The use of LigaSure in patients with hyperthyroidism

Systematic review and meta-analysis of the use of high-energy devices for thyroid surgery

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the role of High Energy Devices (HEDs) versus conventional clamp and tie technique in thyroidectomy. This work is endorsed by the Italian Society of Surgical Endoscopy (Italian Society of Endoscopic Surgery and new technologies-SICE) in the broader project on the evaluation of the role of HEDs in different surgical settings with the full health technology assessment report.

MEHODS

Inclusion criteria were adult patients (≥ 18 years old) undergoing Thyroidectomy/Parathyroidectomy conducted with High Energy Devices (as ultrasonic (US), radiofrequency (RF), and hybrid energy (H-US/RF)) in the setting of thyroid surgery (both partial and total) for benign and malign diseases. However, some variability was found in included studies and described in the text. This systematic review and meta-analysis were performed according to the Cochrane handbook for systematic reviews, and the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines were pursuit. Selection of abstracts was performed in Ryyan system by 2 independent reviewers, and doubts were solved by another independent reviewer. At the end of literature research, Randomized controlled trials and observational studies were included. Risk of Bias was assessed with ROB2 for RCTs, and New Castle Ottawa Scale for Observational studies.

RESULTS

The literature search yielded 47 studies, including 29 RCTs and 18 observational studies. Meta-analysis was performed for 29 randomized clinical trials. Outcomes included in the comparison between High Energy Devise and conventional technique groups were operative time, operative blood loss, overall post-operative drainage volume, length of stay, complications, and costs. HED significantly reduced operative time (28 studies, 3097patients; MD -128.8; 95% CI -34.4 to -23.20; I2 = 96%, p < 0.00001, Random-effect), intra-operative blood loss (13 studies, 642 vs 519 patients; SMD -0.82; 95% CI -1.33 to -0.32; I2 = 93%, p < 0.00001, Random-effect), LOS (22 studies, 2808 vs 2789 patients; MD -0.38, 95% CI -0.59 to -0.17; I2 = 98%, p < 0.00001 Random-effect), and healthcare costs (8 studies, 1138 vs 1129 patients, SMD 1.05; 95% CI -0.06 to 2.16; I2 = 99%, p < 0.00001 Random-effect). The rate of overall intraoperative complications was significantly different between both groups (25 studies, 2804 vs 2775 patients; RR 0.88, 95% CI 0.80 to 0.97; I2 = 38%, p = 0.03 Random-effect), but the sensitivity analysis did not find a statistically significant difference (6 studies, 605 vs 594 patients, RR; 95% CI to; I2 = 0%, p = 0.50, Random-effect). There was no difference in the subgroup analysis for the occurrence of transient and permanent RLN palsy, nor hematoma formation and hypocalcaemia.

DISCUSSION

Though findings of our systematic review and metanalysis are limited by heterogeneous data, surgeons, hospital managers, and policymakers should note that the use of High Energy Devices compared to conventional clamp and tie technique have reduced operative times, intra-operative blood loss, length of stay, and hospital costs in patients underwent to tyroid surgery. Future work must explore issues of equity to mitigate barriers to patient access to safe thyroid surgical care and define better this initial results.

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

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.

Network meta-analysis of topical haemostatic agents in thyroid surgery

Background

The objective of this study was to investigate the potential benefit of local haemostatic agents for the prevention of postoperative bleeding after thyroidectomy.

Methods

A systematic literature search was performed, and RCTs involving adult patients who underwent thyroid surgery using either active (AHA) or passive (PHA) haemostatic agents were included in the review. The main outcome was the rate of cervical haematoma that required reoperation. A Bayesian random-effects model was used for network meta-analysis with minimally informative prior distributions.

Results

Thirteen RCTs were included. The rate of cervical haematoma requiring reoperation ranged from 0 to 9·1 per cent, and was not reduced by haemostatic agents: AHA versus control (odds ratio (OR) 1·53, 95 per cent credibility interval 0·21 to 10·77); PHA versus control (OR 2·74, 0·41 to 16·62) and AHA versus PHA (OR 1·77, 0·12 to 25·06). No difference was observed in the time required for drain removal, duration of hospital stay, and the rate of postoperative hypocalcaemia or recurrent nerve palsy. AHA led to a significantly lower total postoperative blood loss and reduced operating time in comparison with both the control and PHA groups.

Conclusion

The general use of local haemostatic agents has not been shown to reduce the rate of clinically relevant bleeding.

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.

Is sutureless thyroid surgery safe in the hands of surgical trainees. A single centre retrospective study

Background

The safety and efficacy of sutureless thyroid surgery have been confirmed in many series. Equally, surgical expertise has been shown to influence postoperative outcome. This study aimed at investigating the safety of sutureless thyroid surgery in the hands of surgical trainees and to find out if this technique could be safely integrated into endocrine surgical training programs.

Methods

A single center retrospective comparison of the outcome of surgeries performed by experienced surgical attendings and trainees was performed. The LigaSure Precise was used in all cases.

Results

Two hundred and eight patients were included. The trainee group comprised of 61 cases managed by surgical trainees. Surgery was performed by surgical attendings in 147 cases (consultant group). The incidences of transient and permanent hypocalcaemia were 20.7 and 0.9 % respectively, the corresponding values for recurrent nerve injury were 6.3 and 0.9 %. Postoperative bleeding occurred in 3.4 %. There was no difference amongst both groups with regard to postoperative outcome (p > 0.05).

Conclusions

While sutureless thyroid surgery was safely performed by surgical trainees without relevant increase in perioperative complications in our department, further larger scale studies would be needed to confirm this would be the case more widely.

The approach of general surgeons to the use of vessel sealing device in thyroid surgery

OBJECTIVE

Vascular sealing devices (VSD) can be safely used in thyroid surgery. The purpose of this survey was to investigate general surgeons' approach to the use of VSD in thyroid surgery in Turkey.

MATERIAL AND METHODS

A questionnaire containing 10 items was prepared and announced via the Dialogue in Endocrinology Society website. The results were then analyzed.

RESULTS

Fifty surgeons (65.8%) stated that they always use VSD, 20 (26.3%) stated that they sometimes use these devices and six (7.9%) declared that they never use VSD. Thirty-six surgeons (47.4%) reported that they use ligation all the time, and 42 (55.3%) stated that upper pole vessels should be ligated at least once. Twenty two point four percent of the responders stated that they faced a complication, which they thought was related to VSD.

CONCLUSION

The vast majority of surgeons routinely uses VSD and accepts it as a safe tool. However, the observed complication rate was very high.

Sutureless thyroidectomy with energy-based devices: Cerrahpasa experience

Total thyroidectomy makes up the majority of all thyroidectomy cases. Energy-based advanced vessel-sealing devices which were developed in recent years for the control of vascular pedicles allowed significant progress in thyroid surgery. This study is designed to compare the efficiency and safety of the two energy-based vessel-sealing devices (Ligasure™ LF1212 and Harmonic FOCUS(®)) in sutureless thyroidectomy. Two hundred and forty-five consecutive patients underwent sutureless total thyroidectomy. Patients were randomized for the Ligasure™ LF1212 (n = 126) or Harmonic FOCUS(®) (n = 119). The parameters of demographics, surgical indications, morbidity, incision length, duration of operation, weight of specimen, amount of drainage, postoperative pain, hospital stay, and histopathology of specimen were recorded. Mean duration of operation was 37.98 ± 14.98 min (16-92 min) and was significantly shorter for Harmonic FOCUS(®) (p < 0.001). Mean hospital stay was 1.09 ± 0.3 (1-3) days. Morbidity rate was 9.8 % in total, whereas no mortality was observed. In terms of morbidity rates, no significant difference was determined between the two groups (p = 0.476). In both groups, there was no need for extra analgesic application other than the routine given after surgery. According to our experience, sutureless thyroidectomy can be performed with low morbidity rates in secure and efficient way.

The safety of energy-based devices in open thyroidectomy: a prospective, randomised study comparing the LigaSure™ (LF1212) and the Harmonic® FOCUS

PURPOSE

The options for haemostasis and dissection during modern thyroid surgery include the use of a bipolar vessel sealing system and ultrasonic technology. The aim of this study was to compare these energy-based devices (EBDs) with respect to their use in open thyroidectomy.

METHODS

The FOCUS Shear (F) and LigaSure LF1212 (L) were evaluated. A total of 182 consecutive patients scheduled for open thyroidectomy were prospectively randomised into two similarly sized groups. The parameters of operative time, morbidity, incision length, postoperative pain and hospital stay were analysed.

RESULTS

The main clinically primary endpoints of the two devices were identical in the study as the rate of nerve lesions, bleeding, drainage, operative time and postoperative calcium concentration with no significant differences with respect to the instrument utilised. The mean length of the incision was greater in the F group (p < 0.05). Patients in the F group were more likely to complain of pain while swallowing (p < 0.001). Early postoperative measurements of intact parathyroid hormone plasma levels revealed that although the levels were within the reference range, they were significantly lower in the F group (p < 0.001). Oral calcium supplementation was significantly higher and more prolonged in the F group.

CONCLUSIONS

The present study demonstrated no significant difference in the rates of postoperative morbidity associated with these two different EBDs used. Differences in clinically less significant were founded and focused on.

Thyroidectomy with LigaSure

PURPOSE

A new method for ensuring hemostasis during thyroid surgery has recently been introduced. This technique, electrothermal (LigaSure) and ultrasound blood vessel sealing, is still experimental. The aim of the present study was to evaluate the applications and efficacy of LigaSure by analyzing the duration of the surgery and the rate of complications of the surgical procedure.

METHODS

A total of 23 patients who underwent the LigaSure operation (n(LS) group) were analyzed in a prospective nonrandomized/partly randomized clinical study, and were compared with patients who underwent treatment using the conventional (ligature) surgical technique.

RESULTS

At our institutions, 187 patients were treated surgically for thyroid disease in 2006, and 23 of these patients were treated using LigaSure. The complication rate in the patients treated with LigaSure (n(LS): 4.3%) was lower than those who received conventional ligature surgery. However, given the small number of patients, this difference was not statistically significant (retrospective group n(1): 10.7%; nonrandomized group n(2): 9.8%; and randomized group n(3): 9.1%). The length of surgery in the LigaSure group (n(LS) = 65 ± 3 min) was significantly shorter (P < 0.001) compared with both nonrandomized (n(2) = 71 ± 6 min) and randomized (n(3) = 70 ± 4 min) patients who received a conventional ligature.

CONCLUSIONS

The application of LigaSure using meticulous surgical technique provides a new option for a safe thyroidectomy. Moreover, the duration of the LigaSure procedure is significantly shorter, and there are fewer complications as compared with the classic surgical thyroidectomy technique.

Safe incorporation of new technologies in thyroid surgery

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between the years of 1873 and 1910. In general the essential objectives for thyroidectomy are: sparing the parathyroid glands, avoidance of injury to the laryngeal nerves, an accurate hemostasis and an excellent cosmesis. In the last 10 years, major improvements and new technologies have been proposed and applied in thyroid surgery. These include mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia, intraoperative neuromonitoring, parathyroid hormone assay technology and genetic screening. This paper reviews the relevant medical literature published on the influence of these new technologies on the quality of thyroid surgery, as well as prevention of postoperative morbidity and mortality. Searches were last updated in April 2008.

Novel hemostatic devices in thyroid surgery: electrothermal bipolar vessel sealing system and harmonic scalpel

Accurate and efficient hemostasis is one of the first priorities of the thyroid surgeon to prevent or minimize complications, including injury to the laryngeal nerves or parathyroid glands, perioperative hemorrhage and the potentially life-threatening hematoma. Means to prevent and control intra- or postoperative bleeding therefore remain a topic of utmost importance. Although thyroidectomy is one of the most common surgical procedures, the safest, most efficient and cost-effective way to achieve hemostasis is debated by endocrine surgeons and otorhinolaryngologists. In our opinion, there is no substitute for meticulous surgical technique and hemostasis, while experience in such operations is essential for the best outcome with the fewest complications. Ties, suture-ligations, monopolar/bipolar diathermy, clips, and hemostatic agents/sealants or tissue adhesives have been used. Over the last 10 years, innovative hemostatic devices, such as the electrothermal bipolar vessel sealing system and ultrasonically activated shears, have been developed and have been welcome adjuncts to the thyroid surgeon's armamentarium. In this review we aim to cover both novel and well-established traditional techniques of hemostasis in thyroid surgery, with specific focus on the bipolar vessel sealer and harmonic scalpel.

The use of electrothermal bipolar vessel sealing system in minimally invasive video-assisted thyroidectomy (MIVAT)

PURPOSE

Options for controlling hemostasis during endoscopic thyroid surgery include vessel clips and ultrasonic technology. The aim of this study was to evaluate the use of the electrothermal bipolar vessel sealing system on the performance of minimally invasive video-assisted thyroidectomy (MIVAT).

METHODS

Between January 2006 and July 2007, 63 consecutive patients underwent MIVAT. The operative time, complications, and hospital stay were analyzed prospectively. As endoscopic instruments are important variables for incision length, the mini-incision was routinely measured at the end of the endoscopic procedure and compared with the initial standard approach (ie, 1.5 cm).

RESULTS

The mean operative time for lobectomy was 49.5 minutes (range, 39 to 120) and for total thyroidectomy 97.6 (59 to 130) minutes. No cases required conversion to open surgery and none involved significant intraoperative complications. Postoperative recovery was uneventful in all procedures. All patients were satisfied with the cosmetic results. At the end of the procedure, the mean length of the incision was not significantly increased.

CONCLUSIONS

This study showed that the utilization of electrothermal bipolar vessel sealing system for MIVAT is feasible and safe. A reduction of the rates for postoperative complications such as hypoparathyroidism and recurrent laryngeal nerve injuries was not possible to demonstrate in the present study.