The use of cautery in "bloodless" radical mastectomy

Harmonic scalpels compared with electrocautery in reconstructive flap harvesting: A meta-analysis

BACKGROUND

Numerous studies have compared electrical devices used for flap surgery, but the results are inconsistent. This research was performed to evaluate the efficacy of two different types of electric devices: electrocautery and ultrasonic shears.

METHODS

The PubMed, Embase, and Scopus databases were searched systematically. A total of 505 cases were included in this study, including 209 electrocautery and 296 harmonic scalpel cases. The following information was retrieved from the included studies: the first author of the article, publication year, flap type, flap harvest time, drain volume, bleeding volume and postoperative complications. Hematoma, infection, flap necrosis and wound dehiscence were considered postoperative complications. The Q statistic for heterogeneity and the I² index were calculated. If I²  < 50%, we used a fixed-effects model; if I²  > 50%, we employed a random-effects model in our meta-analysis.

RESULTS

A total of eight studies which met the inclusion criteria were included and reviewed systematically for a meta-analysis. The harmonic scalpel yielded a statistically significantly more favorable flap harvest time and drain volume than did electrocautery. The Harmonic scalpel led to a shorter flap harvest time by 26.29 min (95% CI = -39.38 to -13.2; p < .00001) and smaller drain volume by 58.76 ml (95% CI = -105.27 to -12.25; p = .01) on average. However, there were no significant differences in the bleeding volume or incidence rates of infection, flap necrosis and wound dehiscence.

CONCLUSION

The Harmonic scalpel method yields better outcomes in terms of the flap harvest time and drain volume than does the conventional electrocautery method. Therefore, the Harmonic scalpel is a better option for cauterization and dissection in flap surgery.

Seroma formation after mastectomy: pathogenesis and prevention

Post mastectomy seroma remains an unresolved quandary as the risk factors for its formation have still not been identified. Seromas of the axillary space following breast surgery can lead to significant morbidity and delay in the initiation of adjuvant therapy. Various techniques and their modifications have been practiced and published in English literature, but there seems to be no consensus. In this article, all aspects of seroma formation from pathogenesis to prevention including drug therapies have been discussed.

Concepts of seroma formation and prevention in breast cancer surgery

BACKGROUND

Seroma formation is the commonest early sequel to breast cancer surgery especially when axillary dissection is undertaken. It is associated with significant morbidity and financial burden. The main pathophysiology of seroma is still poorly understood and remains controversial. The optimal ways to reduce the incidence of seroma formation are unknown. The aim of this paper is to review the concepts of pathophysiology of seroma formation following mastectomy and breast-conserving surgery for cancer. The various techniques in practice to reduce its incidence and treatment are outlined.

METHOD

MEDLINE search of published work on the subject with respect to its pathophysiology, prevention and treatment was carried out. Manual retrieval of relevant articles in the reference lists of the original papers from the MEDLINE was then carried out.

RESULT

The pathophysiology and mechanism of seroma formation in breast cancer surgery remains controversial and not fully understood. Methods of prevention and treatment of seroma remain varied and inconclusive.

CONCLUSION

Evidence suggests an increase in the incidence of seroma because of thermal trauma from electrocautery dissection, but this is indispensable for surgical haemostasis. Obliteration of dead space by various flap apposition techniques has been shown to be advantageous in reducing incidence and volume of seroma. Low-pressure suction drainage reduces seroma volume and duration of drainage leading to earlier drain removal. Preventive measures have to be tailored according to individual patient and operative factors.

Electrocautery as a factor in seroma formation following mastectomy

BACKGROUND

Electrocautery has been postulated as a factor in the risk of seroma formation after mastectomy.

METHODS

Eighty consecutive mastectomies in 74 patients were randomly assigned to dissection of the mastectomy flaps with either scalpel (n = 38) or electrocautery (n = 42). Total volume of fluid output through drains and aspirated from seromas was recorded. Other factors investigated included the type of drain utilized, estimated blood loss, and complications.

RESULTS

Seromas developed in 16 wounds in the electrocautery group compared with 5 in the scalpel group (38% and 13%, respectively; P = 0.01). Other factors with an independent risk for seroma included use of Jackson-Pratt drains compared with Blake drains (P = 0.006), and lower estimated blood loss (P = 0.006). No differences in characteristics of patients or in other complications were noted.

CONCLUSIONS

Use of electrocautery to create skin flaps in mastectomy reduced blood loss but increased the rate of seroma formation.

Randomized trial of laser scalpel for modified radical mastectomy

The efficacy of a contact neodymium yttrium-aluminium-garnet laser scalpel was assessed during breast surgery. Forty consecutive women undergoing modified radical mastectomy were randomized to operation performed with a conventional or laser scalpel. The laser scalpel was associated with a significant reduction in mean operative blood loss (149 versus 421 ml; 95 per cent confidence interval of difference 176-368 ml, P < 0.001), but the mean operating time was longer (105 versus 80 min; 95 per cent confidence interval of difference 16-34 min, P < 0.001). No significant differences were found in the volume of postoperative wound drainage, incidence of axillary seroma, postoperative pain score or time to return of shoulder mobility. Use of a laser scalpel in breast surgery cannot be recommended.