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

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.

Ambulatory thyroidectomy. Recommendations of the Association francophone de chirurgie endocrinienne (AFCE), with the Société française d'endocrinologie (SFE) and the Société française de médecine nucléaire (SFMN)

Before ambulatory thyroidectomy is proposed, the patient and his family and/or friends will need to be informed by the surgeon of the specificity of this procedure, the normal postoperative effects of a thyroidectomy, and potential complications. Also known as outpatient thyroid surgery, it can only be proposed by an experienced surgeon supported by an adequately trained medical and paramedical team. The healthcare establishment must be in possession of all the resources needed in ambulatory management, with continuity of care guaranteed 24h/24 7d/7 in the event of possible emergency rehospitalization. In all cases, contact the day after the operation between the healthcare facility and the patient is imperative. Ambulatory management can be proposed for lobo-isthmectomy or isthmectomy, possibly involving lymph node dissection. It is also possible for secondary totalization of thyroidectomy (following lobectomy). On the other hand, indications for single-stage total thyroidectomy must be limited and ensure proximity between the patient's home and a healthcare structure with a platform adapted to the pathology necessitating surgical intervention (non-plunging euthyroid goiter). A precise clinical pathway must be set out, including pre-, peri- and postoperative protocols having been formalized for surgery (hemostasis procedures) and for anesthesia (prevention of pain, of vomiting and of hypertension). We recommend at least 6hours of postoperative surveillance in outpatient care. When outpatient treatment is not possible or not recommended, hospitalization stay after thyroidectomy can be limited to 24hours, except in the event of postoperative complications, or a need for effectively dosed anticoagulant treatment.

Prevalence and Predictors of Post-Thyroidectomy Voice Dysfunction in a Nigerian Cohort

BACKGROUND

Advances in surgical techniques have significantly improved the safety of thyroidectomy. Quality of life issues, such as voice changes, however continue to be important considerations. This study evaluated the prevalence and determinants of voice changes following thyroidectomies for non-malignant goiters in a Nigerian Hospital.

METHODOLOGY

Consecutive adults who had thyroidectomy for non-malignant goiters were evaluated. Preoperatively, each participant had laryngoscopy and voice assessment using the Voice Handicap Index-10. At surgery, the intubation difficulty score, size of endotracheal tubes, and duration of operation were recorded. Laryngoscopy and VHI-10 assessments were repeated 1 week, 1 month, and 3 months after surgery. Pre and postoperative assessments were compared.

RESULT

Fifty-four patients completed the study. Subtotal thyroidectomy was the commonest operation performed in 17 patients (31.48%), with 14 (25.93%) having total thyroidectomy. Baseline median VHI-10 score was 6.5(IQR-10). Five patients had abnormal preoperative laryngoscopy findings (benign vocal cord lesions). Postoperatively, seven patients had endoscopic evidence of vocal cord paralysis, six were unilateral while one was bilateral. Ten patients (18.5%) had early voice changes. Median VHI-10 score at one week was significantly higher than baseline (10 vs. 6.5, p = 0.01). At 3 months, VHI-10 reverted back to baseline in five of the ten patients while five patients (9.3%) had persistent voice changes. Abnormal endoscopic findings predicted the occurrence of early postoperative voice changes.

CONCLUSION

Thyroidectomy for non-malignant goiters is associated with transient voice changes, many of which revert to normal over time. Abnormal endoscopic findings predict its occurrence.

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.

Vessel Sealant Devices in Thyroidectomies: An ACS-NSQIP Study

OBJECTIVES

Thyroidectomies involve meticulous dissection of a highly vascularized organ and complications may develop, such as hematoma, hypocalcemia, and even hypoparathyroidism. Because some of these complications may be fatal, we sought to identify the differences in postthyroidectomy outcomes when the use of a vessel sealant device (VSD) such, as LigaSure or Harmonic scalpel, is compared with more traditional techniques, such as ligatures and clips.

METHODS

Using the 2016 American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database, we compared patients who underwent a thyroidectomy using a VSD with patients without a VSD for differences in postoperative complications.

RESULTS

A total of 5146 cases were identified and 3452 of those cases used a VSD, whose use was associated with significantly lower rates of hematoma, deep vein thrombosis, and hypocalcemia before discharge, as well as a shorter length of stay and longer operation time. Multivariate logistic regression showed that VSD was associated with 32.27% and 39.15% lower odds of hypocalcemia and hematoma, respectively. VSDs also were used more frequently in cases that had multinodular, severe, or substernal goiter or Graves disease as the primary indication for surgery and in patients with a higher body mass index. There was no significant difference in the incidence of recurrent laryngeal nerve injury between the two groups.

CONCLUSIONS

Analysis of the American College of Surgeons National Surgical Quality Improvement Program data indicates that VSDs are associated with a lower risk of complications, such as hypocalcemia, hematoma, and deep vein thrombosis, suggesting that VSDs may be a more effective method of hemostasis than traditional techniques.

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction

Background

To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach).

Methods

All thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included.

Results

Surgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery.

Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8–20%) and 3% (95% CI: 1–8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6–12%) and 0.3% (95%CI: 0.01–2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33–47 min), 48 min (IQR: 40–60 min), and 40 min (IQR: 35–51 min) respectively. 1% of cases required conversion to an alternative surgical approach.

Conclusion

In a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.

Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis

Background

As compared to conventional techniques, recent meta-analyses have reported cost savings with Harmonic devices; however, only in thyroidectomy. Thus, the aim of this study was to evaluate the costs associated with Harmonic devices versus conventional techniques across a range of surgical procedures.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane Library was conducted from inception to October 01, 2016 without language restrictions to identify randomized controlled trials comparing Harmonic devices to conventional techniques and reporting procedure costs (operating time plus operating equipment/consumables/device costs). Costs were pooled using the ratio of geometric means, and a random effects model was applied. Sensitivity analyses varying statistical methods, number of included studies, and cost outcomes were completed to test the robustness of the results.

Results

Thirteen studies met the inclusion criteria. A total of 561 and 540 participants had procedures performed with Harmonic devices and conventional methods, respectively, with procedures including gastrectomy, thyroidectomy, colectomy, cholecystectomy, Nissen fundoplication, and pancreaticoduodenectomy. As compared to conventional methods, Harmonic devices reduced total procedure costs by 8.7% (p=0.029), resulting in an absolute reduction of US$227.77 from mean conventional technique costs, derived primarily from a reduction in operating time costs. When operating time costs, excluding operating equipment/consumables/device costs, were analyzed, costs were reduced by $544 per procedure with the use of Harmonic devices. The results from all sensitivity analyses demonstrated cost reductions with Harmonic devices.

Conclusion

This systematic review and meta-analysis showed that despite a higher device cost, Harmonic devices provide a statistically significant reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures. In addition to functionality benefits, Harmonic devices may represent a potentially cost saving method to reduce overall hospital resource use. Future research should focus on potential costs and benefits from use of Harmonic devices in procedures not covered here.

Intra-capsular total thyroid enucleation versus total thyroidectomy in treatment of benign multinodular goiter. A prospective randomized controlled clinical trial

BACKGROUND

Due to high recurrence rate after subtotal thyroidectomy, most of centers have shifted to total thyroidectomy as a surgical treatment for benign multinodular goiter (BMNG), but serious complications, as laryngeal nerve affection & hypocalcaemia, are still present. This study aimed to evaluate treatment of BMNG using intra-capsular total thyroid enucleation in comparison to standard total thyroidectomy.

PATIENTS &METHODS

This is a prospective randomized controlled clinical trial conducted in a hospital in the period from December 2009 to December 2015. Of total 224 patients with clinically BMNG. 112 patients operated by intracapsular total thyroid enucleation (ITTE group) and the other 112 patients operated by standard total thyroidectomy (STT group). The minimal follow up period was 36 months.

RESULTS

The mean operative time in ITTE group was (93.7 ± 9.6 min) compared to (86.9 ± 8.3 min) in STT group. Transient recurrent laryngeal nerve (RLN) palsy was 0% in ITTE group VS 7.1% in STT group. No cases (0%) developed permanent RLN palsy in ITTE group VS 0.9% in STT group. Symptomatic transient hypocalcaemia occurred in 1.8% in ITTE group VS 11.6% in STT group. No cases (0%) developed permanent hypocalcaemia in ITTE group VS 0.9% in STT group. No recurrence (0%) in both groups after minimal 3 years of follow up.

CONCLUSION

Intracapsular Total thyroid enucleation technique is safe with the least serious complications, especially RLN injury and hypoparathyroidism, with no recurrence, but this technique still not radical so couldn't be used in suspicious cases for malignancy.

Comparative analysis between a bipolar vessel sealing and cutting device and the tie and suture technique in thyroidectomy: A randomized clinical trial

BACKGROUND

Advanced bipolar and ultrasonic devices have shown significant reduction in the surgical time of thyroid operations. This randomized, controlled trial assessed if operative time and other relevant outcomes are different for thyroidectomies performed either with a second-generation advanced bipolar device or traditional tie and suture technique.

METHODS

Forty-one patients were randomized into 2 groups (advanced bipolar device and traditional tie and suture). Secondary end points included estimated blood loss, postoperative hemorrhage or hematoma requiring operative reintervention, recurrent laryngeal nerve injury, hypoparathyroidism, pain intensity, number of ligatures, analgesia usage, and loss of signal during recurrent laryngeal nerve monitoring.

RESULTS

Preoperative characteristics were similar between both groups. Mean operative time in the advanced bipolar device group was reduced by 32.5 minutes compared with the traditional tie and suture group (P = .006). Intraoperative blood loss was similar in both groups. Four patients presented postoperative vocal cord dysmotility, 3 in the traditional tie and suture group and 1 in the advanced bipolar device group (P = ns). Two of these 4 patients also had a >50% amplitude decrease during continuous intraoperative neuromonitoring, 1 in each group. Pain intensity, 12 hours after operation, was significantly greater in the traditional tie and suture group (P = .015), even though pain medication requirements during the initial 24 hours after operation were similar between groups (P = .97). There were no cases of postoperative hemorrhage or hematoma requiring reintervention. Postoperative, symptomatic hypocalcemia occurred in 6 patients, 4 in the traditional tie and suture, and 2 in the advanced bipolar device group. One of them developed permanent hypocalcemia.

CONCLUSION

The use of an advanced bipolar device in thyroid operation reduces operative time by >30 minutes, with a similar postoperative outcome profile when compared with the traditional tie and suture technique.

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.

Hospital costs associated with thyroidectomy performed with a Harmonic device compared to conventional techniques: a systematic review and meta-analysis

OBJECTIVES

Harmonic devices have become a world-wide standard for dissection and hemostasis in thyroidectomy. Numerous systematic reviews have reported superior operating times, blood loss, post-operative pain, length of stay, and overall safety outcomes. What has not been extensively evaluated in a robust manner is their economic impact. The purpose of this study is to evaluate the hospital costs associated with open thyroidectomy using Harmonic devices compared with conventional techniques for hemostasis.

METHODS

A systematic review of Medline, Scopus, and CENTRAL was performed from January 1, 2000 to May 23, 2014 without language restrictions for randomized clinical trials comparing Harmonic surgical devices to conventional methods in thyroidectomy. The main outcome measure was total reported costs. Costs were pooled using the ratio of means and a random effects model. Sensitivity analyses assessed whether differences in patient and trial characteristics, healthcare setting, or choice of statistical model affected outcomes.

RESULTS

Seven studies met the inclusion criteria. A total of 476 participants had procedures performed with Harmonic devices and 478 with conventional monopolar electrosurgery and clamp, cut and tie techniques. Compared with conventional techniques, Harmonic devices reduced total reported costs by 10% (p = 0.007), resulting in a $229 US dollars (USD) absolute reduction from mean baseline costs. Results remained relatively robust to additional sensitivity analyses.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that the Harmonic family of surgical devices is associated with a reduction in total reported costs in thyroidectomy compared with conventional techniques. A large portion of the overall savings derives from a reduction in operative costs.

Ultrasonic, bipolar, and integrated energy devices: comparing heat spread in collateral tissues

BACKGROUND

Integrated devices incorporating ultrasonic and bipolar technology have been used in laparoscopic surgery, however, are not yet incorporated into open operations. Here, we compare thermal spread and recurrent laryngeal nerve (RLN) functional data of the integrated THUNDERBEAT Open Fine Jaw device, the bipolar Ligasure Small Jaw, and the ultrasonic Harmonic Focus for open thyroidectomy.

MATERIALS AND METHODS

The three energy devices were compared in a live porcine model using three tissue types including liver, muscle, and thyroid. The devices were fired three times on each energy setting, and the thermal spread was measured by thermocouples that were inserted in surrounding tissues at 1-mm intervals. To determine RLN injury, devices were fired at successive 1-mm increments from the RLN until the monitor signal was lost.

RESULTS

When comparing heat generated across these devices at 1 mm, the peak temperature (Celsius) reached in liver tissue was observed with the ultrasonic device (115.4 ± 86.7), in muscle tissue with the integrated device (104.2 ± 82.1), and in thyroid with the bipolar device (81.4 ± 41.3). Temperatures generated at individual settings on each device were similar (P = 0.11-0.81). RLN injury occurred after firing on manually approximated tissue 1-mm away from the RLN for all devices; however, there was no signal loss at ≥2 mm.

CONCLUSIONS

Heat transfer was similar among all devices with the exception of the ultrasonic device when used in the liver, which showed higher temperatures. Liver tissue showed the most consistent results. RLN injury did not occur if the devices were fired on manually approximated tissue ≥2 mm from the nerve.

Education in thyroid surgery: a matched-pair analysis comparing residents and board-certified surgeons

PURPOSE

Resident participation in operative procedures is mandatory in educational residency programs but remains controversial, especially in the context of patient safety. This study compared the surgical quality and outcomes of thyroidectomies performed by surgical residents (RESs) and board-certified surgeons (BCSs).

METHODS

This retrospective matched-pair study included patients undergoing thyroidectomies for multinodular goiter, Grave's disease and early-stage thyroid cancer that were performed by a RES with BCS supervision between 2006 and 2014. The intraoperative and postoperative course, complication rates and handling of the recurrent laryngeal nerve (RLN) and parathyroid glands were analyzed.

RESULTS

In total, 112 thyroidectomies that were performed by a RES fulfilled the inclusion criteria and were matched 1:1 with BCS patients. We included 88 hemithyroidectomies, 80 subtotal thyroidectomies and 56 total thyroidectomies. No significant differences in the handling of the RLN or parathyroid glands, the rates of postoperative RLN palsies or the rates of hypocalcaemia were found. No intraoperative complications led to the replacement of the RES as the surgeon-in-charge. Three RES and two BCS patients experienced postoperative haemorrhages (p = 0.205), and three surgical site infections (p = 1.000) occurred in each group. The mean operative time and the length of stay did not differ significantly between the two groups.

CONCLUSIONS

Major aspects of patient safety in thyroid surgery are not affected by resident participation. Thyroidectomies performed by RES are not significantly longer and reveal no differences in length of stay or complication rates. The economic burden of resident involvement is modest.