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Thyroidectomy using the harmonic scalpel: A pilot study
THYROIDECTOMY USING THE HARMONIC SCALPEL: A PILOT STUDY LARRY SHEMEN, MD, FRCS(C), FACS, STEPHEN MARRA, MD, VICKEN PAMOUKIAN, MD
The harmonic scalpel has been successfully used in other surgical disciplines and general otolaryngology. We present a pilot study with the harmonic scalpel for 20 successive thyroidectomies. The advantages conferred by this instrument are superior hemostasis allowing for shortened operating time and smaller incisions.
Thyroidectomy is an established procedure for the treatment of benign and malignant diseases of the thyroid. Extirpation of the thyroid was rarely undertaken before the late 19th century because of the ensuant profuse blood loss. The first accounts of successful surgical resections of the thyroid were described by Halsted 1 and Kocher, 2 and little has changed since that time. There are 3 essential steps to the successful performance of thyroidectomy: (1) The identification and ligation of the feeding vessels, (2) identification and preservation of the laryngeal nerve(s), and (3) identification and preservation (or transplantation) of the parathyroid glands. One of the most challenging aspects of the procedure is the ligation of the superior thyroid artery and vein above the superior pole of the thyroid with preservation of the external branch of the superior laryngeal nerve. To facilitate this dissection, particularly when the access is limited, we have recently used the harmonic scalpel. This report describes our experience with this device.
MATERIALS AND METHODS Twenty consecutive thyroidectomies were performed with the harmonic scalpel using the CS-14C handpiece (TM Ethicon Endosurgical, Cincinatti, OH). These included large mediastinal goiters, toxic glands, and thyroid cancers. We evaluated the ease of dissection, security of the vessel ligation, operating time, and complications. These results were compared against 20 consecutive thyroidectomies performed before the the harmonic scalpel was introduced into our practice. From the Department of Surgery, Lenox Hill Hospital, St. Vincent's Hospital, New York Hospital, Queens, NY, and the Department of Otorhinolaryngology, Weill Medical College, Cornell University, Ithaca, NY; the Department of Otolaryngology, New York University, Lenox Hill Hospital, New York, NY; and the Department of General Surgery, Lenox Hill Hospital, New York, NY. Presented at the New York Thyroid Club Meeting, October 6, 2000. Address reprint requests to Larry Shemen, MD, 233 East 69th St., Suite 1D, New York, NY 10021. Copyright © 2001 by W.B. Saunders Company 1043-1810/01/1204-0017535.00/0 doi:10.1053/otot.2001.30055 256
TECHNIQUE The harmonic scalpel is available as a straight or curved instrument, either 5 or 10 mm wide. We used the harmonic scalpel CS14C handpiece in all cases. It is composed of an active, curved blade, a protective anvil, and a shaft 14-cm long and 5-mm wide (Fig 1). The superior pole of the thyroid was exposed by retracting the strap muscles laterally and superiorly. When necessary, the medial edge of the sternothyroid muscle was transected just below the thyroid cartilage to gain additional exposure. The superior thyroid vessels were then skeletonized with a right angle dissector or McCabe dissector. The harmonic scalpel blade was then clasped around the superior thyroid vein or artery, and the instrument was then activated using a foot pedal. With the protective blade facing upwards, a gentle upward pressure was applied, and the vessels were sealed and transected. This was lParticularly useful when the exposure of these vessels was imited. The harmonic scalpel was also used in a similar fashion to transect the inferior thyroid artery and soft tissue at the inferior pole of the thyroid and the middle thyroid vein. Finally, the device was used to divide the isthmus when it was small. In this case, the blade was applied sequentially. None of these incisions were drained.
RESULTS Among those undergoing surgery with the harmonic scalpel, there were a total of 18 patients undergoing 20 procedures; 1 man and 17 women. Two women were found on frozen section to have follicular lesions, which was subsequently changed to follicular cancer on permanent sections, and therefore underwent completion thyroidectomy at a second operation. The average age was 44.7 years, with a range of 28 to 68 years. There was one case each of papillary cancer, follicular cancer, and Hurthle cell cancer. Total thyroidectomy was performed in 6 patients at the first sitting and a completion thyroidectomy in 2. The average thyroid gland size was 5.12 cm in maximum diameter. When comparing the operating time for a hemithyroidectomy, the use of the harmonic scalpel shortened the
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 12, NO 4 (DEC), 2001: PP 256-258
FIGURE 2, View of the entire harmonic scalpel handpiece (CS 14C).
FIGURE 1. Enlarged view of the harmonic scalpel tip (CS 14C), showing the active blade and inactive anvil.
duration by 30 minutes to an average of 50 minutes, as compared with 90 minutes using the conventional technique. Operating time for total thyroidectomy was reduced to 80 minutes when using the harmonic scalpel, as compared with 120 minutes for the conventional technique. More importantly, the operative blood loss with the harmonic scalpel was negligible in all cases, and the severed vessels did not bleed at all. We tested the sealed vessels by performing a Valsalva maneuver before closure to verify the absence of bleeding. The average skin incision was 4.7 cm and varied from 4 cm to 5.5 cm. Early in the study, 2 patients had small, superficial skin burns when the active blade touched the skin surface while transecting a given vessel. These healed uneventfully. No other complications were enumerated. This compared with an average incision length of 5.5 cm for the conventional method (Table 1). No patient in either group had a postoperative hematoma/hemorrhage, permanent hypocalcemia, or recurrent laryngeal nerve injury. DISCUSSION
The thyroid is supplied superiorly, laterally, and inferiorly by vascular structures. These vessels must be securely sealed to perform a safe and expeditious operation. The superior thyroid artery and vein are, at times, difficult to approach and ligate as they enter the superior aspect of the gland under the cover of the sternothyroid muscle. In our study, a new technology was instituted to perform this oftentimes difficult task. The harmonic scalpel was chosen
because of its favorable use in general, laproscopic, and gynecologic surgery. The harmonic scalpel is a system composed of a generator, foot pedal, handpiece and disposable blade (Fig 2). It generates a natural harmonic frequency of 55,000 Hz. The acoustic wave is then transmitted down the shaft of the scalpel to the active blade, causing it to vibrate at that same frequency. When applied to tissues, it causes cavitational fragmentation and cavitational cutting rather than electrical or thermal coagulation, as is the case with a standard cautery. The harmonic scalpel can effectively seal and cut a vessel up to 3 mm in diameter. Moreover, because it does not operate through electrical energy, less heat is generated than conventional cautery. As compared with the Bovie or bipolar, far less thermal energy is transmitted to the surrounding structures, with a resultant less chance of thermal injury. When compared with electrosurgery or CO2 laser, the harmonic scalpel caused 1 m m 2 of epidermal destruction and 0.5 m m 2 of dermal collagen denaturation as opposed to 2.5 m m 2 and 4 m m 2 epidermal destruction for the electrosurgery and laser respectfully, or 1.5 mm 2 and 2.5 mm 2 collagen denaturation for the electrosurgery and laser respectfully.3 The vibration does cause some heat that will injure the skin if it is contacted, as in 2 of our cases. It has been used for several years in general surgery, laparoscopic surgery 4'5 and gynecologic surgery. 6 There are several advantages to the device. The tip is of narrow caliber, thereby allowing it to access tight spaces. It reliably seals the vessels. It transmits little heat to the surrounding structures. It affords the surgeon the ability to control these vessels despite limited access, thus obviating the need for large incisions. The disadvantages of the harmonic scalpel are that the active blade can easily injure surrounding vital structures or skin if inadvertently applied. Secondly, the actual grip is rather bulky and a w k w a r d and requires familiarity before one becomes comfortable with its use. Finally, we have found the activator foot pedal to be difficult to use. Several modifications have been suggested to deal with these issues.
TABLE 1. Comparison Between Conventional Thyroidectomy Versus Thyroidectomy With the Harmonic Scalpel Type of Surgery
Average Operating Time
Average Incision Length
Complications
Conventional Harmonic Scalpel
90 minutes 50 minutes
5.5 cm 4.7 cm
None 2 superficial skin burns
SHEMEN, MARRA, AND PAMOUKIAN
257
SUMMARY
REFERENCES
A retrospective analysis of 2 groups of patients u n d e r g o ing t h y r o i d e c t o m y was performed. The s t u d y group of 20 thyroidectomies was p e r f o r m e d with the harmonic scalpel, whereas the c o m p a r i s o n g r o u p u n d e r w e n t conventional thyroidectomy. Those in the s t u d y group had a shortened operating time and the incisions were smaller. N o patient in either group had a postoperative hematoma, recurrent laryngeal nerve injury, or p e r m a n e n t hypocalcemia. Early in the s t u d y group, 2 patients h a d superficial skin burns caused w h e n the active blade inadvertently contacted the skin; they healed uneventfully. We conclude that the harmonic scalpel has conferred significant advantages in the successful performance of thyroidectomy.
1. Halsted WS: The operative story of goiter. Johns Hopkins Hosp Rep 19:169, 1920 2. Becker WF: Pioneers in thyroid surgery. Ann Surg 185:493, 1977 3. Hambley R, Hebda PA, Abell E, et al: Wound healing of skin incisions produced by ultrasonically vibrating knife, scalpel, electrosurgery and carbon dioxide laser. J Derm Surg Oncol 14:12131217, 1988 4. Rothenberg S: Laparoscopic splenectomy using the harmonic scalpel. J. Laparoendos Surg 6:S-61, 1996 5. Amaral J: Laparoscopic cholecystectomy in 200 consecutive patients using an ultrasonically activated scalpel. Surg Laparosc Endos 5:255262, 1995 6. Robbins ML, Ferland RJ. Laparoscopic-assistedvaginal hysterectomy using the laparascopic coagulating shears. J Am Assoc Gynecol Laparoscop 2:339-343, 1995
258
THYROIDECTOMY USING THE HARMONIC SCALPEL
The harmonic scalpel has been successfully used in other surgical disciplines and general otolaryngology. We present a pilot study with the harmonic scalpel for 20 successive thyroidectomies. The advantages conferred by this instrument are superior hemostasis allowing for shortened operating time and smaller incisions.
Thyroidectomy is an established procedure for the treatment of benign and malignant diseases of the thyroid. Extirpation of the thyroid was rarely undertaken before the late 19th century because of the ensuant profuse blood loss. The first accounts of successful surgical resections of the thyroid were described by Halsted 1 and Kocher, 2 and little has changed since that time. There are 3 essential steps to the successful performance of thyroidectomy: (1) The identification and ligation of the feeding vessels, (2) identification and preservation of the laryngeal nerve(s), and (3) identification and preservation (or transplantation) of the parathyroid glands. One of the most challenging aspects of the procedure is the ligation of the superior thyroid artery and vein above the superior pole of the thyroid with preservation of the external branch of the superior laryngeal nerve. To facilitate this dissection, particularly when the access is limited, we have recently used the harmonic scalpel. This report describes our experience with this device.
MATERIALS AND METHODS Twenty consecutive thyroidectomies were performed with the harmonic scalpel using the CS-14C handpiece (TM Ethicon Endosurgical, Cincinatti, OH). These included large mediastinal goiters, toxic glands, and thyroid cancers. We evaluated the ease of dissection, security of the vessel ligation, operating time, and complications. These results were compared against 20 consecutive thyroidectomies performed before the the harmonic scalpel was introduced into our practice. From the Department of Surgery, Lenox Hill Hospital, St. Vincent's Hospital, New York Hospital, Queens, NY, and the Department of Otorhinolaryngology, Weill Medical College, Cornell University, Ithaca, NY; the Department of Otolaryngology, New York University, Lenox Hill Hospital, New York, NY; and the Department of General Surgery, Lenox Hill Hospital, New York, NY. Presented at the New York Thyroid Club Meeting, October 6, 2000. Address reprint requests to Larry Shemen, MD, 233 East 69th St., Suite 1D, New York, NY 10021. Copyright © 2001 by W.B. Saunders Company 1043-1810/01/1204-0017535.00/0 doi:10.1053/otot.2001.30055 256
TECHNIQUE The harmonic scalpel is available as a straight or curved instrument, either 5 or 10 mm wide. We used the harmonic scalpel CS14C handpiece in all cases. It is composed of an active, curved blade, a protective anvil, and a shaft 14-cm long and 5-mm wide (Fig 1). The superior pole of the thyroid was exposed by retracting the strap muscles laterally and superiorly. When necessary, the medial edge of the sternothyroid muscle was transected just below the thyroid cartilage to gain additional exposure. The superior thyroid vessels were then skeletonized with a right angle dissector or McCabe dissector. The harmonic scalpel blade was then clasped around the superior thyroid vein or artery, and the instrument was then activated using a foot pedal. With the protective blade facing upwards, a gentle upward pressure was applied, and the vessels were sealed and transected. This was lParticularly useful when the exposure of these vessels was imited. The harmonic scalpel was also used in a similar fashion to transect the inferior thyroid artery and soft tissue at the inferior pole of the thyroid and the middle thyroid vein. Finally, the device was used to divide the isthmus when it was small. In this case, the blade was applied sequentially. None of these incisions were drained.
RESULTS Among those undergoing surgery with the harmonic scalpel, there were a total of 18 patients undergoing 20 procedures; 1 man and 17 women. Two women were found on frozen section to have follicular lesions, which was subsequently changed to follicular cancer on permanent sections, and therefore underwent completion thyroidectomy at a second operation. The average age was 44.7 years, with a range of 28 to 68 years. There was one case each of papillary cancer, follicular cancer, and Hurthle cell cancer. Total thyroidectomy was performed in 6 patients at the first sitting and a completion thyroidectomy in 2. The average thyroid gland size was 5.12 cm in maximum diameter. When comparing the operating time for a hemithyroidectomy, the use of the harmonic scalpel shortened the
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 12, NO 4 (DEC), 2001: PP 256-258
FIGURE 2, View of the entire harmonic scalpel handpiece (CS 14C).
FIGURE 1. Enlarged view of the harmonic scalpel tip (CS 14C), showing the active blade and inactive anvil.
duration by 30 minutes to an average of 50 minutes, as compared with 90 minutes using the conventional technique. Operating time for total thyroidectomy was reduced to 80 minutes when using the harmonic scalpel, as compared with 120 minutes for the conventional technique. More importantly, the operative blood loss with the harmonic scalpel was negligible in all cases, and the severed vessels did not bleed at all. We tested the sealed vessels by performing a Valsalva maneuver before closure to verify the absence of bleeding. The average skin incision was 4.7 cm and varied from 4 cm to 5.5 cm. Early in the study, 2 patients had small, superficial skin burns when the active blade touched the skin surface while transecting a given vessel. These healed uneventfully. No other complications were enumerated. This compared with an average incision length of 5.5 cm for the conventional method (Table 1). No patient in either group had a postoperative hematoma/hemorrhage, permanent hypocalcemia, or recurrent laryngeal nerve injury. DISCUSSION
The thyroid is supplied superiorly, laterally, and inferiorly by vascular structures. These vessels must be securely sealed to perform a safe and expeditious operation. The superior thyroid artery and vein are, at times, difficult to approach and ligate as they enter the superior aspect of the gland under the cover of the sternothyroid muscle. In our study, a new technology was instituted to perform this oftentimes difficult task. The harmonic scalpel was chosen
because of its favorable use in general, laproscopic, and gynecologic surgery. The harmonic scalpel is a system composed of a generator, foot pedal, handpiece and disposable blade (Fig 2). It generates a natural harmonic frequency of 55,000 Hz. The acoustic wave is then transmitted down the shaft of the scalpel to the active blade, causing it to vibrate at that same frequency. When applied to tissues, it causes cavitational fragmentation and cavitational cutting rather than electrical or thermal coagulation, as is the case with a standard cautery. The harmonic scalpel can effectively seal and cut a vessel up to 3 mm in diameter. Moreover, because it does not operate through electrical energy, less heat is generated than conventional cautery. As compared with the Bovie or bipolar, far less thermal energy is transmitted to the surrounding structures, with a resultant less chance of thermal injury. When compared with electrosurgery or CO2 laser, the harmonic scalpel caused 1 m m 2 of epidermal destruction and 0.5 m m 2 of dermal collagen denaturation as opposed to 2.5 m m 2 and 4 m m 2 epidermal destruction for the electrosurgery and laser respectfully, or 1.5 mm 2 and 2.5 mm 2 collagen denaturation for the electrosurgery and laser respectfully.3 The vibration does cause some heat that will injure the skin if it is contacted, as in 2 of our cases. It has been used for several years in general surgery, laparoscopic surgery 4'5 and gynecologic surgery. 6 There are several advantages to the device. The tip is of narrow caliber, thereby allowing it to access tight spaces. It reliably seals the vessels. It transmits little heat to the surrounding structures. It affords the surgeon the ability to control these vessels despite limited access, thus obviating the need for large incisions. The disadvantages of the harmonic scalpel are that the active blade can easily injure surrounding vital structures or skin if inadvertently applied. Secondly, the actual grip is rather bulky and a w k w a r d and requires familiarity before one becomes comfortable with its use. Finally, we have found the activator foot pedal to be difficult to use. Several modifications have been suggested to deal with these issues.
TABLE 1. Comparison Between Conventional Thyroidectomy Versus Thyroidectomy With the Harmonic Scalpel Type of Surgery
Average Operating Time
Average Incision Length
Complications
Conventional Harmonic Scalpel
90 minutes 50 minutes
5.5 cm 4.7 cm
None 2 superficial skin burns
SHEMEN, MARRA, AND PAMOUKIAN
257
SUMMARY
REFERENCES
A retrospective analysis of 2 groups of patients u n d e r g o ing t h y r o i d e c t o m y was performed. The s t u d y group of 20 thyroidectomies was p e r f o r m e d with the harmonic scalpel, whereas the c o m p a r i s o n g r o u p u n d e r w e n t conventional thyroidectomy. Those in the s t u d y group had a shortened operating time and the incisions were smaller. N o patient in either group had a postoperative hematoma, recurrent laryngeal nerve injury, or p e r m a n e n t hypocalcemia. Early in the s t u d y group, 2 patients h a d superficial skin burns caused w h e n the active blade inadvertently contacted the skin; they healed uneventfully. We conclude that the harmonic scalpel has conferred significant advantages in the successful performance of thyroidectomy.
1. Halsted WS: The operative story of goiter. Johns Hopkins Hosp Rep 19:169, 1920 2. Becker WF: Pioneers in thyroid surgery. Ann Surg 185:493, 1977 3. Hambley R, Hebda PA, Abell E, et al: Wound healing of skin incisions produced by ultrasonically vibrating knife, scalpel, electrosurgery and carbon dioxide laser. J Derm Surg Oncol 14:12131217, 1988 4. Rothenberg S: Laparoscopic splenectomy using the harmonic scalpel. J. Laparoendos Surg 6:S-61, 1996 5. Amaral J: Laparoscopic cholecystectomy in 200 consecutive patients using an ultrasonically activated scalpel. Surg Laparosc Endos 5:255262, 1995 6. Robbins ML, Ferland RJ. Laparoscopic-assistedvaginal hysterectomy using the laparascopic coagulating shears. J Am Assoc Gynecol Laparoscop 2:339-343, 1995
258
THYROIDECTOMY USING THE HARMONIC SCALPEL