The use of a vessel sealing system in thyroid surgery

Thyroidectomy is one of the most common operations performed for thyroid diseases throughout the world and has an extremely low morbidity rate. Although the technique of thyroidectomy has changed little for several years, different techniques have been developed for haemostasis in addition to the conventional methods. The vessel sealing system (Ligasure) is a new technology that can be applied in several surgical situations. However, there is no data in the literature regarding its use in thyroid surgery. Fifteen consecutive euthyroid patients (ten women, five men) with a range of 37-71 years of age who met the inclusion criteria were studied. The surgical procedures were performed by a single surgeon using standard techniques, but all vascular structures encountered were sealed by Ligasure and no suture material was used. The pre-operative, intraoperative and postoperative parameters were recorded and analyzed. Fluid collection was evaluated by ultrasonography and clinical examination on the 3rd postoperative day, The results were compared with the conventional knot tying method in a group of 25 patients. A Ligasure device was successfully used in 15 consecutive procedures, including ten total thyroidectomies, three hemithyroidectomies, one subtotal thyroidectomy and one near-total thyroidectomy. There was no operative mortality or technique-related morbidity in patients. The operating time was 75 +/- 11 minutes. The mean volume of the resected thyroid specimens was 68.3 +/- 18.9 cm3. The mean fluid collection at postoperative day three was 7.5 +/- 1.6 cm3. In conclusion, we have found that a Ligasure device can be safely used for haemostasis in thyroid surgery. It has the potential to decrease the operating time, fluid collection and blood loss.     

Endoscopic Thyroidectomy Using a New Bilateral Axillo-Breast Approach

Introduction Endoscopic techniques have recently been applied in thyroid surgery using cervical, axillary, and breast approaches. We modified the axillo-bilateral breast approach (ABBA) and developed the bilateral axillo-breast approach (BABA) to obtain optimal visualization for total thyroidectomy. Methods We used two 12-mm ports through bilateral circumareolar incisions for flexible videoscopy and Harmonic scalpel and two 5-mm ports through both axillae for graspers and dissectors. Thyroidectomy was performed under full visualization of the superior and inferior thyroidal arteries, parathyroid glands, and recurrent laryngeal nerves. Results After performing 25 ABBA endoscopic thyroid surgeries, we developed BABA and performed 110 operations using this method. The BABA operations included 52 total thyroidectomies, 2 near-total thyroidectomies, 8 subtotal thyroidectomies, 43 lobectomies, and 3 subtotal lobectomies. Pathology revealed 41 benign lesions and 69 cancers. Mean operation time was 165.3 ± 43.5 minutes. There were 2 cases of conversion to open surgery, 1 due to cancer with capsular invasion and the other due to tracheal injury. Nine postoperative complications developed: transient unilateral vocal cord palsy in 4 cases, transient hypocalcemia in 4 cases, and postoperative infection in 1 case. The 2-month postoperative thyroglobulin level was less than 1 ng/ml in all examined cases of total thyroidectomy. Cosmetic results were excellent. Conclusions The BABA technique for endoscopic thyroid surgery is a feasible method of total thyroidectomy with a low rate of postoperative complications and, additionally, excellent cosmetic results. Therefore, in selected cases of thyroid cancer, the BABA endoscopic total thyroidectomy should be considered as a valid surgical option.     

The Use of a Vessel Sealing System in Thyroid Surgery

Thyroidectomy is one of the most common operations performed for thyroid diseases throughout the world and has an extremely low morbidity rate. Although the technique of thyroidectomy has changed little for several years, different techniques have been developed for haemostasis in addition to the conventional methods. The vessel sealing system (Ligasure?) is a new technology that can be applied in several surgical situations. However, there is no data in the literature regarding its use in thyroid surgery.

Fifteen consecutive euthyroid patients (ten women, five men) with a range of 37–71 years of age who met the inclusion criteria were studied. The surgical procedures were performed by a single surgeon using standard techniques, but all vascular structures encountered were sealed by Ligasure? and no suture material was used. The pre-operative, intraoperative and postoperative parameters were recorded and analyzed. Fluid collection was evaluated by ultrasonography and clinical examination on the 3rd postoperative day, The results were compared with the conventional knot tying method in a group of 25 patients.

A Ligasure? device was successfully used in 15 consecutive procedures, including ten total thyroidectomies, three hemithyroidectomies, one subtotal thyroidectomy and one near-total thyroidectomy. There was no operative mortality or technique-related morbidity in patients. The operating time was 75 ± 11 minutes. The mean volume of the resected thyroid specimens was 68.3 ± 18.9 cm³. The mean fluid collection at postoperative day three was 7.5 ± 1.6 cm³.

In conclusion, we have found that a Ligasure? device can be safely used for haemostasis in thyroid surgery. It has the potential to decrease the operating time, fluid collection and blood loss.     

Efficacy and cost-effectiveness of the UltraCision harmonic scalpel in thyroid surgery: an analysis of 200 cases in a randomized trial

BACKGROUND: Thyroid surgery technique has undergone very few changes in the last century. The UltraCision harmonic scalpel (UHS) (Smithfield, RI) has been widely used in laparoscopic surgery and is documented to be safe and fast for cutting and coagulating tissue. We studied whether the use of the UHS could have advantages in thyroid surgery in terms of operative time, length of hospitalization, morbidity, and general costs. METHOD: Our study was a prospective randomized trial of thyroidectomies and lobectomies performed for benign thyroid diseases in an endocrine surgery unit between February 2001 and July 2002. Patients were randomized in two groups: group A (n=100) underwent thyroidectomy using UHS and group B (n=100) with the conventional clamp-and-tie technique. Main outcome measures were demographics, operating time, length of hospitalization, intra- and postoperative complications, sequelae, and general costs. We used the unpaired 2-tailed Student's t test and the chi2 test to compare the series. RESULTS: The two groups were similar in age and sex. Mean +/- SD operative time was shorter in the UHS group compared with the conventional technique group for both lobectomy (61 +/- 06 vs. 78 +/- 10 minutes) and total thyroidectomy (86 +/- 20 vs. 101 +/- 16 minutes). Length of hospitalization was similar in both groups (1.07 vs. 1.15 days). We did not find statistical differences between the two techniques regarding transient postoperative complications. There were no deaths, no blood transfusions, no intraoperative complications, and no postoperative definitive sequelae. The global charges for every patient were significantly less in the UHS group (985.77 +/- 107.08 euro vs. 1148.40 +/- 153.25 euro). CONCLUSION: The use of ultrasonically activated shears resulted in a reduction of 15-20% in operative time and was cost-effective compared to the conventional technique group.     

Video-assisted thyroidectomy

OBJECTIVE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this paper, we report on the entire series of patients who underwent VAT and discuss the results obtained. METHODS: Seventy-three patients were selected for VAT. Eligibility criteria were: thyroid nodules 相似文献   

Electrothermal bipolar vessel sealing system is a safe and time-saving alternative to classic suture ligation in total thyroidectomy

BACKGROUND: Total thyroidectomy is associated with minimal morbidity. The electrothermal bipolar vessel sealing system is an adjunct to the surgical technique, recently made available to thyroid surgery. METHODS: This is a prospective randomized trial of total thyroidectomies performed in single unit from July 2003 to May 2004. Patients were randomly assigned in two groups: group A (n = 90), total thyroidectomy with the classic suture ligation technique; and group B (n = 94), total thyroidectomy with the use of the electrothermal bipolar vessel sealing system. RESULTS: Operative time was significantly reduced in group B by 14 minutes (mean difference, 14.3 +/- 4.2 minutes, 95% CI, 5.88-22.6 minutes). No statistically significant differences were found in postoperative complications, postoperative serum calcium measurements, or hospital stay between the two groups. CONCLUSIONS: The electrothermal bipolar vessel sealing system is a safe and useful, time-saving adjunct for total thyroidectomy.     

超声刀在开腹直肠癌根治术中的临床应用价值

目的探讨超声刀在开腹直肠癌根治术中的临床应用价值。方法回顾性分析我院2003年9月-2006年9月收治的行直肠癌根治术72例的临床资料。其中，采用超声刀38例，采用传统术式34例。观察两组的手术时间、术中出血量、术后第1个24h引流量以及术后并发症的差异。结果超声刀组手术时间较传统手术组有明显缩短。超声刀组手术出血量、术后第1个24h引流量以及术后并发症的发生率均较传统手术组显著减少。结论超声刀在直肠癌根治术中具有很好的应用前景。     

How much skill should we need for a VATS lobectomy in stage I lung cancer? An evaluation of surgeon groups

Although there has been progress in video-assisted thoracic surgery (VATS), there have been no reports about the skill needed to perform this surgery for patients with stage I lung cancer. We reviewed a randomized series of surgeons in a single institution and attempted to identify the quality of skill needed in this surgery. Cases of surgery on clinical stage I non-small cell lung cancer (NSCLC) involving 103 patients (56 VATS and 47 conventional approach) from January 2000 to April 2006 were assessed for eligibility. We reviewed these patients and placed them in random order into three surgeon groups (groups A, B, and C) that were based on surgeons who had performed 50 lobectomies through thoracotomy. Three patients were converted to a thoracotomy. Of the remaining 53 patients, 17 were in group A, 15 were in group B, and 21 were in group C. There were no significant differences between the three surgeon groups regarding technical factors such as blood loss and operation time. After a short initial learning period, two of the three surgeon groups significantly decreased total blood loss. Morbidity and recurrence did not differ between the groups, and there was no mortality in our sample. The volume of VATS operations performed by individual surgeons who have had good training in open lobectomy may not make for a positive impact on clinical outcomes. The decision for a VATS lobectomy in cases of stage I NSCLC should not be limited only by a surgeon's thoracoscopic experience.     

Minimally invasive video-assisted thyroidectomy

BACKGROUND: In this paper we describe the results of our personal technique for minimally invasive video-assisted thyroidectomy (MIVAT). METHODS: Sixty-seven patients were selected for MIVAT. Selection criteria were nodule size less than 30 mm, thyroid volume less than 20 mL, no thyroiditis, no previous neck surgery or irradiation. The procedure, totally gasless, is carried out through a 15-mm central incision above the sternal notch. Dissection is performed under endoscopic vision, using conventional and endoscopic instruments. RESULTS: We performed 51 lobectomies and 15 total thyroidectomies. Mean operative time was 73.6 minutes for lobectomy and 109.6 minutes for total thyroidectomy. Conversion to open procedure was required twice (3%). We observed 2 cases of transient postoperative hypocalcemia and 1 case of transient recurrent laryngeal nerve palsy. The cosmetic result was considered excellent by most patients. CONCLUSIONS: MIVAT is safe and feasible. The indications are limited at present, but the results are encouraging, and we are optimistic about the future expansion of its applicability.     

Thyroid and parathyroid surgery performed with patient under regional anesthesia

Thyroid and parathyroid surgery is usually performed with the patient under general anesthesia; however, for selected patients regional anesthesia may be preferable. Between September 1977 and March 1986 regional anesthesia was used successfully as the sole anesthetic technique in 17 patients who underwent thyroid surgery and two patients who underwent parathyroid surgery. Procedures included two total thyroidectomies, 14 lobectomies or lobectomies with isthmusectomies, and one isthmusectomy. These 17 operations represent approximately 5% of the thyroid operations performed by the senior surgeon over the corresponding time. One patient underwent combined completion thyroidectomy and parathyroidectomy, and another patient underwent successful parathyroidectomy under regional anesthesia. In two additional patients, procedures could not be completed under regional anesthesia alone. In one of these two patients regional anesthesia appeared to effect a transient recurrent nerve paralysis. The indications for use of regional anesthesia have been primarily patient preference and associated cardiac or pulmonary disease. We now consider as contraindications to regional anesthesia patient apprehension about the technique, deafness, high spinal cord injury, recurrent laryngeal or phrenic nerve palsy, and allergy to local anesthesia. During this period, from 1977 to 1986, our administration of regional anesthesia has evolved from bilateral deep and superficial cervical plexus blocks to bilateral superficial blocks alone using bupivacaine with epinephrine, 1:200,000.     

Usefulness of the ultrasonically activated shears in total thyroidectomy

Surgical technique of total thyroidectomy is nowadays well known. Technology could determine some improvement of this kind of surgery. Two groups of patients that underwent total thyroidectomy were compared retrospectively. In group 1 we described 105 total thyroidectomies performed with ultrasonically activated shears; in group 2, 76 performed with conventional methods of haemostasis. Comparing the two groups for several parameters, it results that in the total thyroidectomies performed with ultrasonically actived shears, operative time is shorter of 24 minutes compared with conventional method (81 vs 105 minutes), the mean amount of intraoperative blood loss is smaller (70 ml vs 125 ml), the postoperative pain is less, the cosmetic result is better (length of incision 6 cm vs 10 cm) and the costs is not more expensive. Complications of thyroid surgery are similar between the two methods. The use of ultrasonically actived shears in total thyroidectomy is safe (no increase of complications) and useful because it reduces operative time, improves the recovery of the patient (less pain, better cosmetic results) and, finally, is not more expensive than conventional method of haemostasis.     

A randomized, prospective, parallel group study comparing the Harmonic Scalpel to electrocautery in thyroidectomy

BACKGROUND: Exhaustive hemostasis is essential to successful thyroidectomy. Electrocoagulation to control bleeding has the potential risk of injuring the surrounding structures from lateral dispersion of heat. The Harmonic Scalpel (HS) cuts and coagulates simultaneously using mechanical vibration rather than high temperatures. Because its use in thyroidectomies has been limited, we sought to compare procedure parameters and complications of thyroidectomies performed using the HS with those using electrocoagulation. METHODS: Sixty patients were randomized into 2 surgical groups, HS and the standard technique using electrocautery and ligatures as the primary hemostatic method. A sample t test or Wilcoxon rank sum test was used to compare the following parameters: operative time, number of ligatures, blood loss, pain intensity, need for extra dose(s) of analgesic, incidence of recurrent laryngeal nerve palsy, and hypoparathyroidism. RESULTS: Both groups of 30 patients were comparable in age, gender, and nature of disease. In 38 patients (63%), surgery was performed for benign disease, and in 22 (37%), for differentiated carcinoma. Operative time (arithmetic mean +/- SD) was 25 minutes less in the HS group (96 +/- 23 vs 121 +/- 34, P = .005). Median number of ligatures in the HS group was 1 (range, 0-7) versus 17 (range, 6-28) ( P < .001). Mean blood loss, estimated by gauze weight, was less with HS (35 +/- 27 mL vs 54 +/- 51 mL, P = .06). Drainage during the first 24 postoperative hours and pain intensity during the first postoperative week were similar in both groups. There were no episodes of persistent nerve palsy or hypoparathyroidism in either group. CONCLUSION: The use of HS in thyroidectomies requires less operative time than does electrocoagulation.     

A Randomized Prospective Study of Complications Between General Surgery Residents and Attending Surgeons in Near-Total Thyroidectomies

Purpose Recurrent laryngeal nerve palsy and hypoparathyroidism are the most common and serious complications after thyroid operations. Surgeon experience has been defined as a significant factor in the number of complications occurring in thyroid surgery. There has so far been no prospective randomized study that compares the complication rates between residents and the attending surgeon in statistically similar patient groups in which all of the patients undergo the same type of thyroid surgery by the same surgical team. In this prospective study the performances of residents and attending surgeons were evaluated and compared according to the complication rates in near-total thyroidectomies.Methods One hundred and fifty-two patients underwent near-total thyroidectomies between April 2001 and May 2003. The number of randomly selected patients operated on by residents at the level of postgraduate year two, under the direct supervision of an attending surgeon, and the number of patients operated on by attending surgeons were 78 and 74, respectively. All patients had preoperative and postoperative videolaryngostroboscopic examinations of the vocal cords and serum calcium level evaluation.Results The rates of temporary vocal cord paralysis with respect to the nerves at risk for residents and attending surgeons were 3.7% and 2.7%, respectively. The temporary hypoparathyroidism rate was 8.1% for attending surgeons, whereas it was found to be 6.4% for residents. Neither any cases of permanent vocal cord paralysis nor permanent hypoparathyroidism were detected.Conclusion Our results indicate that the complication rates in near-total thyroidectomies performed by residents and attending surgeons are similar. Thyroid surgery can therefore be safely and effectively performed by residents under close supervision.     

Hand-assisted laparoscopic abdominal aortic aneurysm repair.

Hand-assisted laparoscopic aneurysm resection enables the surgeon to use his tactile senses while performing a laparoscopic aneurysm repair. Even more complex procedures that involve suprarenal clamping of the aorta can be performed by using this laparoscopically assisted approach. Twenty-nine laparoscopic patients were compared with a control group of 19 patients who were operated on conventionally. Transperitoneal hand-assisted laparoscopic aneurysm resection with a tube graft or a bifurcated graft was performed. The anastomosis was sutured with conventional instruments using the mini-incision as an access. The time for laparoscopy did not exceed 40 minutes. The incidence of complications did not vary between groups. The mean operating time was 135 minutes in the conventional group versus 180 minutes in the minimal invasive group. Intensive care stay and postoperative hospital stay were significantly shorter after the laparoscopic procedure. An oral diet was resumed significantly earlier, and the time until complete recovery was shortened in the miniaccess group. Hand-assisted laparoscopic aneurysm resection can be performed safely with operating times almost as expeditiously as in open surgery. Because it can be offered to the majority of patients with aortic disease, the technique described has distinct advantages over a total laparoscopic approach and a less steep learning curve.     

Epidural anesthesia with high dose fentanyl for thoracic surgeries]

Twenty-two elective thoracic surgeries were performed under epidural high dose fentanyl anesthesia. These included 11 mastectomies, 3 lung lobectomies, and 8 operations for esophageal carcinoma. Through an epidural catheter, 10 micrograms.kg-1 fentanyl with [E (+)] or without [E (-)] epinephrine (1: 100,000) was given. N2O (66%) and enflurane (0.2-0.8%) were also administered, and muscle relaxants were given as needed. The onset and duration of the action were approximately 20 minutes and 3 hours, respectively. Anesthesia was maintained with enflurane (up to 0.4%) in 17 patients (77.3%). There were no differences between the E (+) group and the E (-) group. Systolic pressure, diastolic pressure and heart rate during operations were about 30% lower than those observed before the operations. Patients recovered from anesthesia rapidly. Naloxone was administered intravenously in 6 patients after mastectomies or lung lobectomies (42.9%), whose respiratory rate was below 10.min-1. The patients with short operating time (shorter than 2 hours) needed more naloxone. Troubles did not occur either in the recovery room or in the ward with both naloxone and non-naloxone groups.     

Video-assisted thyroidectomy with minimally invasive central cervicotomy: initial experience in an endocrine surgery division

Minimally invasive video-assisted thyroidectomy, a recently developed technique, has been shown to be feasible and safe. Nevertheless, to obtain the best results, the surgeon should be well trained in endoscopic surgery. We attempted to answer the question whether an endocrine surgery division with no previous experience in endoscopic neck surgery could easily import the new technique. The inclusion criteria were nodules < or = 3.5 cm diameter or thyroid lobe volume less than 15 ml, and no thyroiditis or previous neck surgery. Suspect malignant nodules were excluded. The procedure was carried out through a 20 to 30 mm central neck incision, with external retraction and no neck insufflation. The vessels were ligated or closed by means of clips. From March 2004 to March 2005, 127 thyroidectomies were performed, of which 36 were thyroid lobectomies. Of these, 12 lobectomies by minimally invasive video-assisted thyroidectomy were performed for monolateral goiter (4 left, 8 right). There were no intraoperative complications. No recurrent laryngeal nerve palsy or permanent hypoparathyroidism occurred. The mean operative time was 74.4 min (median: 70; range: 45-115). The results, in terms of patient comfort, reduced postoperative pain and cosmetic quality were excellent. The technique allowed careful assessment of the inferior and superior laryngeal nerve. Thorough haemostasis was aided by the magnification of the image and optimal illumination. The learning curve appeared short, owing probably to previous experience in conventional endocrine surgery and the closer similarities of minimally invasive video-assisted thyroidectomy to enhanced-view conventional surgery than to laparoscopic surgery. In our experience the clinical impact was limited as a result of the small percentage of patients fulfilling the strict inclusion criteria.     

超声刀在乳腺癌改良根治术中应用效果研究

目的研究超声刀在乳腺癌改良根治术中的应用效果。方法回顾性分析77例乳腺癌改良根治术患者的临床资料,其中41例使用超声刀,36例用电刀,对比两组手术时间、术中出血量、术中副损伤(血管、淋巴管、神经损伤)率、淋巴结检出数、术后24 h引流量、腋窝引流管留置时间、拆线时间、术后住院时间、术后再出血、皮瓣坏死、皮下积液等术后并发症的发生率。结果两组比较手术时间、术中出血量、术中副损伤率、术后再出血率、皮瓣坏死率、皮下积液率和淋巴结检出数无明显差别(P>0.05);对比术后24 h引流量、腋窝引流管留置时间、住院时间、拆线时间,超声刀组均优于电刀组(P<0.05或P<0.01)。结论在乳腺癌改良根治术中应用超声刀效果好,并发症发生率低,术后恢复时间短,值得推广。     

The use of the harmonic scalpel in thyroid surgery. Our experience

The aim of this study was to evaluate the potential advantages of the use of Harmonic Scalpel in thyroidectomies in terms of operative time and complications. Between May 2007 and June 2010 1151 patients were submitted to total thyroidectomy. In 681 thyroidectomies were performed using harmonic scalpel FOCUS (group A), in 470 without it (group B). Mean operative time was 97 minutes in group A and 114 in group B with a mean difference of 17 minutes (14.9%). 554 patients in group A (81.35%) and 345 in group B (73.4%) were discharged in second postoperative day. In group A, hypoparathyroidism was present in 348 patients at discharge (48%), in 23 at 6 months (3.38%) and in 10 at 12 months (2.13%), in group B, in 255 at discharge (54.26%), in 61 at 6 months (12.98%) and in 28 at 12 months (5.96%). The major benefit of Harmonic Scalpel used during thyroidectomy is the reduction in the time of operation. All studies but one to date have reported reductions in operative time, ranging from 6 to 78 minutes with a 10% to 35% savings in operative time and this was confirmed in our study. A reduction of hypoparathyroidism, particularly transitory, and in length of hospital stay was reported in some studies and confirmed in our experience. The use of Harmonic Scalpel in thyroid surgery is safe and effective and is associated with a significant reduction in operative time, postoperative hypocalcaemia and hospital stay, without increasing complications rate.     

Robotic assisted, laparoscopic pelvic lymph node dissection in humans

PURPOSE: We evaluate the feasibility and efficacy of robotic assisted, laparoscopic pelvic lymph node dissection for locally advanced prostate cancer staging. MATERIALS AND METHODS: Robotic assisted, laparoscopic pelvic lymph node dissection was performed in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic group). Operative, postoperative and pathological parameters were compared with the results of the last 10 patients undergoing conventional, laparoscopic pelvic lymph node dissection performed with similar indications by the same operator (laparoscopy group). RESULTS: All operations were performed according to the established protocol with no specific intraoperative or postoperative complications. No conversion was required, and no technical incidents were observed in the robotic group. Mean operating time plus or minus standard deviation for the robotic group was 125 +/- 57 minutes (range 75 to 215), significantly longer than that for the laparoscopy group, which was 60 +/- 15 minutes (p = 0.0013). In the robotic group 2 patients presented with postoperative lymphoceles revealed in 1 by deep venous thrombosis and in the second by obturator pain. In the laparoscopy group 1 patient presented with acute urinary retention. The histological results concerning the number of lymph nodes removed were similar in both groups (p = 0.5). CONCLUSIONS: We show the technical feasibility of robotic assisted, laparoscopic pelvic lymph node dissection in humans. Although the benefit of this technique has not yet been established, predictable technological improvements would suggest the development of telesurgery and an improved precision of surgical procedure.