A novel technique of harmonic tissue dissection reduces seroma formation after modified radical mastectomy compared to conventional electrocautery: a single-blind randomized controlled trial

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).

Total Sealing Technique (TST) with a bipolar vessel sealing system reduces lymphorrhea and seroma formation for axillary lymph node dissection in primary breast cancer

Background

The purpose of this study is to evaluate the potential of a novel surgical procedure, the Total Sealing Technique (TST), using the latest bipolar vessel sealing system (BVSS; LigaSure™ Exact Dissector) to reduce lymphatic leakage and seroma formation after electrocautery axillary lymph node dissection (ALND) in breast cancer surgery. Prolonged drainage is a common occurrence after ALND, primarily due to lymphatic leakage. In addition, the presence of seroma often leads to delays in the administration of postoperative adjuvant chemotherapy even after drain removal.

Methods

We conducted a comparative analysis of 36 patients who underwent total mastectomy with ALND using conventional electrocautery technique (CONV) during the first 3 years, and 35 patients who underwent the same procedure using TST during the subsequent 3 years. The following factors were compared to assess the impact of TST: operation time, blood loss, total drainage volume, mean time to drain removal, postoperative hospital stay, mean time to initiation of postoperative chemotherapy, and postoperative complications in each group.

Results

TST significantly reduced drainage volume (360.5 vs. 820.6 mL, p < 0.001), days to drain removal (4.8 vs. 6.8 days, p < 0.001), postoperative hospital stay (5.9 vs. 9.6 days, p < 0.001), the incidence of seroma (28.6 % vs. 65.9 %, p = 0.001), and time to chemotherapy initiation (33.1 vs. 61.4 days, p < 0.001) compared to CONV.

Conclusions

TST in total mastectomy with ALND effectively decreases the incidence of lymphorrhea and seroma formation; thus, it can be recommended for total mastectomy with ALND.

Comparison of the effect of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer

OBJECTIVE

To compare the efficacy of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer.

METHODS

A prospective study was conducted in the Department of Breast Surgery, Zhongda Hospital Affiliated to Southeast University. A total of 128 patients with pathologically confirmed breast cancer who were treated by the same surgeon from July 2023 to November 2023 were included in the analysis. All breast operations were performed using electrocautery, and surgical instruments for axillary lymph nodes were divided into ultrasounic-harmonic scalpel group and electrocautery group using a random number table. According to the extent of lymph node surgery, it was divided into four groups: sentinel lymph node biopsy, lymph node at station I, lymph node at station I and II, and lymph node dissection at station I, II and III. Under the premise of controlling variables such as BMI, age and neoadjuvant chemotherapy, the effects of ultrasounic-harmonic scalpel and electrocautery in axillary surgery were compared.

RESULTS

Compared with the electrosurgical group, there were no significant differences in lymph node operation time, intraoperative blood loss, postoperative axillary drainage volume, axillary drainage tube indwelling time, postoperative pain score on the day after surgery, and the incidence of postoperative complications (p>0.05).

CONCLUSION

There is no significant difference between ultrasounic-harmonic scalpel and electrocautery in axillary lymph node treatment for breast cancer patients, which can provide a basis for the selection of surgical energy instruments.

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.

An umbrella review of the surgical performance of Harmonic ultrasonic devices and impact on patient outcomes

BACKGROUND

For thirty years, the Harmonic scalpel has been used for precise dissection, sealing and transection. There are numerous meta-analyses on individual surgical procedures with Harmonic, but no overarching review covering all the areas. This umbrella review seeks to summarize the clinical results from the use of Harmonic across surgical fields and broadly quantify its effects on patient outcomes.

METHODS

MEDLINE, EMBASE, and Cochrane Databases were searched for meta-analyses (MAs) of randomized controlled trials (RCTs) comparing Harmonic devices to conventional techniques or advanced bipolar (ABP) devices. For each procedure type, the most comprehensive MAs were evaluated. RCTs not already analysed in a MA were also included. Operating time, length of stay, intraoperative blood loss, drainage volume, pain, and overall complications were evaluated, and the methodological quality and certainty of evidence were assessed.

RESULTS

Twenty-four systematic literature reviews were identified on colectomy, hemorrhoidectomy, gastrectomy, mastectomy, flap harvesting, cholecystectomy, thyroidectomy, tonsillectomy, and neck dissection. There were also 83 RCTs included. In every MA evaluated, Harmonic devices were associated with either statistically significant or numerical improvements in every outcome compared with conventional techniques; most MAs reported a reduction in operating time of ≥ 25 min. Harmonic versus ABP device MAs in colectomy and thyroidectomy showed no significant differences in outcomes.

CONCLUSION

Across surgical procedures, Harmonic devices demonstrated improved patient outcomes for operating time, length of stay, intraoperative bleeding, drainage volume, pain, and overall complications compared to conventional techniques. Additional studies are required to assess differences between Harmonic and ABP devices.

Efficacy and safety of surgical energy devices for axillary node dissection: a systematic review and network meta-analysis

Various surgical energy devices are used for axillary lymph-node dissection. However, those that reduce seroma during axillary lymph-node dissection are unknown. We aimed to determine the best surgical energy device for reducing seroma by performing a network meta-analysis to synthesize the current evidence on the effectiveness of surgical energy devices for axillary node dissection for breast cancer patients. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform Search Portal. Two reviewers independently selected randomized controlled trials (RCTs) comparing electrosurgical bipolar vessel sealing (EBVS), ultrasonic coagulation shears (UCS), and conventional techniques for axillary node dissection. Primary outcomes were seroma, drained fluid volume (mL), and drainage duration (days). We analyzed random-effects and Bayesian network meta-analyses. We evaluated the confidence of each outcome using the CINeMA tool. We registered with PROSPERO (CRD42022335434). We included 34 RCTs with 2916 participants. Compared to the conventional techniques, UCS likely reduces seroma (risk ratio [RR], 0.61; 95% credible interval [CrI], 0.49-0.73), the drained fluid volume (mean difference [MD], - 313 mL; 95% CrI - 496 to - 130), and drainage duration (MD - 1.79 days; 95% CrI - 2.91 to - 0.66). EBVS might have little effect on seroma, the drained fluid volume, and drainage duration compared to conventional techniques. UCS likely reduce seroma (RR 0.44; 95% CrI 0.28-0.69) compared to EBVS. Confidence levels were low to moderate. In conclusion, UCS are likely the best surgical energy device for seroma reduction during axillary node dissection for breast cancer patients.

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.

Clinical Experience with Compression Taping to Treat Seroma After Breast Cancer Surgery: A Medical Device Clinical Study

OBJECTIVE

To evaluate the safety of compressive taping in patients with seroma secondary to breast cancer surgery.

METHODS

This study was a nonrandomized clinical study of medical devices applied to women indicated for seroma aspiration puncture after breast cancer surgery in a public reference hospital in Brazil. The intervention consisted of applying compressive taping over the seroma fluctuation area and maintained for 5 days. Evaluated outcomes comprised dermal changes caused by taping, subjective symptoms reported during the intervention period, and percent change in the punctured volume before and after the intervention.

RESULTS

A total of 35 women (mean age, 56.7 ± 12.2 years) were included. Most presented with an advanced disease stage (≥IIB; 62.9%). Although a 28.6% incidence of dermal changes caused by taping was observed, an average reduction in the aspirated volume of -28.2 mL was identified (95% confidence interval, -48.3 to -8.0; P = .008). Treatment adherence was high (91.4%), and most patients reported satisfaction with the treatment (85.7%).

CONCLUSIONS

The use of compressive taping on seroma areas can be considered safe, is well accepted by patients, and might be used as a noninvasive treatment option for seroma developing after breast cancer surgery.

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.

Effect of autologous fibrin glue on seroma reduction after modified radical mastectomy for breast cancer: A randomized controlled trial

Introduction

Breast cancer stands out as the second most common cancer in the world with incidence 35.1% of all malignancies among females in Egypt. Fluid build-up after breast surgery is still the most annoying complication which leads to worse outcome. We aimed to evaluate whether autologous fibrin glue might lessen the formation of seroma following modified radical mastectomy.

Methods

This was a randomized controlled trial designed to configure the effect of autologous fibrin glue given in the study group using the drain in comparison to a control group who received the drain only; seroma volume was calculated every 24 h. For all of the cases. The drains were removed when the daily drainage was less than 30 ml for 3 consecutive days.

Results

We recruited 30 patients to each of the two groups. Age, pathology, breast cancer stage, number of lymph nodes and tumour size did not differ significantly between groups. A comparison of the median days to drain removal showed 8 days reduction in median days to drain removal compared in the intervention group (7 days) than the control (15 days). The patients in the fibrin glue group had a significantly lower cumulative drain output volume (mean ± SD of 505,6 ± 209,3 ml) than those in the control group (1674.1 ± 1 373,8 ml).

Conclusions

Autologous fibrin glue significantly decrease seroma formation post-modified radical mastectomy.

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Seroma is the most annoying complication after breast cancer surgery.

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Fibrin glue is an adhesive agent has been associated with reduction in the fluid build-up post mastectomy.

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Autologous Fibrin Glue is easily prepared and safe agent.

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The usage of Autologous fibrin glue help in short hospital stay after mastectomy.

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This is the first randomized clinical intervention to use fibrin glue from autologous nature to reduce seroma formation after MRM.

Ultrasonic dissection versus electrocautery for immediate prosthetic breast reconstruction

Background

Ultrasonic dissection devices cause less thermal damage to the surrounding tissue than monopolar electrosurgical devices. We compared the effects of using an ultrasonic dissection device or an electrocautery device during prosthetic breast reconstruction on seroma development and short-term postoperative complications.

Methods

We retrospectively reviewed the medical records of patients who underwent implant-based reconstruction following mastectomy between March 2017 and September 2018. Mastectomy was performed by general surgeons and reconstruction by plastic surgeons. From March 2017 to January 2018, a monopolar electrosurgical device was used, and an ultrasonic dissection device was used thereafter. The other surgical methods were the same in both groups.

Results

The incidence of seroma was lower in the ultrasonic dissection device group than in the electrocautery group (11 [17.2%] vs. 18 [31.0%]; P=0.090). The duration of surgery, total drainage volume, duration of drainage, overall complication rate, surgical site infection rate, and flap necrosis rate were comparable between the groups. Multivariate analysis revealed that the risk of seroma development was significantly lower in the ultrasonic dissection device group than in the electrocautery group (odds ratio for electrocautery, 3.252; 95% confidence interval, 1.242–8.516; P=0.016).

Conclusions

The findings of this study suggest that the incidence of seroma can be reduced slightly by using an ultrasonic dissection device for prosthesis-based breast reconstruction. However, further randomized controlled studies are required to verify our results and to assess the cost-effectiveness of this technique.

Impact of the surgical modality for axillary lymph node dissection on postoperative drainage and seroma formation after total mastectomy

Background

The most common complications after total mastectomy with axillary lymph node treatment are prolonged drainage and seroma formation. The aim of this study was to find factors correlated with prolonged fluid discharge (prolonged drainage or seroma formation after 20th operative day or later), including surgical techniques or devices and clinical factors.

Patients and methods

A total of 202 conclusive primary breast cancer patients underwent total mastectomy with axillary lymph node treatment between January 7, 2014 and June 20, 2018 at our hospital. The factors that correlated with the total fluid discharge volume and prolonged fluid discharge were examined statistically. The surgical modalities for total mastectomy with axillary treatment were classified into the following three groups:, Group A; skin flap formation by EC and axillary lymph node dissection by EC with ligation of the arteries and veins, Group B; skin flap formation by EC and axillary lymph node dissection by ultrasonic dissector (UD) without ligation of the vessels. Group D; skin flap formation by electrocautery (EC) and axillary lymph node dissection by picking up using forceps and ligation (PL).

Results

The total fluid discharge volume and prolonged fluid discharge after total mastectomy with sentinel node retrieval (33 patients) were significantly lower than those after total mastectomy with axillary lymph node dissection (169 patients). In patients treated without drainage, a high rate of seroma formation and prolonged fluid discharge were observed, and 1 patient developed seroma infection.In the total mastectomy with axillary lymph node dissection group, logistic regression analysis revealed that body mass index, 1-week drainage volume, and surgical modality were independently correlated with prolonged fluid discharge.

Conclusions

The surgical procedure for axillary lymph node dissection should be considered to avoid prolonged fluid discharge, and the lymph vessels should be ligated in axillary lymph node dissection. An ultrasonic dissector was not effective in reducing the total fluid discharge volume. An optimal axillary lymph node dissection technique should be developed. For the patients without drainage, careful postoperative treatment should be given to avoid infectious seroma formation, even for patients who underwent total mastectomy with sentinel lymph node retrieval.