Evaluation of a new ultrasonic device in thyroid surgery: comparative randomized study

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.

A comparison of harmonic and traditional sharp staphylectomy techniques in 15 brachycephalic dogs

OBJECTIVES

The objective was to compare sharp staphylectomy and staphylectomy using harmonic focus shears, assess surgical time, intraoperative haemorrhage and outcome. Our hypothesis was that harmonic staphylectomy would result in reduced surgical time, decreased intraoperative haemorrhage and greater relative improvement.

MATERIALS AND METHODS

Dogs that were presented to Highcroft Veterinary Referrals between July 2020 and September 2021 with brachycephalic obstructive airway syndrome and underwent surgical correction were prospectively enrolled. Surgical technique was randomised, and surgical time, staphylectomy time, intraoperative haemorrhage, hospitalisation and change in patients' Cambridge BOAS Grade at a 14-day recheck were recorded.

RESULTS

Fifteen dogs were enrolled: seven dogs underwent sharp and eight underwent harmonic staphylectomy. Nine patients returned for follow-up, four of seven and five of eight, respectively. Harmonic staphylectomy was associated with less haemorrhage (0 versus 9 cotton buds) and a shorter average staphylectomy time (3 minutes 36 seconds versus 14 minutes 50 seconds). No statistically significant differences were observed in total surgery time, number of nights hospitalised, or change in Cambridge BOAS Grade. An average of 0.68 mm of thermal necrosis was seen at the cut edges of soft palates removed by harmonic staphylectomy.

CLINICAL SIGNIFICANCE

Harmonic staphylectomy can result in a reduction in staphylectomy time and degree of intraoperative haemorrhage compared to sharp staphylectomy, with no deleterious impact on postoperative recovery or the long-term outcome of patients.

Ultrasonic scissors decrease postoperative bleeding complications in mastectomy: A retrospective multicenter cohort study on 728 patients

INTRODUCTION

The aim of this study was to evaluate the rate of postoperative bleeding complications (primary outcome) and any other surgical complications (secondary outcome) in mastectomy between two surgical instruments, ultrasonic SonoSurg® scissors (US) and traditional electrocautery (EC).

MATERIALS AND METHODS

In total 728 patients undergoing mastectomy in two adjacent university hospitals were retrospectively evaluated in terms of postoperative bleeding episodes, surgical site infections, skin flap necrosis, and any reoperations for 30 postoperative days. A propensity score matching was performed to acquire balanced groups. Patients consuming medications affecting hemostasis were excluded from the study. A multivariable logistic regression analysis was conducted to define the odds ratio (OR) for each complication separately. A cost analysis was performed.

RESULTS

The rate of postoperative bleeding complications was significantly lower in patients operated with US (0.3% vs 11.5%, OR 0.020, 95% CI 0.034-0.14) when compared to EC. The rate of surgical site infections (OR 0.65, 95% CI 0.35-1.23) was similar with both instruments, but there were less skin flap necroses (OR 0.35, 95% CI 0.13-0.98) in US group. For any reoperation, the OR for US was 0.13 (95% CI 0.046-0.39), mainly due to the lower number of acute bleeding complications. Even though the US instrument is more expensive than EC, the total cost of the treatment is lower in patients operated with US (3419 vs. 3475 euro).

CONCLUSIONS

US seems to be associated with a lower risk of bleeding complications in mastectomy.

Minimally invasive thyroid and parathyroid surgery: modifications for low-resource environments

Minimally invasive thyroidectomy (MIT) and parathyroidectomy (MIP) are gaining popularity in the current surgical practice. The need for specific equipment and technology is an obstacle in the low-resource environment. This article provides simple and practical guidance for surgeons practicing in low-resource environments to help them attain quality surgical practice, maintain patient safety, preserve available resources, and achieve the best outcomes.

A Novel Technique Using Ultrasonic Shears Versus Traditional Methods of Reduction of Bilateral Labia Minora Hypertrophy: A Retrospective Case-Control Study

INTRODUCTION

To compare the clinical outcomes of bilateral labia minora hypertrophy reduction using ultrasonic shears versus traditional methods.

MATERIALS AND METHODS

In this retrospective study, we evaluate the surgical outcomes of 11 women who underwent bilateral labia minora hypertrophy reduction using ultrasonic shears to 14 women who underwent the same procedure using various traditional methods between January 1, 2015 and February 29, 2020 in a single center. The primary outcomes evaluated are total operative time, estimated blood loss, and postoperative pain. Secondary outcomes include postoperative complications and total admission time. The statistical analyses used were exact Wilconxon Rank and Fisher's exact test.

RESULTS

25 total bilateral labiaplasty procedures were included in the analysis. 11 procedures were performed using ultrasonic shears and 14 were performed using traditional methods. The mean reduction operative time for the ultrasonic shears technique when compared with traditional methods was 43.25 minutes (22.82 minutes versus 66.07 minutes, P = .0002). A statistically significant but non-clinically significant difference in estimated blood loss was noted. No statistically significant differences existed with postoperative pain score, total admission time, or postoperative complications.

CONCLUSIONS

Ultrasonic shears significantly reduce the time needed for the reduction of bilateral labia minora hypertrophy and therefore should be considered by surgeons as a useful tool in increasing the efficiency of this procedure.

A longitudinal-torsional mode ultrasonic needle for deep penetration into bone

This work presents a longitudinal-torsional (L-T) composite mode ultrasonic needle device for deep bone penetration. The L-T needle is a geometrically modified version of an L-mode needle whose efficacy as a prototype ultrasonic bone biopsy device has been previously demonstrated by the authors. Finite element analysis (FEA) aided in the design of the L-T needle, with the aim of maximising the achievable torsional displacement while matching the longitudinal displacement achieved by the L-mode needle. Experimental modal analysis (EMA) of the fabricated ultrasonic device was used to identify the modal parameters and validate the FEA model. Harmonic analysis then provided an insight into how the inherent nonlinearities of the high-power transducer are affected by incorporating the geometrical features that degenerate the L mode into an L-T mode. High power characterisation shows that the longitudinal displacement amplitude of the L-T mode needle is larger than that of the L-mode needle. Comparative penetration tests in fresh Wistar rat skull were evaluated by investigating cell death and cell survival. The region of statistically significant cell death was small for both devices, with the combined axial and shear motion of the L-T device causing increased osteocyte necrosis within this region. Nevertheless, the results suggest a promising environment for post-operative healing. It is shown how this technology offers a potential technique for a surgical approach to the petrous apex, an application that requires a deep penetration into bone.

Association of Vessel-Sealant Devices vs Conventional Hemostasis With Postoperative Neck Hematoma After Thyroid Operations

Importance

Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied.

Objective

To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma.

Design, Setting, and Participants

This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups.

Main Outcomes and Measures

The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay.

Results

One-to-one propensity score matching yielded 6522 patients (mean [SD] age, 52 [15] years; 8544 [78.4%] female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001]) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24).

Conclusions and Relevance

Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.

A Novel Piezoelectric Ceramic Actuator with Scissoring Composite Vibration for Medical Applications

This paper presents a novel scissoring composite actuator which can successfully degenerate longitudinal vibration into scissoring vibration at actuator tips for potential medical applications. The proposed actuator consists of back mass, multilayer piezoceramic stack, front mass with netted pre-stress structure and beam. The actuator is driven by only a small axially poled multilayer piezoceramic stack. Moreover, a special symmetrical grooved structure is designed at the beam end to convert longitudinal driving vibration into opposite bending vibrations at the beam tip, resulting in scissoring-type composite vibration. The converted scissoring vibration concentrates on the beam tip without any deflection along other parts, which is highly desirable for narrow-spaced medical operations. The proposed design principle is demonstrated by structural analysis and verified by different types of finite element modeling (FEM) simulations, including Eigen frequency analysis, harmonic analysis, and transient analysis. The results reveal the design effectiveness of the actuator’s structure on scissoring-type mode excitation. Finally, a prototype of the proposed piezoelectric actuator is fabricated and tested, rendering superior performance and highly reliable mode conversion. The proposed actuator exhibits potential for advanced medical applications.

Evaluation of a Novel Wellness Assessment Device (Preventiometer): A Feasibility Pilot Study

Background

Periodic wellness assessments can provide an estimate of a person’s relative risks for major diseases, but wellness visits are underused. Our suggestion is to use a comprehensive device during a single visit.

Objective

The goal of this pilot study was to evaluate the feasibility of a novel one-stop wellness device (Preventiometer; iPEx5 GmbH, Greifswald, Germany) for performing multiple tests and providing a comprehensive wellness assessment in a short period.

Methods

A Preventiometer was used to provide wellness assessments for 10 healthy volunteers who then answered a 25-question survey to rate their satisfaction with the testing and their overall impression.

Results

All volunteers agreed or strongly agreed with the following: The assessment reports were easy to understand, the Preventiometer met their satisfaction, the participants were comfortable during the assessment, and all measurements and testing were well coordinated. Participants liked the instant test result feature. Most (90%) agreed that the machine was useful for a quick health assessment for busy people, and 70% felt that it was time efficient.

Conclusion

In this feasibility pilot study, the Preventiometer performed multiple tasks and provided a comprehensive wellness assessment in a short period. Participants reported remarkably high satisfaction with the tests. A larger study is needed to prove that this is a pragmatic approach to help individuals improve their health.

Comparing the safety of harmonic ACE and ACE+ around the recurrent laryngeal nerve in swine models

Purpose

Among the various energy-based devices, ultrasonic shears are popular in thyroid surgeries. In this study, we tested the safety of Harmonic ACE and Harmonic ACE+ around the recurrent laryngeal nerve (RLN) in experimental swine models.

Methods

Harmonic ACE and Harmonic ACE+ were each tested in 4 piglets. Harmonic ACE and Harmonic ACE+ were activated at a 0- to 5-mm distance from the RLN. The function of the RLN was assessed using continuous electrophysiological monitoring.

Results

For Harmonic ACE, there was no adverse EMG event found when activated at 4- and 5-mm distances from the RLN. At a 2- to 3-mm distance, there were 4 adverse EMG events observed. In these 4 cases, adjacent tissue shrinkage occurred after 6 to 15 seconds of activation, and the RLN touched the Harmonic ACE. At a 1-mm distance, there were 2 adverse EMG events found after 25 seconds of activation. For Harmonic ACE+, there was no adverse EMG event observed when activated at 1- and 3-mm distances from the RLN. At a 0-mm distance, 2 adverse EMG events occurred after 6 to 10 seconds of activation.

Conclusion

The safe distance of Harmonic ACE and ACE+ was 4 and 1 mm, respectively, in the swine models. Harmonic ACE+ is safer than Harmonic ACE because it did not cause any tissue shrinkage. Surgeons need to understand the characteristics of devices for safe operation.

Update on sutureless thyroidectomy

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.

Randomized clinical trial of ultrasonic scissors versus conventional haemostasis to compare complications and economics after total thyroidectomy (FOThyr)

Background

The benefits of single‐use ultrasonic scissors in thyroid surgery are still debated. Although this device has been shown to reduce operating time compared with conventional haemostasis, its cost‐effectiveness has never been demonstrated. The aim of this study was to evaluate the efficacy, cost‐effectiveness and safety of ultrasonic scissors for total thyroidectomy.

Methods

This was a prospective, randomized, multicentre trial conducted at 13 hospital sites. The primary endpoint was the percentage of patients with hypocalcaemia (serum calcium level below 2 mmol/l) on day 2. Secondary endpoints included postoperative complications and costs, with calculation of incremental cost differences and cost‐effectiveness ratios.

Results

In total, 1329 patients who underwent total thyroidectomy were included in the analysis: 670 were randomized to treatment with ultrasonic scissors and 659 to conventional haemostasis. There was no difference between groups in the rate of complications, including hypocalcaemia on day 2 (19^.7 per cent in ultrasonic scissors group versus 20^.3 per cent in conventional haemostasis group; P = 0·743). Median operating times were significantly shorter with ultrasonic scissors (90 versus 100 min with conventional haemostasis; P < 0·001). Total mean(s.d.) direct costs at 6 months were €4311(1547) and €4011(1596) respectively (P < 0·001).

Conclusion

Ultrasonic scissors were no more clinically effective than conventional haemostasis, but use of these devices was more costly. Registration number: NCT01551914 (http://www.clinicaltrials.gov).

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis

BACKGROUND

The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures.

METHODS

An extensive search was conducted using the PubMed and Cochrane databases from January 2008 to October 2014. Operating time, blood loss, pain, complications, and hospital stay were evaluated.

RESULTS

When compared with conventional techniques or LigaSure Precise Vessel Sealing System (Medtronic, Minneapolis, MN), the use of the Focus Harmonic scalpel reduced operative time by 22,428 minutes and blood loss by 13,914 mL. Length of hospital stay was significantly shorter in the Focus Harmonic scalpel group with a mean reduction of 0.410 days.

CONCLUSION

According to our meta-analysis, when comparing the Focus Harmonic scalpel versus conventional techniques, it seems evident that the use of this device in thyroid surgery is associated with a mean reduction in operating time, blood loss, and hospital stay, without any increase in pain and complications. There was no appreciable difference between the Focus Harmonic scalpel and the LigaSure Precise Vessel Sealing System. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1578, 2016.

Large-Vessel Sealing in Laparoscopic Colectomy with an Ultrasonic Device

BACKGROUND AND OBJECTIVE

The Harmonic ACE+7 Shears with Advanced Hemostasis Mode (Ethicon, Somerville, NJ, USA) is an ultrasonic device designed to transect and seal vessels up to 7 mm in diameter. The device applies an algorithm that optimizes ultrasonic energy delivery combined with a longer sealing cycle. The purpose of this study was to assess the initial clinical experience with the Harmonic device by evaluating large-vessel sealing during laparoscopic colectomy in consecutive cases.

METHODS

This prospective, multicenter, observational series involved 40 adult patients who were to undergo elective laparoscopic colectomy where dissection and transection of the inferior mesenteric artery was indicated. The primary study endpoint was first-pass hemostasis, defined as a single activation of the Advanced Hemostasis Mode to transect and seal the inferior mesenteric artery. The use of any additional energy device or hemostatic product to establish or maintain hemostasis was noted. Patients were observed after surgery for ∼4 weeks for adverse events that were considered to be related to the study procedure or study device. Descriptive statistical analyses were performed for study endpoints.

RESULTS

Forty patients underwent the laparoscopic colectomy procedure. First-pass hemostasis of the inferior mesenteric artery was achieved and maintained in all 40 patients, with no required additional hemostatic measures. Exposure of the vessel was reported as skeletonized in 22 of 40 (55%) patients. Mean transection time was 21.9 ± 7.4 s. One adverse event (postoperative anemia) was considered possibly related to the study device.

CONCLUSION

In this initial clinical consecutive series, the device demonstrated successful transection and sealing of the large mesenteric vessels during laparoscopic colorectal surgery.

Total thyroidectomy: Conventional Suture Ligation technique versus sutureless techniques using Harmonic Scalpel or Maxium

Objectives

Harmonic Scalpel (HS) and Maxium (MAX) are surgical shears that enable simultaneous vessel sealing and tissue coagulation. This study compares the outcome of Total Thyroidectomy (TT) using Conventional Suture Ligation (CSL) technique versus (vs) two sutureless techniques; H S and MAX techniques in terms of safety, operative time, blood drainage volume, hospital stay and surgical complications.

Study design

This is a prospective observational cohort study.

Setting

This study was performed in AL-Karama Teaching Hospital/College of Medicine/University of Wasit/Iraq.

Patients and methods

This study was performed from June 2012 to 2015. A total of 80 patients, 60 patients were females and 20 patients were males (average/mean of age was 39/38 years). They underwent TT after been randomized into the following three groups: CSL group when Suture Ligation Technique was used, HS group when Harmonic Scalpel was used and MAX group when bipolar electrosurgery Maxium was used.

Results

The postoperative evaluation of operative time, blood drainage volume and surgical complications revealed no statistically significant differences between HS group & MAX group, but there were statistically significant differences between CSL group vs. HS and MAX groups. Operative time statistics showed significant differences between CSL vs. HS and MAX groups, 113 ± 10.9 minutes (min), 93 ± 13 min and 92 ± 10.6 min respectively, p-value < 0.001 and 95% confidence interval [CI] (92.3712, 101.6288). The postoperative blood drainage volumes were significantly different between the three groups: CSL group = 150 ± 12.7 ml, HS group = 89 ± 16.21 ml and MAX group = 118 ± 9.6 ml, P-value = 0.046 and 95% [CI] (89.9932, 99.6068).

Conclusions

HS and MAX are safe, effective, and time-saving techniques. They are also associated with low blood loss and low complication rates. HS and MAX are good alternative techniques to CSL for thyroid surgery.

•

HS and MAX are safe useful and fast alternatives to conventional techniques in total thyroidectomy.

•

These two devices facilitate surgical procedures and cancel any need for clips and suture ligations.

•

They significantly reduce operative time without increases in the amount of blood losses and hospital stay.

•

Probably the only disadvantage of these two devices is the cost of the single-use devices.

Complications in thyroid surgery. Harmonic Scalpel, Harmonic Focus versus Conventional Hemostasis: A meta-analysis

BACKGROUND

To evaluate the incidence of postoperative complications, hemostatic effects and safety of Total Thyroidectomy (TT) performed using the Harmonic Scalpel (HS), the Harmonic Focus (HF) or Conventional Hemostasis (CH).

METHODS

The meta-analysis was performed according to PRISMA guidelines. A literature search was conducted from 2003 to 2014 and stringent criteria were required for inclusion. Thirteen studies concerning an overall population of 1458 compared HS versus CH, whilst 8 studies with 1667 patients compared HF versus CH.

RESULTS

There was a significant reduction of operative time (Mean Difference [MD] = -25.49 min.; 95% CI -32.43 to -18.55), intraoperative blood loss (MD = -30.49 mL; 95% CI -53.01 to -7.97), postoperative drainage volume (MD = -12.90 mL; 95% CI -22.83 to -2.98) and postoperative pain (MD = -0.87; 95% CI -1.27 to -0.46) in patients underwent TT with HS. Regarding HF group, a significant reduction of operative time (MD = -25.99 min., 95% CI -34.56 to -17.41), length of hospital stay (MD = -0.57; 95% CI -0.97 to -0.17), transient hypocalcemia (OR = 0.56; 95% CI 0.39 to 0.81) and postoperative pain (MD = -1.33 days; 95% CI -2.49 to -0.17) resulted.

CONCLUSIONS

HS TT can be a safe, useful and fast alternative to conventional TT. The newer HF can reduce the rate of hypocalcemia. Future RCTs of larger patient cohorts with more detailed data of postoperative complications, cost-effectiveness and cosmetic results, randomization procedures, intention-to-treat analyses and blinding of outcome assessors are needed to draw more meaningful conclusions.

A systematic review and meta-analysis of Harmonic Focus in thyroidectomy compared to conventional techniques

Introduction

Several meta-analyses have been performed comparing the use of a variety of ultrasonic devices in thyroidectomy to conventional procedures. These studies have shown the superiority of ultrasonic devices for most outcomes studied including faster operative time and less blood loss, and equivalent or better safety for recurrent laryngeal nerve paresis and hypocalcemia. The current work is the first to examine a single ultrasonic device specifically designed for thyroid surgery, the Harmonic Focus, in order to confirm its efficacy and safety in thyroidectomy.

Methods

A comprehensive literature search without language restrictions was performed for randomized clinical trials comparing Harmonic Focus and conventional clamp, cut and tie in thyroidectomy. Outcome measures included operating time, blood loss, post-operative pain, length of hospital stay, hypocalcemia and recurrent laryngeal nerve paresis. Risk of bias was analyzed for all studies. Meta-analysis was performed using random effects models with the inverse-variance method for mean differences of continuous variables and the Mantel-Haenszel method for risk ratios of dichotomous variables.

Results

A total of 14 studies met the inclusion criteria. Harmonic Focus reduced operative time by 29 min, a 31 % decrease (p < 0.001), intra-operative blood loss by 45 ml (p < 0.001), post-operative pain (p < 0.001), length of hospital stay by 0.68 days (p = 0.005), drainage volume by 29 ml (p = 0.01), and occurrence of transient hypocalcemia by 40 % (p = 0.001). There were no significant differences between Harmonic Focus and conventional procedures in rate of persistent hypocalcemia, or rates of transient and persistent recurrent laryngeal nerve paresis.

Conclusion

This is the first meta-analysis of Harmonic Focus in thyroid surgery. In agreement with meta-analyses previously performed on ultrasonic devices, use of the Harmonic Focus has been shown to be a more effective surgical procedure compared to conventional methods in thyroidectomy. The low occurrence of hypocalcemia and recurrent laryngeal nerve paresis confirms that Harmonic Focus can improve thyroidectomy efficiency without increasing the risk of complications.

Recurrent laryngeal nerve safety parameters of the Harmonic Focus during thyroid surgery: Porcine model using continuous monitoring

OBJECTIVES/HYPOTHESIS

The Harmonic Focus (HF) is one of the most popular energy-based devices. The aim of this study was to provide recurrent laryngeal nerve (RLN) functional data that define the safety parameters of the HF during thyroidectomy.

STUDY DESIGN

Prospective porcine model using continuous electrophysiologic monitoring.

METHODS

Ten piglets were used. At varying distances from the RLN, the HF was activated (activation study). The HF was also applied directly on the RLN after activation on sternocleidomastoid muscle for 10 seconds with different cooling times (cooling study).

RESULTS

In the activation study, there was no adverse electromyography (EMG) event at more than 1 mm distance. In the cooling study, there was no adverse EMG event after a 10-second cooling period. When the HF was cooled on the sternocleidomastoid muscle, there was no adverse EMG event after 2 seconds cooling time.

CONCLUSIONS

The safe distance of the HF was 1 mm, and it should be cooled for more than 10 seconds or 2 seconds after cooling on muscle. The HF should be used in a standardized manner to avoid RLN injury.

LEVEL OF EVIDENCE

NA.

Harmonic curved shears system prevent of bile leakage after liver resection in a pig model

We evaluated the efficacy of TachoComb (TC) collagen fleece and Harmonic Focus (HF) shears in a pig liver resection model. Pigs were divided into 3 groups of 7, in which vessels were tied with silk and TC was applied to the cut surfaces (Silk+TC group), sealed and sheared with HF and TC (HF+TC group), or sealed using HF alone (HF-TC group). After 1 month, we conducted a histologic evaluation and recorded the incidence of bile leakage with infected collections at the liver cut surface. Six pigs were evaluated in each group. In the Silk+TC group, 4 of the 6 pigs had infected collections at the cut surface. Histologically, the silk had remained under the fibrotic tissue, which contained remnants of TC fragments. In the HF+TC group, 5 of the 6 pigs also had infected collections, and histologically, TC had remained in the hard fibrotic tissues. In the HF-TC group, none of the 6 pigs had infected collections, and the histologic findings were normal. Use of the HF alone may be an effective method for preventing bile leakage in infected collections after liver resection.

Sutureless thyroidectomy

OBJECTIVE

The ultrasonic scalpel is a surgical shear that uses high-frequency mechanical energy to enable simultaneous vessel sealing and tissue coagulation at the same time. We conducted a prospective study to compare the outcome of total thyroidectomy using the ultrasonic scalpel versus the device Ligasure in terms of safety, operative time, overall drainage volume, complications, hospital stay.

METHODS

Between January 2008 and December 2013,400 patients (260 women, 140 men; mean age 46 years) undergoing thyroidectomy were randomized into two groups: group A, where Ultracision were used, and group B, where the Ligasure device was used.

RESULTS

There was no significant differences between the two groups in terms of age, gender, indication for thyroidectomy, thyroid gland weight and diameter, histopathologic diagnosis, preoperative and postoperative serum calcium levels, postoperative complications and reoperative thyroid surgery, time of operation and amount of drainage.

CONCLUSIONS

The ultrasonic scalpel and the Ligasure ares safe, effective, useful, and time-saving alternative to the traditional suture ligation technique for thyroid surgery. They simplified total thyroidectomy, eliminating the need for clamp-and-tie maneuvers while achieving efficient hemostasis.

ENERgized vessel sealing systems versus CONventional hemostasis techniques in thyroid surgery--the ENERCON systematic review and network meta-analysis

PURPOSE

Energized vessel-sealing systems have been proposed to save operation time and reduce post-operative complications. The aim of the present systematic review was to compare operation time and postoperative morbidity for ultrasonic and electrothermal bipolar-activated devices with conventional hemostasis techniques and with each other in open thyroidectomy.

METHODS

A systematic literature search (MEDLINE, Cochrane Library, EMBASE and ISI Web of Science) was performed to identify randomised controlled trials (RCTs) comparing conventional hemostasis techniques, ultrasonic devices (Harmonic® scalpel) and/or electrothermal bipolar-activated vessel sealing systems (Ligasure®) during open thyroidectomy. For the primary endpoint (operation time), a network meta-analysis with Bayesian random effects model was performed. Pairwise meta-analyses with random effects were calculated for primary and secondary endpoints.

RESULTS

One hundred sixteen publications were evaluated for eligibility; 35 RCTs (4,061 patients) were included. There was considerable methodological and clinical heterogeneity of included trials. The Harmonic scalpel significantly reduced operation time compared with conventional techniques (22.26 min, 22.7 min in the inconsistency model). The use of Ligasure significantly reduced operation time in total thyroidectomy (13.84 min in the consistency model, 12.18 min in the inconsistency model). In direct comparison, operations with the Harmonic scalpel were faster than with Ligasure (8.42 min in the consistency model, 2.45 min in the inconsistency model). The rates of recurrent nerve palsy and postoperative hypocalcaemia did not significantly differ in the intervention groups.

CONCLUSIONS

This meta-analysis shows superiority of ultrasonic devices in terms of operation time compared with conventional hemostasis techniques in thyroid surgery, with no detriment to safety outcomes.

Ultrasonic dissection system technology in breast cancer: a case-control study in a large cohort of patients requiring axillary dissection

In the sentinel node era, axillary dissection (ALND) for breast cancer (BC) is required much less frequently than in the past. However, complications, such as prolonged drainage output and seroma formation, are still observed. Harmonic dissection devices (HDDs) are widely used in laparoscopic and minimally invasive surgery to reduce collateral damage during tissue dissection, but its usefulness in breast surgery is unclear. The aim of this study was to evaluate the efficacy of HDDs compared to that of conventional dissection in performing ALND. One hundred thirty-nine women (median age 61 years, range 34-71 years) with confirmed pT1-2 primary infiltrating ductal BC undergoing curative surgery were enrolled in the study. The population was prospectively randomized between two age- and stage-matched arms: group A (cases)-68 (48.9 %) patients (HDD technique), versus group B (controls)-71 (51.1 %) patients (conventional technique). In group B, skin flaps were obtained using a scalpel, scissors, and electrocautery which was never used for ALND. In group A, for each operation time, the HDDs were used exclusively. The mean operative time, intraoperative blood loss, and drainage output were (A vs. B) 95 ± 22 versus 109 ± 25 min, 56 ± 12 versus 86 ± 15 mL, and 412 ± 83 versus 456 ± 69 mL, respectively (p < 0.01). Twenty-nine (20.9 %) patients developed an axillary seroma: 9 (13.2 %) and 20 (28.2 %) for groups A and B, respectively (p = 0.030). Our study confirms that in patients with BC requiring ALND the use of HDDs is more time efficient than conventional surgery, and reduces intraoperative bleeding, the amount of drainage, and the risk of seroma formation. These results may lead to several short- and long-term advantages. Thus, a careful evaluation of the cost-benefits of nontraditional tools, such as HDDs, should be performed in all patients undergoing modified radical or partial mastectomy and ALND for BC.

Health technology assessment and thyroid surgery

The growth of technological innovation, the request for assistance, the rising patient's expectations and the interest of the industry have led to a rise in the cost of health care systems. In this context the role of the National Health System is not to delay the development or adoption of new technologies, but rather to drive the development selecting priorities and promoting its use. Health Technology Assessment (HTA) is a multidisciplinary and multidimensional approach for analyzing the medical-clinical, social, organizational, economic, ethical and legal implications of a technology (devices, drugs, procedures) through the assessment of multiple parameters such as effectiveness, safety, costs of the social and organizational impact. A health technology assessment is a comprehensive, systematic evaluation of the prerequisites for estimating the consequences of using health technology. Main characteristic of HTA is that the problem is tackled using an approach focused on four main elements: - technology; - patient; - organization; - economy. The authors have applied the HTA method for the analysis of the ultrasonic focus dissector on thyroid surgery. They compared the cost of the surgical procedure using the ultrasonic dissector and without it in a case study of 440 patients who underwent thyroidectomy.

Which hemostatic device in thyroid surgery? A network meta-analysis of surgical technologies

BACKGROUND

Energy-based hemostatic devices are increasingly being used in thyroid surgery. However, there are several limitations with regard to the existing evidence and a paucity of guidelines on the subject. The goal of this review is to employ the novel evidence synthesis technique of a network meta-analysis to assess the comparative effectiveness of surgical technologies in thyroid surgery and contribute to enhanced governance in the field of thyroid surgery.

METHODS

Articles published between January 2000 and June 2012 were identified from Embase, Medline, Cochrane Library, and PubMed databases. Randomized controlled trials of any size comparing the use of ultrasonic coagulation (harmonic scalpel) or Ligasure either head-to-head or against the "clamp-and-tie" technique were included. Two reviewers independently critically appraised and extracted the data from each study. The number of patients who experienced postoperative events was extracted in dichotomous format or continuous outcomes. Odds ratios were calculated by a Bayesian network meta-analysis, and metaregression was used for pair-wise comparisons. Indirect and direct comparisons were performed and inconsistency was assessed.

RESULTS

Thirty-five randomized controlled trials with 2856 patients were included. Ultrasonic coagulation ranked first (followed by Ligasure and then clamp-and-tie) with the lowest risk of postoperative hypoparathyroidism (odds ratio 1.43 [95% confidence interval (CI) 0.77-2.67] and 0.70 [CI 0.43-1.13], ultrasonic coagulation vs. Ligasure and ultrasonic coagulation vs. clamp-and-tie, respectively), least blood loss (-0.25 [CI -0.84 to -0.35] and -1.22 [CI -1.85 to -0.59]), and drain output (0.28 [CI -0.35 to -0.91] and -0.36 [CI -0.70 to -0.03]). From a health technology viewpoint, ultrasonic coagulation was associated with the shortest operative time (-0.66 [CI -1.17 to -0.14] and -1.29 [CI -1.59 to -1.00]) and hospital stay (-0.28 [CI -0.78 to 0.22] and -0.56 [CI -1.28 to 0.15]). The only exception occurs with the clinically important complication of recurrent laryngeal nerve paralysis, where the reverse trend applies (1.36 [CI 0.25-7.46] and 1.74 [CI 0.94-3.26]).

CONCLUSIONS

The comparative effectiveness of ultrasonic coagulation in thyroid surgery outcomes seems superior to other techniques with the exception of recurrent laryngeal nerve injury. This network meta-analysis, one of a handful in a surgical field, offers preliminary and robust evidence to guide clinical decisions and policy makers to adopt safer thyroid operations.

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.

Ultrasonic scalpel for gastric cancer surgery: a prospective randomized study

BACKGROUND

The aim of the study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in gastric cancer surgery.

METHODS

Patients with resectable adenocarcinoma of the stomach were randomly assigned to ultrasonic scalpel or conventional technique. We used the HARMONIC FOCUS (Ethicon Endo-Surgery, Inc.) as ultrasonic scalpel.

RESULTS

Between February 2010 and December 2010, 60 patients with resectable gastric cancer were enrolled into the study. Operative time was significantly shorter with the ultrasonic arm than with the conventional arm (median 238.5 vs. 300.5 min; P = 0.0004). Blood loss was also significantly lower in the ultrasonic arm than in the conventional arm (median 351.0 vs. 569.5 ml; P = 0.016). Clavien-Dindo grades of postoperative complications were similar in the two groups. From a questionnaire survey of operators, the ultrasonic scalpel significantly reduced the stress of lymph node dissection (3.67 vs. 2.87; P = 0.0006). However, in assisting surgeons, the contributions to surgery, study, and technical improvement of the ultrasonic group were lower than in the conventional group.

CONCLUSIONS

This study shows that the ultrasonic scalpel is a reliable and safe tool for open gastric cancer surgery.

Parathyroid function after open thyroidectomy: A prospective randomized study for ligasure precise versus harmonic FOCUS

BACKGROUND

Options for controlling hemostasis during thyroidectomy include bipolar vessel sealing system and ultrasonic technology. The purpose of this study was to compare these energy-based devices on the performance of open thyroidectomy for benign disease with emphasis given to postoperative parathyroid function.

METHODS

Among the available energy-based devices, the LigaSure Precise (LP; Valleylab, Boulder, CO) and FOCUS Shears (FS; Ethicon Endo-Surgery, Cincinnati, OH) were evaluated. One hundred ninety-nine consecutive patients scheduled for open thyroidectomy were prospectively randomized into 2 similar-sized groups. Operative time, morbidity, incision length, postoperative pain, and hospital stay were analyzed. Postoperative hypoparathyroidism was monitored with serial determinations of intact parathyroid hormone (iPTH) and serum calcium.

RESULTS

Early postoperative measurement of iPTH plasma level, although within the reference range, was significantly lower in the FS group (p < .001). Oral calcium supplementation was significantly higher and prolonged in the FS group.

CONCLUSION

The present study demonstrates a significant difference of the rates for postoperative parathyroid malfunction when using different energy-based devices.

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.

Harmonic focus in total thyroidectomy plus level III-IV and VI dissection: a prospective randomized study

The aim of this study was to compare operating time, postoperative outcomes, and surgical complications of total thyroidectomy plus level III-IV and VI dissection between the no-tie technique using the Harmonic Focus and classic suture ligation for hemostasis. Fifty-four patients underwent total thyroidectomy plus level III-IV and VI dissection by classic suture ligation and 51 patients by the Harmonic Focus. There was obvious distinction as to the operating time between the Focus and classic group (102.8 and 150.1 minutes, respectively, P < 0.05). Drainage volume (202.7 ± 187.0 mL vs 299.7 ± 201.4 mL, P < 0.05) were significantly lower in the Focus group. Transient hypoparathyroidism had no statistically significant difference between the groups (17.6% vs 18.5%, P > 0 .05). No patient experienced nerve injury or permanent hypocalcemia. The use of Harmonic Focus for the control of thyroid vessels during thyroid surgery is reliable and safe. The device can offer extraordinary capabilities for delicate tissue grasping and dissection.