (6.3±3.8 cm vs 4.8±2.9 cm; P=.08) compared with the conventional technique. Mean±SD operative time was shorter in the harmonic scal- Design: Retrospective case-controlled study. pel group compared with the conventional technique group for both lobectomy (89±20 minutes vs 115±25 minutes; Setting: Teaching institution. PϽ.01) and total thyroidectomy (132±39 minutes vs 161±42 minutes; PϽ.01) procedures. There was no dif- Patients: One hundred seventy-one consecutive pa- ference between the 2 techniques regarding the amount of tients undergoing lobectomy or total thyroidectomy by blood loss for different procedures. There was no effect of one surgeon (A.E.S.). tumor size on operative time (Pearson correlation factors: 0.14 for total, 0.21 for unilateral thyroidectomy). Interventions: Eighty-six patients underwent thyroid surgery with the conventional clamp-and-tie technique Conclusions: The use of the harmonic scalpel for the (lobectomy, n=49; total thyroidectomy, n=36) and 85 control of thyroid vessels during thyroid surgery is safe, with the harmonic scalpel (lobectomy, n=38; total thy- and it shortens the operative time by almost 30 minutes roidectomy, n=47). compared with the conventional technique for both uni- lateral lobectomy or total thyroidectomy procedures. Main Outcome Measures: Demographics, pathologi- cal characteristics, thyroid size, operative time, blood loss, Arch Surg. 2002;137:137-142 HE HARMONIC scalpel is a troduction of ether anesthesia, antisep- new device that has been sis, and artery forceps to practice.12 The introduced to surgery dur- pioneers of thyroid surgery, Theodor ing the last decade. It is a Kocher and Theodor Billroth, developed device that uses high- an acceptable technique of standardized frequency mechanical energy to cut and thyroid surgery between the years 1873 T 1 coagulate tissues at the same time. Lapa- and 1883. By 1920, the principles of safe roscopists were the first ones to use this and efficient thyroid surgery had been es- method widely. It has been proven to de- tablished.13 Since the technique has be- crease operation time and complications come standardized, safe, and efficient, in studies of abdominal solid organ sur- there has not really been a major change gery,2-5 adrenalectomy,6 and thoracic sur- in our technique of thyroidectomy. The gery,7,8 as well as many other proce- only debate and change have been with re- dures.9-11 gard to the choice of a certain type of op- From the Department of Thyroid surgery initially started in the eration (ie, lobectomy, total thyroidec- General Surgery, Cleveland 12th century with the use of setons, hot tomy, or subtotal thyroidectomy) for a Clinic Foundation, Cleveland, irons, and caustric powers (often with fa- given diagnosis. Some alternative meth- Ohio. tal results). A major advance was the in- ods in thyroid surgery that have been tried (REPRINTED) ARCH SURG/ VOL 137, FEB 2002 WWW.ARCHSURG.COM 137 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 PATIENTS AND METHODS separated in the midline and laterally reflected. The infe- rior, middle, and superior thyroid vessels were then di- PATIENTS vided either with the harmonic scalpel or with conven- tional knot tying (Figure 3). The thyroid lobe was then Between February 1994 and December 2000, 227 patients medially rotated, and the vessels in the ligament of Berry, underwent various thyroid surgical procedures per- with the nerve under direct vision, were clamped and tied formed by one surgeon (A.E.S.) using either conventional in both groups. The same steps are repeated for removal knot tying (n=124) or the harmonic scalpel (n=103) for of the contralateral lobe. Finally, the wound was irrigated vessel control. Those patients undergoing either lobec- and closed using interrupted 3-0 polyglactin sutures to ap- tomy or total thyroidectomy form the subject of this study proximate the strap muscles and the platysmal layer. The for practical considerations. There were 85 patients oper- skin was closed using Michel clips, which were removed ated on with the conventional technique (lobectomy, n=49; on postoperative day 1. total thyroidectomy, n=36) and 86 with the harmonic scal- pel (lobectomy, n=39; total thyroidectomy, n=47). The ANALYSIS choice between the type of surgery for a given patient de- pended on the availability of the equipment. We started us- Medical records of the patients enrolled in the study were ing the harmonic scalpel for thyroid procedures in April reviewed from the first author’s endocrine surgery data- 1998. Three different models were used in the study, in- base, and the patients in the 2 surgical groups were com- cluding the Ultracision CS (Ethicon EndoSurgery, Cincin- pared regarding age, sex, diagnosis, thyroid size, opera- nati, Ohio), AutoSonix Ultrashears (United States Surgi- tive time, estimated blood loss, and complications using a cal Co, Norwalk, Conn), and the Ultracision Harmonic 2-tailed t test, ␹2 test, and Wilcoxon rank sum test. Statis- Ͻ Scalpel CS-14C (Ethicon EndoSurgery) (Figure 1 and tical significance was reached at P .05. Patients with pre- Figure 2). vious neck surgery, those with extrathyroidal invasion of malignant tumors of the thyroid, and those undergoing an PROCEDURE accompanying additional procedure (ie, parathyroidec- tomy, lymph node dissection) were not considered for analy- All patients had routine preoperative workup for their dis- sis. No additional time was spent in any case for waiting ease and the same anesthetic and hospital care regardless for the frozen-section pathology report. of the surgical technique employed. All patients were ad- To investigate the effect of histopathology on surgery mitted on the morning of the scheduled operation and had time, histopathology was divided into 2 major categories: a 23-hour hospital stay. All procedures were performed us- focal pathologies, comprising benign and malignant thy- ing endotracheal general anesthesia. The patients were po- roid tumors; and diffuse pathologies, including goiter, thy- sitioned and draped in the conventional manner. A 4- to roiditis, and Graves disease. Subtotal thyroidectomies were 6-cm incision (depending on the size of the thyroid) was also considered under total thyroidectomy cases for prac- made over the level of the thyroid isthmus. Subplatysmal tical reasons. All patients were followed up with office vis- flaps were developed, and the strap muscles were its 2 weeks after surgery. of the thyroid vessels followed by excision of the gland, as is true for all resectional surgical procedures. The unique feature of this operation is that the thyroid gland has one of the richest blood supplies among the organs, with numerous blood vessels and plexuses entering the parenchyma. These need to be controlled with liga- tures. The ligation and division of these vessels is time consuming. Reduction of the time spent with the con- ventional clamp-tie technique can significantly reduce the operative time in this procedure. Since time spent in the operating room is expensive,17 this will both decrease the operation time and the operative costs. In this sense, we hypothesized that the use of the harmonic scalpel could lead to a significant reduction of the operative time in Figure 1. Ultrasonic coagulating shears used in this study. Top, Ultracision CS (Ethicon EndoSurgery, Cincinnatti, Ohio). Center, AutoSonix Ultrashears thyroid surgery and report the results of an initial case- (United States Surgical Co, Norwalk, Conn). Bottom, Ultracision Harmonic controlled study comparing the use of conventional su- Scalpel CS-14C (Ethicon EndoSurgery). All have a shaft length shorter than ture tying vs the harmonic scalpel in patients undergo- their counterparts used in laparoscopic surgery. The older devices (top) had a shaft 10 mm in diameter. Newer devices have a shaft 5 mm in diameter ing lobectomy or total thyroidectomy. that takes up less room in the small incisions used for thyroid surgery. RESULTS during the last decade include endoscopic surgery, nerve stimulations, and even hypnosis for anesthesia; how- The 2 groups were similar regarding age and sex. For the ever, none has been widely accepted.14-16 total thyroidectomy procedure, there was no difference Thyroidectomy is, in essence, devascularization of between groups regarding the distribution of focal vs dif- the thyroid by double ligating and dividing the branches fuse pathologies. For unilateral lobectomy, there was no (REPRINTED) ARCH SURG/ VOL 137, FEB 2002 WWW.ARCHSURG.COM 138 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 A B Sealed Vessel C Figure 2. Active tips of the ultrasonic coagulating shears. All employ a rigid active lower blade through which the vibrating energy is transmitted. The movable upper jaw is used to compress the vessel against the lower blade, thus allowing transfer of the vibrational energy. The top 2 devices have straight blades. The bottom device has a curved blade facilitating perpendicular placement across vessels.