Ultracision reduces acute blood loss but not seroma formation after mastectomy and axillary dissection: a pilot study

A Comparative Study of Harmonic Scalpel Versus Electrocautery Dissection in Modified Radical Mastectomy in Breast Carcinoma Cases

AIM

This study aimed to compare the outcomes of modified radical mastectomy (MRM) with the use of a harmonic scalpel versus electrocautery in patients with breast carcinoma.

METHODOLOGY

A prospective, non-randomized comparative study conducted from August 2022 to June 2024 on 40 female patients with stage II breast carcinoma undergoing MRM with electrocautery and harmonic scalpel.

RESULTS

Patients with MRM by harmonic scalpel exhibited significantly lower intraoperative blood loss (92.50 ± 9.67 mL) than by electrocautery (172.50 ± 30.76 mL) (p-value <.0001). The average operative time was significantly shorter for the harmonic scalpel (111.00 ± 10.71 minutes) than for the electrocautery (169.50 ± 19.32 minutes) (p-value <.0001). Postoperative pain was lower for the harmonic scalpel (visual analog scale (VAS) score 3.75 ± 0.79) than for the electrocautery (VAS score 6.10 ± 0.85) (p-value <.0001). The incidence of flap necrosis was not substantially different between the categories; seroma formation was significantly lower with the use of a harmonic scalpel (p-value <.0001). Subjects in the group of harmonic scalpels also had shorter hospital stays (8.35 ± 0.93 days) compared with the electrocautery group (12.20 ± 1.06 days) (p-value <.0001).

Comparison of Intraoperative and Postoperative Outcomes With Skin Flaps Raised Using Either Harmonic Scalpels or Electrocautery During Modified Radical Mastectomy

BACKGROUND

Breast cancer is one of the most common malignancies in women. Hence, its treatment has become our utmost priority in developing countries like India. Modified radical mastectomy (MRM) has traditionally been used as the standard of care for early-stage invasive breast carcinoma and still is the most commonly used surgical treatment for carcinoma breast.

AIM

The study compared the incidence of intraoperative and postoperative outcomes with skin flaps raised using a harmonic scalpel versus those raised using electrocautery.

METHODS

Sixty women with biopsy-proven breast cancer who had to undergo MRM were randomly assigned to undergo skin flap raising during mastectomy by using electrocautery or harmonic scalpel. Thirty patients had surgery with electrocautery (Group 1) and 30 with a harmonic scalpel (Group 2) by the same surgical team.

RESULTS

The mean operative time was significantly longer with harmonic scalpel when compared to that with electrocautery (140.67 ± 28.55 vs. 122.00 ± 19.16 mins, P =0.004). The amount of intraoperative blood loss (178.33 ± 21.06 vs 138.50 ± 28.53 mL P = 0.001) was less in the group operated with the harmonic scalpel, which was statistically significant. There was no significant difference between the groups regarding total drainage content (310.83 ± 88.93 vs 298.20 ± 127.87 mL, P = 0.659), drain duration (6.83 ± 0.75 vs 7.43 ± 2.27 days, p=0.174), seroma (3.3% vs. 0%) wound infection (3.3% vs 0%), flap necrosis (16.7% vs. 3.3%, P = 0.195), duration of hospital stays (8.57 ± 0.77 vs 8.43 ± 1.61 days, p=0.684).

CONCLUSION

Harmonic scalpels have a few advantages over electrocautery, but are not cost-effective.

Latissimus dorsi seroma prevention with running quilting suture using barbed suture

Dorsal seroma is a common complication of autologous latissimus dorsi flap (ALDF) in breast reconstruction, and has limited the use of this technique, despite its aesthetic success. It is important to find a right technique to limit the incidence of seroma formation after ALDF. The aim of this study was to evaluate the effectiveness and tolerance of a dorsal quilting technique called "running quilting" using barbed resorbable suture in seroma prevention. Three hundred patients who underwent ALDF breast reconstruction in the period between 2004 and 2014 were included in this study. The population was divided in 3 groups; without quilting, with simple quilting suture, and with running quilting using barbed suture. The incidence of small seromas (requiring 1 or 2 aspirations during routine postoperative visits without adding additional appointments to the follow-up routine) was not significantly decreased: it was 54% in the non-quilted group, 47% in group 2 Quilting, and 34% in group 3 running quilting. However, quilting reduced the duration of drainage, and the rate of late seromas (from 8% to 0%), and chronic sero-hematomas completely disappeared in our experience. Running quilting using barbed suture is highly effective in preventing late and refractory donor-site seromas. Its effectiveness is expected to increase the use of ALDF in breast reconstruction, which we consider currently as one of the best autologous reconstruction techniques.

Is Using the Harmonic Scalpel Better than Conventional Hemostasis in Neck Dissection? A Meta-Analysis

Study Design

Systematic review and meta-analysis.

Objective

The clinical decision to pursue harmonic scalpel (HS) method vs conventional hemostasis to treat head and neck cancers has been arguably predicated on the clinical outcomes observed. This study aims to evaluate the surgical outcomes of neck dissection between both techniques and perform an updated meta-analysis using the available literature.

Methods

We searched PubMed, Scopus, and Cochrane Library through 31st December 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcome metrics included operative time and intraoperative blood loss. Secondary outcomes consisted of length of hospital stay, length of drain stay, total drain output, and postoperative complications. A meta-analysis was conducted using Review Manager Version 5.3 (RevMan) software employing the Random Effects Model.

Results

We identified 114 articles, out of which 10 randomized control trials (RCTs) analyzing a combined total of 558 patients met the inclusion criteria after title and full-text screening. Meta-analysis shows the group treated with HS had a significantly shorter operative time. [MD = -23.21, 95% CI (-34.30, -12.12) P value <.0001 I2 = 92%] but an insignificant lesser intraoperative blood loss [MD = -61.53, 95% CI (-88.61, -34.45) P < .00001 I2 = 79%].

Conclusions

This study confirms that that HS use in neck dissection yields a reduced operative time and intra operative blood loss relative to conventional hemostasis. Furthermore, our paper shows no superiority of HS method over conventional hemostasis where length of hospital stays, length of drain stays, and postoperative complications are concerned. Future RCTs with high-level evidence may further elucidate the relative effectiveness of HS method over conventional hemostasis in treating head and neck cancers.

Surgical Advantage of Ultrasonically Activated Devices During Axillary Lymph Node Dissection for Breast Cancer

Purposes

Axillary dissection is the gold standard for axillary lymph node metastasis in breast cancer patients. We compared surgical outcomes between ultrasonically activated devices (USADs) and thermal scalpel (TS) during axillary lymph node dissection in breast cancer patients.

Methods

We conducted a retrospective analysis for 73 patients using TS between June 2012 to May 2016 and 63 patients using USADs between June 2016 to January 2019 in the breast cancer patients who received axillary dissection. Surgical outcomes were compared among the groups statistically.

Results

Median operative time in the USAD group was significantly shorter than in the TS group (136 versus 182 minutes, P &lt; 0.001). Intraoperative blood loss in the USAD group was also significantly lower than in the TS group (35 versus 120 mL, P &lt; 0.001). Furthermore, the total drainage discharge in the USAD group was also significantly lower than in the TS group (570 versus 700 mL, P = 0.016). The lymphedema frequency in the USAD group was significantly less than in the TS groups (1 of 63 versus 7 of 73, P = 0.0296).

Conclusion

The USADs could improve surgical outcomes, such as lymphedema, for axillary dissection of the breast cancer surgery compared with TS.

Current practice patterns of society of urologic oncology members in performing inguinal lymph node staging/therapy for penile cancer: A survey study

OBJECTIVES

Inguinal lymph node (ILN) staging and therapeutic procedures are important for the diagnosis and management of suspected Inguinal lymph node metastasis in the setting of penile cancer. Morbidity associated with inguinal lymph node dissection (ILND) and the lack of standardization in its perioperative management are both significant. In this study, we aimed to define current management approaches and potential opportunities for improving outcomes.

METHODS AND MATERIALS

A questionnaire was developed with 16 questions regarding pre, peri, and postoperative management of patients undergoing ILND. The questionnaire was approved by the Society of Urologic Oncology (SUO) Questionnaire Committee, which facilitated its dissemination through an initial email and a follow-up reminder to 1,003 members. The study was conducted from July to August, 2020.

RESULTS

Of the 1,003 SUO members invited to participate, 93 responded (9.3% response rate); 49% performed 1 to 2 ILNDs annually, and 60% chose open ILND for high-risk primary cancer cN0. For suspicious lymph nodes > 2 cm, 69% preferred ILND, 86% preoperative systemic neoadjuvant chemotherapy, followed by surgery for bulky inguinal metastasis, and 84% used perioperative antibiotics (ABX), 53% of whom discontinued ABX 24 hours after surgery. Prophylactic anticoagulation was used by 78% of respondents, and 60% stopped it after ambulation. Specific ligation of lymphatics (versus none) was used by 82% of respondents, 55% obtained frozen sections, and 94% used inguinal drains. A saphenous sparing technique was used by 75% of respondents. An incisional wound vacuum device was used by 17% of respondents. Compression stockings and/or referral to a lymphedema specialist were used to manage postoperative lymphedema by 61% of respondents.

CONCLUSIONS

Responses to a penile lymphadenectomy survey were relatively low and were primarily from the academic surgeon subset of the SUO. Significant consensus ( ≥ 70%) was noted for neoadjuvant chemotherapy for bulky nodal metastasis prior to surgery, perioperative antibiotic use, ligation of lymphatics, drain placement, and saphenous sparing dissection techniques. Other evidenced-based strategies that could decrease morbidity were rarely used, including dynamic sentinel node biopsy, incisional wound vacuums, and lymphedema prevention. Prospective trials are needed to validate and resolve existing treatment paradigms and to optimize perioperative pathways to reduce complications in penile cancer management.

A Prospective Randomised Controlled Study Comparing Ultrasonic Dissector with Electrocautery for Axillary Dissection in Patients of Carcinoma Breast

Background

Axillary dissection is one of the important components of modified radical mastectomy (MRM). The present study was conducted to compare surgical outcomes by using monopolar electrocautery and ultrasonic dissector for axillary dissection in MRM.

Methods

A parallel randomised controlled single blinded study was conducted with a sample size of 70 patients who were randomised into two groups. One group underwent MRM using ultrasonic dissector (Group A) and the other one using electrocautery (Group B). Intra- and post-operative outcomes were compared.

Results

Group A had an average operating time of 30.86 min, which was statistically less than that of Group B. The mean mop count and the daily drain output in Group A were less as compared to Group B and the differences were statistically significant. Drain was removed early in Group A as compared to Group B. However, post-operative pain scores and seroma formation were not statistically significant among the two groups.

Conclusion

Ultrasonic dissector group had significantly lesser intra-operative bleeding, operating time and post-operative drain output when compared to electrocautery group. However, the two groups had no significant difference in post-operative pain scores and seroma formation.

The use of ultrasonic scalpel lowers the risk of post-mastectomy seroma formation in obese women

Introduction: Seroma formation (SF) is the most common postoperative complication after mastectomy and axillary surgery. The aim of this study was to assess its incidence and risk factors following a modified radical mastectomy in breast cancer patients.

Materials and methods: 271 patients who underwent a modified radical mastectomy (250 with traditional electrocautery and 21 with an ultrasonic scalpel) were studied. The SF rate was calculated and its association with patient-related factors, surgical features and postoperative variables was assessed and statistically analyzed with P<0.05 as a significance threshold.

Results: SF was observed in 18% of patients. Patient's age, operating time and number of removed axillary lymph nodes did not significantly differ between SF and non-SF patients. Patients BMI, total drainage amount, number of days with drain were higher and postoperative hospital stay was significantly longer in SF patients (P<0.001 each). The dissection instrument was also an important risk factor: SF developed in 20% of patients operated with electrocautery and in none with an ultrasonic scalpel (P<0.05). The association between surgical instrument and the number of removed lymph nodes, patient's age and BMI was not significant. Dissection with an ultrasonic scalpel resulted in a statistically significant lower total drainage amount. However, it was also related to a significantly longer operating time (P<0.001 each).

Conclusions: Risk of SF after a modified radical mastectomy is significantly higher in patients with obesity. Despite longer operating time, using an ultrasonic scalpel is a valuable option in those cases because it lowers the total drainage amount and seems to be an important protective factor against SF.

Advanced hemostasis in axillary lymph node dissection for locally advanced breast cancer: new technology devices compared in the prevention of seroma formation

Background

Breast cancer is the most frequent neoplasm in women. Axillary lymph nodes dissection represents the treatment of choice in locally advanced breast cancer for prognostic and curative purposes. Seroma formation, an abnormal collection of fluid in the dead space of the axilla, is described in Literature with a wide range of incidence (3–85%). It is a source of significant morbidity and discomfort. The aim of the study is to compare the different haemostasis devices used in breast surgery, investigating the eventual superiority of an instrument among the others in terms of intraoperative and postoperative outcome, especially of seroma formation.

Methods

Clinical cases of female patients undergone axillary lymph nodes dissection for local advanced breast cancer between January 2013 and July 2017 at the Surgery Unit of University of Campania “Luigi Vanvitelli” were retrospectively reviewed. Patients were divided into four groups, according to device utilized during surgery: Electrocautery, Harmonic Scalpel, LigaSure and Thunderbeat. All patients underwent II level axillary lymph nodes dissection associated to radical mastectomy or quadrantectomy.

Results

One hundred consecutives patients were enrolled in the study. Intra-operative blood loss resulted statistically significant different (P < 0,01) between the Electrocautery group (94,7 ml) and the Thunderbeat group (57,2 ml), while the Harmonic Scalpel group and the Ligasure group, despite presented a lower amount of blood loss, did not differ significantly. Drainage volume resulted significantly lower (P = 0,002) in the comparison between the Electrocautery group and the Thunderbeat group; the Ligasure group and Harmonic Scapel group showed no difference between them and Electrocautery group. About the seroma formation, the Electrocautery group resulted affected by the highest seroma formation rate (64%). Seroma incidence in Harmonic Scalpel group was 24%, in Ligasure group was 44%, while Thunderbeat group showed the lowest presentation of seroma with 16%.

Conclusions

In patients affected by breast cancer requiring axillary lymphnodes dissection, the use of advanced hemostasis devices is highly desirable. Among the non-traditional tools, Thunderbeat resulted to be superior in terms of reduction of intra-operative blood loss and post-operative drainage output, moreover associated to a substantial reduction of postoperative seroma incidence.

Comparison of harmonic scalpel and conventional technique in the surgery for breast cancer: A systematic review and meta-analysis

BACKGROUND

Harmonic scalpel is considered as a promising surgical tool for breast cancer, while its advantage over conventional approach is still controversial. Therefore, we performed this meta-analysis to compare the outcomes of harmonic scalpel and conventional tools in the surgery for breast cancer.

MATERIALS AND METHODS

Studies reporting the outcomes of harmonic scalpel and conventional technologies were systematically searched from online databases, PubMed and EMBASE up to April 30, 2018. Data were presented as odds ratio, risk ratio (RR), and mean difference (MD) with 95% confidence interval (CI).

RESULTS

Intraoperative blood loss (I² = 96%, P < 0.05, MD = -68.78, 95% CI -93.31 to -44.24), seroma (I² = 3%, P = 0.41, RR = 0.63, 95% CI 0.46-0.86) and hematoma formation (I² = 0%, P = 0.64, RR = 0.41, 95% CI 0.23-0.73), drainage volume (I² = 89%, P < 0.05, MD = -105.33, 95% CI -161.33 to -49.33) and time (I² = 93%, P < 0.05, MD = -2.18, 95% CI -3.75 to -0.61), necrosis (I² = 35%, P = 0.20, RR = 0.37, 95% CI 0.16-0.86), surgical duration (I² = 79%, P < 0.05, MD = -8.49, 95% CI -16.56 to -0.43), and hospital stay (I² = 97%, P < 0.05, MD = -0.94, 95% CI -1.74 to -0.14) are significantly different between the two groups.

CONCLUSIONS

Harmonic scalpel is superior to conventional tools in terms of decreasing intraoperative blood loss, seroma and hematoma formation, drainage volume and time, necrosis prevalence, surgical duration, and hospital stay, which should be strongly recommended in the surgery for breast cancer.

Current controversies and developments on the role of lymphadenectomy for penile cancer

Penile squamous cell carcinoma is a rare cancer in men. The main prognosticators of survival for penile cancer patients remain the presence and the extent of lymph node metastasis. While radical inguinal lymphadenectomy has been the cornerstone of regional lymph node management for many years, it is still associated with significant morbidity and psychological distress. Recent developments in penile squamous cell carcinoma management have been met with some controversy in the urologic oncology community. Herein, we review the current controversies and developments on the role of inguinal lymphadenectomy for penile cancer.

Late Shoulder-Arm Morbidity Using Ultrasound Scalpel in Axillary Dissection for Breast Cancer: A Retrospective Analysis

BACKGROUND

We aimed to assess whether the use of the harmonic scalpel (HS) in axillary dissection would reduce long-term shoulder-arm morbidity compared to traditional instruments (TIs).

MATERIALS AND METHODS

A retrospective analysis on 180 patients who underwent standard axillary dissection for breast cancer between 2007 and 2015 was carried out. All patients were evaluated for postoperative pain, impairment of shoulder-arm mobility, seroma formation in axilla, frozen shoulder, and lymphedema.

RESULTS

HS procedure on average was 50% shorter compared to the TI technique. HS reduced by 4.5 times the risk of axillary seroma. TIs were associated with 4 times higher risk of developing a painful frozen shoulder.

CONCLUSIONS

Use of the HS was associated with reduced costs and a positive long-term effect on shoulder-arm morbidity. Axillary seromas are not the only reason of later postoperative shoulder-arm morbidity: other mechanisms are hypothesized in the onset of this very disabling disorder.

Comparing the Harmonic Scalpel with Electrocautery in Reducing Postoperative Flap Necrosis and Seroma Formation after Modified Radical Mastectomy in Carcinoma Breast Patients: A Double-Blind Prospective Randomized Control Trail

Introduction

Only a few studies compare the efficacy of the harmonic scalpel and electrocautery in performing mastectomies, and these have mainly compared their intraoperative parameters. But the main concern with electrocautery is the incidence of flap necrosis and seroma formation. Therefore, this study was done to determine if the harmonic scalpel has any advantages over electrocautery in reducing postoperative flap necrosis and seroma formation in patients undergoing a modified radical mastectomy (MRM).

Methodology

This randomized control trial was carried out over a one-year period in a tertiary care centre in South India. The study patients were randomized into an electrocautery group and a harmonic scalpel group. In the first group, mastectomy including flap and axillary dissection was done using electrocautery. In the second group, a harmonic scalpel was used for dissection. This study compared the efficacy of the harmonic scalpel with electrocautery in terms of postoperative seroma formation and flap necrosis. Various other perioperative parameters like the number of drain days, total drainage volume (in mL), operating time (in minutes), intraoperative blood loss (in mL), and postoperative wound site pain were also studied. During each postoperative visit, the presence of seroma was assessed clinically, and the number of aspirations required for the seroma was also analysed.

Results

A total of 240 patients were randomized into two groups of 120 patients each. Baseline parameters were comparable across both groups. There were significant differences in the duration of surgery [151.38 mins vs. 112.33 mins; p = 0.001] and intraoperative blood loss [276.25 mL vs.200.13 mL; p = 0.001]. On Postoperative Day (POD) 1, the difference in the mean pain scores [6 vs. 4; p = 0.001] was statistically significant. In addition, the differences in the mean total drainage volume [937.5 mL vs. 470 mL; p = 0.002] and the incidence of seroma during the first follow-up [34.2% vs. 21.7 %; p = 0.030] were statistically significant. The difference in the incidence of flap necrosis on POD 4 [7.5% vs. 4.2%; p = 0.2706] was not statistically significant. None of the patients developed flap necrosis after four days.

Conclusion

The harmonic scalpel reduces the total drainage volume of seromas, the number of drain days, intraoperative blood loss, duration of surgery, postoperative pain (especially on POD 1 and 5), and incidence of flap necrosis.

Drainage after Modified Radical Mastectomy - A Methodological Mini-Review

Breast cancer is a socially relevant group of malignant conditions of the mammary gland, affecting both males and females. Most commonly the surgical approach of choice is a modified radical mastectomy (MRM), due to it allowing for both the removal of the main tumor mass and adjacent glandular tissue, which are suspected of infiltration and multifocality of the process, and a sentinel axillary lymph node removal. Most common post-surgical complications following MRM are the formation of a hematoma, the infection of the surgical wound and the formation of a seroma. These post-surgical complications can, at least in part, be attributed to the drainage of the surgical wound. However, the lack of modern and official guidelines provides an ample scope for innovation, but also leads to a need for a randomized comparison of the results. We compared different approaches to wound drainage after MRM, reviewed based on the armamentarium, number of drains, location, type of drainage system, timing of drain removal and no drainage alternatives. Currently, based on the general results, scientific and comparative discussions, seemingly the most affordable methodology with the best patient outcome, with regards to hospital stay and post-operative complications, is the placement of one medial to lateral (pectoro-axillary) drain with low negative pressure. Ideally, the drain should be removed on the second or third postoperative day or when the amount of drained fluid in the last 24 hours reaches below 50 milliliters.

Impact of the Ultrasonic scalpel on the amount of drained lymph after axillary or inguinal lymphadenectomy

BACKGROUND

Seroma formation and lymphoedema are frequently encountered complications after radical lymph node dissection (RLND). Attempts to reduce the lymphatic morbidity include the use of Ultrasonic Scalpel. The aim of the present analysis was to assess the impact of the ultrasonic scalpel on the amount of drained lymph after lymph node dissection.

METHODS

Patients listed for a RLND or completion lymph node dissection (CLND) were enrolled in a prospective randomized trial to compare the impact of two surgical dissection techniques (USS versus control) on the amount of drained lymph. The lymph drained in 24 h was collected. Our primary endpoint was to compare the daily amount of drained lymph between the two groups. Secondary endpoints were the comparison of drained lymph with the BMI of the patients, the gender and the surgical site (axilla, groin).

RESULTS

Eighty patients were randomly assigned to the USS group or the Control (C) group. No difference was measured in the total amount of lymph drained (USS: 2908 ± 2453 ml vs. C: 3898 ± 5791 ml; p-value = 0.382). The result was also similar after adjusting for gender, age, and BMI. A significant higher amount of lymph was measured after inguinal dissection with USS compared to axillary (p < 0.001).

CONCLUSION

The study suggests that the use of Harmonic scalpel did not influence the amount of lymph drained after RLND and not support the theory that USS induces oversealing of lymphatics.

TRIAL REGISTRATION

Clinical Trial NCT02476357 . Registered 20 of February 2015.

A systematic review and meta-analysis of Harmonic technology compared with conventional techniques in mastectomy and breast-conserving surgery with lymphadenectomy for breast cancer

BACKGROUND

Mastectomy and breast-conserving surgery (BCS) are important treatment options for breast cancer patients. A previous meta-analysis demonstrated that the risk of certain complications can be reduced with the Harmonic technology compared with conventional methods in mastectomy. However, the meta-analysis did not include studies of BCS patients and focused on a subset of surgical complications. The objective of this study was to compare Harmonic technology and conventional techniques for a range of clinical outcomes and complications in both mastectomy and BCS patients, including axillary lymph node dissection.

METHODS

A comprehensive literature search was performed for randomized controlled trials comparing Harmonic technology and conventional methods in breast cancer surgery. Outcome measures included blood loss, drainage volume, total complications, seroma, necrosis, wound infections, ecchymosis, hematoma, hospital length of stay, and operating time. Risk of bias was analyzed for all studies. Meta-analysis was performed using random-effects models for mean differences of continuous variables and a fixed-effects model for risk ratios of dichotomous variables.

RESULTS

Twelve studies met the inclusion criteria. Across surgery types, compared to conventional techniques, Harmonic technology reduced total complications by 52% (P=0.002), seroma by 46% (P<0.0001), necrosis by 49% (P=0.04), postoperative chest wall drainage by 46% (P=0.0005), blood loss by 38% (P=0.0005), and length of stay by 22% (P=0.007). Although benefits generally appeared greatest in mastectomy patients with lymph node dissection, Harmonic technology showed significant reductions in complications in the BCS study subgroup.

CONCLUSION

In this meta-analysis of both mastectomy and BCS procedures, the use of Harmonic technology reduced the risk of most complications by about half across breast cancer surgery patients. These benefits may be due to superior hemostatic capabilities of Harmonic technology and better dissection, particularly lymph node dissection. Reduction in complications and other resource outcomes may engender lower downstream health care costs.

Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy

BACKGROUND AND OBJECTIVES

Postoperative seroma after axillary lymphadenectomy leads to an increased use of resources and an impaired quality of life of patients. This randomized clinical trial was designed to assess the value of a hemostatic and sealing agent for decreasing seroma occurrence after axillary lymphadenectomy.

METHODS

A prospective, randomized, blind study was conducted on 91 axillary lymphadenectomies distributed into a control group (n = 47) and a test group in which a collagen sponge coated with human coagulation factors was used (n = 44). Primary end-points were number of days before removal of axillary drainage, axillary drainage output, and occurrence of seroma, wound infection, haematoma, or wound dehiscence, within 8 weeks of surgery. Bivariate and multivariate analyses on seroma occurrence were performed.

RESULTS

Seroma occurred in 29 patients (31.86%). A significant direct relationship (P = 0.002) was only noted between use of the hemostatic and sealing agent and nonoccurrence of seroma. In the multivariate study, the only variable found to be significantly related to seroma occurrence was use of the above agent (P = 0.046; odds ratio: 3.365 [95%CI: 1.024-11.060]).

CONCLUSIONS

Use of a collagen sponge coated with human coagulation factors following axillary lymphadenectomy was associated to a lower incidence of postoperative seroma. J. Surg. Oncol. 2016;114:423-427. © 2016 Wiley Periodicals, Inc.

Prospective Randomized Study to Compare Lymphocele and Lymphorrhea Control Following Inguinal and Axillary Therapeutic Lymph Node Dissection With or Without the Use of an Ultrasonic Scalpel

BACKGROUND

Many attempts to prevent lymphatic complications following therapeutic lymph node dissection (TLND) have included modifications in surgical techniques through the use of ultrasonic scalpels (USS) or lymphostatic agents. Previous randomized studies that enrolled heterogeneous groups of patients attempted to confirm the efficacy of such techniques. The aim of the present study was to evaluate the efficacy of the USS following TLND.

METHODS

Between 2009 and 2013, patients undergoing inguinal or axillary TLND or completion lymph node dissection after positive sentinel lymph node biopsy for melanoma, squamous cell carcinoma or sarcoma were randomized into two surgical dissection technique groups. In the USS dissection arm, surgery was conducted using a USS. These were compared with a control group whereby ligation and monopolar electrocautery was utilized. For axillary dissection, a standardized level III lymphadenectomy was performed. A complete inguinal lymphadenectomy including Cloquet's node was performed, and at the end of the procedure a Redon suction drain was routinely placed in the axilla and groin. The primary endpoint was to compare the time to drain removal in both groups, while the secondary endpoint was to evaluate the rate of complications (infection, fistula, lymphocele formation, wound dehiscence, lymphedema) between the two groups.

RESULTS

A total of 80 patients were enrolled in this trial; 40 patients were randomly assigned to both the USS group and the control (C) group. No significant differences were observed in terms of duration of drainage (USS: 31 ± 20 vs. C: 32 ± 18; p = 0.83); however, a significantly increased rate of lymphedema (defined as an increased circumference of the operated limb of more than 10 %) was identified in the USS group (USS: 50 % vs. C: 27.5 %; p = 0.04). No other significant differences were recorded for postoperative complications, including surgical site infection (USS: 5 % vs. C: 7.5 %; p = 0.68), lymphatic fistula (USS: 5 % vs. C: 2.5 %; p = 0.62), lymphocele (USS: 32.5 % vs. C: 22.5 %; p = 0.33), and hematoma (USS: 5 % vs. C: 2.5 %; p = 0.62).

CONCLUSION

The use of USS failed to offer any significant reduction in length of drain usage and operative complication, but it seems to increase the rate of lymphedema formation.

Harmonic Scalpel versus Electrocautery Dissection in Modified Radical Mastectomy for Breast Cancer: A Meta-Analysis

BACKGROUND

Despite the common use of conventional electrocautery in modified radical mastectomy for breast cancer, the harmonic scalpel is recently emerging as a dominant surgical instrument for dissection and haemostasis, which is thought to reduce the morbidity, such as seroma and blood loss. But the results of published trials are inconsistent. So we made the meta-analysis to assess the intraoperative and postoperative endpoints among women undergoing modified radical mastectomy with harmonic scalpel or electrocautery.

METHODS

A comprehensive literature search of case-control studies from PubMed, MEDLINE, EMBASE and Cochrane Library databases involving modified radical mastectomy with harmonic scalpel or electrocautery was performed. We carried out a meta-analysis of primary endpoints including postoperative drainage, seroma development, intraoperative blood loss and secondly endpoints including operative time and wound complications. We used odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate the effect size for categorical outcomes and standardised mean differences (SMDs) for continuous outcomes.

RESULTS

A total of 11 studies with 702 patients were included for this meta-analysis. There was significant difference in total postoperative drainage (SMD: -0.74 [95%CI: -1.31, -0.16]; P< 0.01), seroma development[OR: 0.49 (0.34, 0.70); P < 0.01], intraoperative blood loss(SMD: -1.14 [95%CI: -1.81,-0.47]; P < 0.01) and wound complications [OR: 0.38 (0.24, 0.59); P < 0.01] between harmonic scalpel dissection and standard electrocautery in modified radical mastectomy for breast cancer. No difference was found as for operative time between harmonic scalpel dissection and standard electrocautery (SMD: 0.04 [95%CI: -0.41, 0.50]; P = 0.85).

CONCLUSION

Compared to standard electrocautery, harmonic scalpel dissection presents significant advantages in decreasing postoperative drainage, seroma development, intraoperative blood loss and wound complications in modified radical mastectomy for breast cancer, without increasing operative time. Harmonic scalpel can be recommended as a preferential surgical instrument in modified radical mastectomy.

Ultrasonic dissection versus conventional electrocautery during gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

Use of ultrasonic surgical instrument is gaining popularity for dissection and coagulation in open surgery. However, there is still no consensus on the efficacy and safety of its use compared with conventional surgical technique in open gastrectomy for gastric cancer. The aim of this meta-analysis was to evaluate the role and surgical outcomes of ultrasonic dissection (UD) compared with conventional electrocautery (EC).

METHODS

A systematic literature search was performed to identify all studies comparing UD and EC in gastric cancer surgery. Intraoperative and postoperative outcomes were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS

Five studies were included in this meta-analysis, comprising 489 patients. Meta-analysis results showed that compared with EC, UD was associated with significantly shorter operation time (P = 0.03), less intraoperative blood loss (P = 0.002), lower morbidity (P = 0.02), and reduced postoperative hospital stay (P = 0.03). However, there was no significant difference between the two surgical techniques with regards to postoperative abdominal drainage (P = 0.17), and total cost in hospital (P = 0.59).

CONCLUSIONS

Compared to EC, the use of UD during open gastrectomy can provide several improved outcomes for operation time, intraoperative blood loss, overall morbidity, and postoperative hospital stay. It appears that UD can be used instead of conventional EC in open gastric cancer surgery, although more larger trials with long follow-up should be performed.

Harmonic scalpel versus electrocautery dissection in modified radical mastectomy: a randomized controlled trial

PURPOSE

To test the hypothesis that the use of a harmonic scalpel increases operative time but results in less estimated blood loss, postoperative pain, drainage volume, and duration of surgery, as well as fewer complications, such as flap necrosis, seroma, and surgical site infection (SSI), than electrocautery.

METHODS

This parallel-group, single-institution blinded randomized controlled trial was conducted at the department of surgery of our institute between April 2010 and July 2011. Women undergoing modified radical mastectomy were randomly allocated to either harmonic dissection (n = 76) or electrocautery (n = 76).

RESULTS

Both the groups were comparable for baseline variables with age of 50.5 ± 12.2 and 48.5 ± 14.5 years in the harmonic and electrocautery groups, respectively. Harmonic dissection yielded better outcomes compared to electrocautery with lower estimated blood loss (100 ± 62 vs. 182 ± 92, p < 0.001), less drain volume (631 ± 275 ml vs. 1035 ± 413 ml, p < 0.001), fewer drain days (12 ± 3 vs. 17 ± 4, p < 0.001), less seroma formation (21.3 vs. 33.3 %, p = 0.071), and less postoperative pain [median (interquartile range) 2 (2-2) vs. 3 (3-4), p < 0.001], whereas mean operative time (191 ± 44 vs. 187 ± 36 min, p = 0.49) and SSI (0 vs. 4 %, p = 0.122) did not differ. On multivariable Cox regression analysis, harmonic dissection was associated with lower risk of significant postoperative pain [adjusted relative risk 0.028 (95 % confidence interval (CI) 0.004-0.2)] and overall complications [adjusted relative risk 0.47, (95 % CI 0.26-0.86)]. On multiple linear regression, duration of drains in the harmonic dissection group was 4.5 days less than electrocautery (r2 = 0.28, β = 11.8, p < 0.001).

CONCLUSIONS

The harmonic scalpel significantly reduces postoperative discomfort and morbidity to the patient without increasing operating time. We thus recommend preferential use of harmonic dissection in modified radical mastectomy. (ClinicalTrials.gov NCT01587248).

Harmonic dissection versus electrocautery in breast surgery in regional Victoria

BACKGROUND

Harmonic instruments are an alternative tool for surgical dissection. The aim of this study is to evaluate differences in clinical outcomes relating to harmonic dissection when compared with electrocautery in patients undergoing major breast surgery in a regional centre over a 3-year period.

METHODS

Retrospective chart analysis was conducted of 52 patients undergoing major breast surgery for carcinoma or ductal carcinoma in situ by a single surgeon in a regional centre from May 2008 to January 2011. Analysis involved the extraction of qualitative data relating to patient demographics, surgery type and specimen histopathology. Quantitative data were extracted relating to duration of surgery, duration of patient-controlled analgesia (PCA) use, length of hospital admission, drainage output and presence of infection, haematoma or seroma.

RESULTS

Fifty-two patients underwent major breast surgery; harmonic dissection n = 32 and electrocautery n = 20. The two groups were comparable. There was no significant difference identified relating the outcome measures. The median operative duration was shorter in the harmonic dissection group, however, was not of statistical significance. No significant difference was identified between groups relating to length of inpatient stay, duration of PCA use and total volume wound drainage and total days of drainage. Incidence of seroma and infection in the groups was not significantly different.

CONCLUSION

The harmonic dissection is safe and effective in major breast surgery. The study did not demonstrate any clinical advantage from the use of harmonic dissection in major breast surgery compared with electrocautery, nor was there any difference in the complication rates measured.

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.

Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue

BACKGROUND

Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.

METHODS

Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.

RESULTS

Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.

CONCLUSIONS

Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

Harmonic scalpel versus conventional dissection technique in pylorus-preserving partial duodenopancreatectomy

BACKGROUND/AIMS

Pancreatic head resection is performed with low mortality, but morbidity remains high. Extensive preparation, long operating times, intraoperative blood loss and the need for blood transfusions are risk factors for postoperative morbidity. The aim of our study was to evaluate the feasibility and safety of the ultrasonic dissection device in pylorus-preserving duodenopancreatectomy (PPPD).

METHODS

Fifty consecutive patients who underwent PPPD with an ultrasonic dissection device (group 1) were compared with a match-controlled group of 50 consecutive patients who underwent PPPD with conventional dissection techniques (group 2). Duration of surgery, intraoperative blood loss, blood units, complications, mortality and duration of hospital stay were analyzed.

RESULTS

There was no difference in age, gender or BMI between groups. In group 1, mean blood loss (446 ± 281.8 ml, p = 0.008) and number of blood units (0.32 ± 0.86, p = 0.001) were significantly lower than in group 2 (819 ± 915.4 ml; 1.36 ± 2.83 units). Duration of surgery was shorter in group 1 (345.6 vs. 373 min, p = 0.28). The rate of postoperative complications, mortality and hospital stay were not significantly different.

CONCLUSIONS

Use of an ultrasonic dissection device in PPPD might significantly reduce intraoperative blood loss and the need for blood transfusions. These results should be verified in a prospective randomized controlled trial.

Ultrasonic dissection versus electrocautery in mastectomy for breast cancer - a meta-analysis

BACKGROUND

Electrocautery has advanced the practice of mastectomy but significant morbidity, such as seroma and blood loss, remains a concern. This has led to newer forms of dissection being introduced including the ultrasonic dissection devices, which are thought to reduce tissue damage. The aim of this systematic review was to compare the outcomes after mastectomy using novel ultrasonic dissection or standard electrocautery in published trials.

METHODS

Medline, Embase, trial registries, conference proceedings and reference lists were searched for comparative trials of ultrasonic dissection versus electrocautery for mastectomy. The primary outcomes were total postoperative drainage, seroma development and intra-operative blood loss. Secondary outcomes were operative time and wound complications. Odds ratios were calculated for categorical outcomes and standardised mean differences for continuous outcomes.

RESULTS

Six trials were included in the analysis of 287 mastectomies. There was no effect in total postoperative drainage (pooled analysis weight mean difference: -0.21 (95% CI: -0.70-0.29); p = 0.41) or seroma development (pooled analysis odds ratio: 0.77 (95% CIs 0.43-1.37); p = 0.37). Intra-operative blood was slightly less for ultrasonic dissection compared to standard electrocautery (pooled analysis weight mean difference: -1.04 (95% CI: -2.00 to -0.08); p = 0.03). Ultrasonic dissection and standard electrocautery had similar outcomes with regard to operative time and wound complications.

CONCLUSION

Ultrasonic dissection and standard electrocautery appear to deliver similar results in the mastectomy setting. Further cost-effectiveness analysis may guide surgeon selection in the use of new technologies for mastectomy.

Axillary lymph node dissection for breast cancer utilizing Harmonic Focus®

Background

For patients with axillary lymph node metastases from breast cancer, performance of a complete axillary lymph node dissection (ALND) is the standard approach. Due to the rich lymphatic network in the axilla, it is necessary to carefully dissect and identify all lymphatic channels. Traditionally, these lymphatics are sealed with titanium clips or individually sutured. Recently, the Harmonic Focus^®, a hand-held ultrasonic dissector, allows lymphatics to be sealed without the utilization of clips or ties. We hypothesize that ALND performed with the Harmonic Focus^® will decrease operative time and reduce post-operative complications.

Methods

Retrospective review identified all patients who underwent ALND at a teaching hospital between January of 2005 and December of 2009. Patient demographics, presenting pathology, treatment course, operative time, days to drain removal, and surgical complications were recorded. Comparisons were made to a selected control group of patients who underwent similar surgical procedures along with an ALND performed utilizing hemostatic clips and electrocautery. A total of 41 patients were included in this study.

Results

Operative time was not improved with the use of ultrasonic dissection, however, there was a decrease in the total number of days that closed suction drainage was required, although this was not statistically significant. Complication rates were similar between the two groups.

Conclusion

In this case-matched retrospective review, there were fewer required days of closed suction drainage when ALND was performed with ultrasonic dissection versus clips and electrocautery.

Comparing scalpel, electrocautery and ultrasonic dissector effects: the impact on wound complications and pro-inflammatory cytokine levels in wound fluid from mastectomy patients

PURPOSE

Introducing the relationship between the surgical instruments used in modified radical mastectomy and wound complications is important for preventing and decreasing complications. This prospective randomized trial was designed to assess the impact of scalpel, electrocautery, and ultrasonic dissector usage on wound complications and tissue damage.

METHODS

Eighty-two consecutive patients operated with mastectomy were studied. The postoperative time period needed for hemovac drainage, the amount and duration of seroma, infection, flap ecchymosis and necrosis rates were compared. Tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) levels in drainage fluids were determined to confirm the inflammatory response and tissue damage.

RESULTS

The numbers of patients included in the scalpel, electrocautery and ultrasonic dissector groups were 27, 26, and 29, respectively. The groups were homogenous with respect to age, body mass index, stage, cormorbidities, breast volume and flap area. Operation time and the amount of bleeding were statistically higher in the scalpel group. The incidence of seroma was higher in the electrocautery group and arm mobilization had to be delayed in this group. There were no differences between groups with respect to hematoma, infection, ecchymosis, necrosis, hemovac drainage and the total and first 3 days of seroma volume. TNF-α and IL-6 levels were significantly higher in samples obtained from the drains of patients operated with electrocautery.

CONCLUSION

Ultrasonic dissector decreases operation time by decreasing the amount of bleeding without increasing the seroma incidence. High cytokine levels in drainage fluids from patients operated with elecrocautery indicates that electrocautery induces more tissue damage and acute inflammatory response. Therefore, seroma, due to acute inflammatory response, was seen more frequently in the electrocautery group. Ultrasonic dissector coagulates protein by breaking hydrogen bonds which may close vascular and lymphatic channels more precisely. But, its actual preventive effect on seroma formation might be related to diminished inflammatory response.

Usefulness of Harmonic Focus During Axillary Lymph Node Dissection

Background: Axillary node dissection (ALND) is affected by various complications, (hematoma, seroma, lymphocele, infections). The aim of this study was to evaluate the effectiveness of Harmonic Focus (HF) in reducing these complications. Materials and Methods: 92 patients requiring ALND, were divided into two group: Group A (HF) (33 women, 14 men), and Group B (control) (28 women, 17 men). Results: Operating time was lower in Group A than in Group B. The amount of drain volume was lower in Group A than in Group B, the drain was removed earlier in Group A than in Group B. Seroma incidence was lower in Group A than in Group B. Conclusions: The use of HF during ALND is effective in reducing operating time, drain volume and complications.

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.

Contemporary inguinal lymph node dissection: minimizing complications

OBJECTIVES

This review describes the morbidity of inguinal lymph node dissection (ILND) performed as part of the management of penile cancer as well as recent modifications that may reduce the incidence of complications.

METHODS

A review of the literature was conducted using Pubmed for studies reporting complication outcomes of ILND for penile cancer. Furthermore, our contemporary results and patient related morbidity associated with ILND performed for penile cancer are reported and compared with prior series.

RESULTS

A review of the literature over the past 25 years identified 27 manuscripts discussing complications of ILND in the context of penile cancer. ILND has traditionally been associated with an 80-100% risk of surgical morbidity, with skin necrosis, wound dehiscence, infection, and lymphedema the predominant findings. Recent technical modifications and management strategies have reduced the associated risks of this surgical procedure. Most recently, we report a 19 and 27% rate of minor and major complications, respectively, for a diagnostic ILND (i.e., superficial ILND alone in the absence of nodal metastasis) and a 29 and 24% rate of minor and major complications, respectively, for a therapeutic ILND (superficial/deep ILND and pelvic lymph node dissection in the presence of nodal metastasis). In contrast, among clinically node negative patients undergoing dynamic sentinel lymph node biopsy as a staging procedure, the reported complication rate was 7%.

CONCLUSIONS

The incorporation of novel management strategies and surgical modifications have resulted in decreasing peri-operative morbidity associated with inguinal staging and therapy.

Does LigaSure reduce fluid drainage in axillary dissection? A randomized prospective clinical trial

Background:

Axillary lymph node dissection (ALND) is an integral part of breast cancer treatment. It is required in about 40–50% of patients. The placement of a drain in the axilla after an operation is current surgical practice. Short surgical stay programmes increase operating efficiency and reduce medical care costs, without compromising quality of care. LigaSure^™ is a new haemostatic device that uses bipolar energy to seal vessels. The aim of this study is to determine whether axillary dissection with LigaSure^™ reduces the time of wound drainage, the duration of surgical intervention and the volume of drainage after treatment.

Patients and methods:

This study is a prospective randomized controlled trial. A total of 100 women with breast cancer who needed axillary dissection were randomized into the LigaSure^™ or conventional axillary dissection group. Levels I to III lymph node dissection was performed. A closed suction drain was always placed in the axilla and removed after 6–8 days or when fluid amount was <60 cc in the previous 24 hours.

Results:

There were no significant differences between the two groups when considering the duration of surgical procedure: average duration was 70.7 ± 24.66 minutes for LigaSure^™ patients, while in the conventional dissection group the mean was 70.6 ± 22.47 minutes (p=0.98). Total amount of drained fluid was 624.49 cc in the LigaSure^™ axillary dissection group and 792.96 in the conventional ALND group; this difference did not achieve statistical significance (p=0.09); the duration of draining was also similar, with no statistical difference (p=0.15).

Conclusions:

The present study did not show clear advantages in LigaSure^™ use for ALND, although it represents a good haemostatic device, especially in abdominal surgery.