A prospective randomised single blinded study comparing harmonic scalpel tonsillectomy with bipolar tonsillectomy

OBJECTIVE: To compare the differences in pain, analgesic use and bleeding in children after tonsillectomy using either a harmonic scalpel or a bipolar diathermy surgical technique. METHODS: Children 6-15 years presenting for tonsillectomy were randomised to either a harmonic scalpel or bipolar diathermy surgical technique. Post-operative pain scores (VAS, 0-10) were recorded within 30 min of surgery and again at the 4h hospital discharge. A subsequent telephone interview daily for 7 days and then every second day until day 13 was used to monitor pain scores, analgesic use and tonsil bed bleeding. RESULTS: There were 204 children studied. The response rate over the first 7 days was 93% for the children in the harmonic scalpel group and 87% for the bipolar group. Children experienced moderate post-operative pain for the first 6 days, after which pain declined from 4-7 to reach a score of 1-2 by day 11. Children undergoing harmonic scalpel tonsillectomy (n=103) reported higher mean pain scores than those who underwent bipolar diathermy (n=101) for current pain (4.7 versus 4.2, p=0.002), worst pain of the day (6.9 versus 6.2, p<0.001) and pain on swallowing (5.9 versus 5.2, p<0.001) over the first 6 post-operative days. Analgesic use (acetaminophen, ibuprofen) was similar in both groups. Hospital readmission for bleeding in children who underwent harmonic scalpel was similar to those who underwent bipolar diathermy tonsillectomy (9% versus 11%) as was bleeding requiring surgical re-exploration (4% versus 2%). CONCLUSIONS: Tonsillectomy was associated with considerable pain for the first 6 post-operative days. Children undergoing harmonic scalpel tonsillectomy had a slight increase in pain compared to the bipolar diathermy group during this time. Both methods of tonsillectomy are effective and safe.     

The ultrasonically activated scalpel versus bipolar diathermy for tonsillectomy: a prospective, randomized trial

Among patients undergoing tonsillectomy, the ultrasonic scalpel has been reported to lead to less intraoperative blood loss than cold dissection, and less postoperative pain and faster recovery than monopolar electrocautery. However, the ultrasonic scalpel has not been compared with bipolar diathermy. The present study was a prospective, randomized, single-blind trial, comparing these two techniques with respect to postoperative pain. Twenty-one adults underwent tonsillectomy on one side using the ultrasonic scalpel, and on the other using bipolar diathermy. Pain scores were obtained on postoperative days 1, 2, 7 and week 3. There was no difference between the two treatments at any of the time points (P = 0.6047, 0.4018, 0.6047 and 0.5000, respectively). Inability to control bleeding with the ultrasonic scalpel resulted in the rescue use of an alternative technique of haemostasis in 14 cases. We conclude that the use of the ultrasonic scalpel in adult tonsillectomy is likely to be limited by its substantial costs and difficulties with haemostasis.     

Harmonic scalpel versus bipolar tonsillectomy: a double-blind clinical trial

This is a double bind clinical trial which evaluated harmonic scalpel versus bipolar diathermy tonsillectomy The study was conducted at Diyarbakir government hospital, Diyarbakir, Turkey. The study population comprised 144 patients, aged 4–18 years (mean 9 years  ± 4.12 SD). All patients underwent tonsillectomy with or without adenoidectomy. The indications for tonsillectomy were obstructive sleep apnea (84 patients [58.3%]) and chronic tonsillitis (60 patients [41.7%]). All 144 patients were randomly divided into two groups: bipolar dissection (81 patients [56.2%] with mean age 8.98 years ± 4.22) and harmonic scalpel (63 patients [43.8%] with mean age 9 years ± 4.02). BD group showed statistically significantly less intraoperative bleeding (< 0.05). There was no statistically significant difference on postoperative day 1 but a statistically significant difference was determined on postoperative days 4, 7 and 14. There was no statistically significant difference between the two techniques with regard to immediate and delayed bleeding. The mean operative time was the same in both the groups. Bipolar dissection group showed statistically significant less intraoperative bleeding than harmonic scalpel group. An analysis of postoperative pain scores showed that the harmonic scalpel group pain scores are lower than the bipolar dissection group on all recorded days, and no statistically significant complications was seen in both groups. The results of this study indicate that the HS technique is associated with lower pain scores with the same complication rates as the BD technique.     

Ligation versus bipolar diathermy for hemostasis in tonsillectomy: a comparative study

Tonsillectomy despite being less performed nowadays still is a very common surgery performed by ENT surgeons. The use of various modalities like bipolar diathermy, laser, cryosurgery, radiofrequency and ionic coblation for hemostasis in tonsillectomy remains controversial so far. A thorough scan of literature comparing the ligation with diathermy has been presented. In this prospective study, we analysed 50 patients undergoing tonsillectomy by dissection method. Right sided tonsillectomies act as study group (bipolar diathermy used) and left sided tonsillectomies as the control group (ligation for hemostasis used). The aim of our study is to compare the amount of blood loss, number of ligatures applied, average time taken and incidence of postoperative haemorrhage following the use of ligation and bipolar diathermy. The study found that diathermy hemostatic technique is associated with a quicker procedure, less intraoperative blood loss, comparable postoperative pain.     

Harmonic scalpel tonsillectomy versus monopolar diathermy tonsillectomy: a prospective study

For tonsillectomy, the ultrasonic harmonic scalpel has been purported to cause less tissue injury and postoperative morbidity while providing adequate levels of hemostasis. We undertook a prospective study to compare outcomes in 162 patients who had undergone harmonic scalpel tonsillectomy and 40 patients who had undergone monopolar diathermy tonsillectomy over a 33-month period. We found that patients in the harmonic scalpel group experienced significantly less intraoperative bleeding (5.0 vs. 16.5 ml; p < 0.0001). There was no clinically significant difference between the groups with respect to (1) the amount of operating time, (2) the incidence of postoperative nausea and vomiting, dysphonia, and primary or secondary bleeding, and (3) the amount of time patients needed to resume normal diet and activities.     

Key messages from the National Prospective Tonsillectomy Audit

OBJECTIVES: Investigation of the occurrence of postoperative hemorrhage after tonsillectomy and risk factors for these complications. STUDY DESIGN: Prospective National Audit with electronic web-based data collection from the National Health Service and independent hospitals in England and Northern Ireland. METHODS: Consenting patients undergoing tonsillectomy between July 2003 and September 2004 were included. A central database of patient and surgical variables was developed for analysis of primary and secondary postoperative hemorrhage and development of risk models for tonsillectomy complications. RESULTS: The Audit received data from 277 hospitals in England and Northern Ireland on 40,514 patients. Analysis was conducted on 33,921 (84%) who gave consent. Over the whole Audit 1,197 (3.5%) postoperative hemorrhages were recorded. One hundred eighty-eight (0.6%) patients sustained a primary hemorrhage and 1,033 (3%) a secondary hemorrhage (24 had both). Elevated hemorrhage rates were observed in tonsillectomies performed using diathermy for dissection and hemostasis compared with cold steel dissection and ties for hemostasis. National guidance issued midway through the Audit influenced practice and reduced hemorrhage rates. Risk models for postoperative hemorrhage were developed incorporating the effect of the guidance. For hemorrhage, compared with the cold steel group, bipolar diathermy tonsillectomy had an odds ratio of 2.47 (1.81-3.36), P < .0001, and bipolar diathermy scissors tonsillectomy an odds ratio of 3.20 (2.09-4.90), P < .0001. Use of bipolar diathermy for hemostasis only after cold steel dissection carried an intermediate risk, odds ratio 1.57 (1.16-2.13), P = .004. CONCLUSIONS: The results confirm that "hot" tonsillectomy techniques carry a substantially elevated risk of postoperative hemorrhage when diathermy is used as a dissection tool in tonsillectomy.     

Harmonic scalpel versus conventional tonsillectomy: a double-blind clinical trial

We conducted a prospective, double-blind clinical trial to evaluate the differences in operating time, intraoperative blood loss, postoperative pain at 3 hours and 1 week, and delayed (>24 hr) bleeding associated with ultrasonic harmonic scalpel tonsillectomy and conventional tonsillectomy. The study was carried out on 28 patients with recurrent tonsillitis and/or adenotonsillar hypertrophy who underwent harmonic scalpel tonsillectomy on one side and cold dissection tonsillectomy with suction electrocautery hemostasis on the other. The harmonic scalpel was associated with significantly less intraoperative blood loss (mean: 6.2 vs. 58.8 ml; p < 0.0001) and less early (3 hr) postoperative pain as determined by scores on a 10-point visual analog scale (mean: 3.5 vs. 4.4; p = 0.0042); although the difference in early pain scores is statistically significant, it is probably not clinically significant. Pain scores at 1 week were nearly identical (mean: 2.7 vs. 2.6; p = 0.9246). The length of operating time was similar (mean: 10.9 vs. 7.7 min; p = 0.0022). An unanticipated finding was the fact that delayed bleeding, which occurred in 3 patients (10.7%), occurred only on the harmonic scalpel side. We conclude that the only clearly demonstrable advantage that the harmonic scalpel had over cold dissection was that it caused less intraoperative blood loss.     

Coblation tonsillectomy versus dissection tonsillectomy: postoperative hemorrhage

OBJECTIVES/HYPOTHESIS: Coblation tonsillectomy is a recently introduced surgical technique. To measure its benefits against traditional tonsillectomy techniques, it is necessary to compare their complication rates. The study aims to identify differences in reactionary and secondary hemorrhage proportions, comparing coblation with dissection tonsillectomy. STUDY DESIGN: Prospective observational cohort study. METHODS: Rates of reactionary and delayed postoperative hemorrhage were measured, comparing 844 coblation tonsillectomies with a control group of 743 tonsillectomies performed by blunt dissection with bipolar diathermy hemostasis. RESULTS: The secondary hemorrhage rate with coblation-assisted tonsillectomy was 2.25% compared with 6.19% in the control group (P <.05). The rate of secondary hemorrhage in children following coblation tonsillectomy was 0.95% compared with 4.77% in the control group (P <.05). The difference was also significant (P <.05) in the adult population (4.40% vs. 8.81%, respectively). No difference was found in the reactionary hemorrhage proportions. CONCLUSION: In the study, coblation tonsillectomy was associated with a lesser incidence of delayed hemorrhage, more significantly in the pediatric population. The new technique using tissue coblation for tonsil dissection offers significant advantages in the postoperative period compared with dissection tonsillectomy with bipolar diathermy hemostasis. Coblation is associated with less postoperative pain and early return to daily activities. Also, there are fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage with coblation. These results and the disposable nature of the coblation equipment promote coblation tonsillectomy as the authors' preferred dissection method.     

超声刀扁桃体切除术与低温等离子扁桃体切除术的对比研究

目的 探讨超声刀扁桃体切除术与低温等离子扁桃体切除术的优缺点、安全性及可行性。 方法 计算机检索中国知网(CNKI)、中国生物医学文献数据库(CBM)、万方数据库和Pubmed等数据库中国内外关于超声刀扁桃体切除术与低温等离子扁桃体切除术的随机对照试验。运用RevMan 5.3软件对两种手术方式在术中、术后指标进行Meta分析。 结果 共纳入8个随机对照试验,共722例患者。超声刀扁桃体切除术与低温等离子扁桃体切除术相比,术后出血率明显降低［SMD=0.30,95%CI(0.15, 0.600.11, 0.79), P=0.010 007］,而在手术时间、术中出血量、术后白膜开始脱落时间及术后疼痛评分等方面,超声刀组与等离子组差异无统计学意义。 结论 超声刀扁桃体切除可明显降低患者术后原发或继发出血的概率,改善患者术后的生活质量。     

How to reduce diathermy in tonsillectomy: description of technique and analysis of results

As the use of electrodissection in tonsillectomy increases, uncertainty remains concerning any association with postoperative haemorrhage. However, there is some evidence to suggest that the more diathermy is used the risk of postoperative haemorrhage increases. The technique of vessel dissection and diathermy tonsillectomy (VDDT) is described and the results of 335 consecutive cases are presented. The results are discussed in relation to bipolar diathermy tonsillectomy and microbipolar diathermy tonsillectomy and also the U.K. National Prospective Tonsillectomy Audit. It is concluded that VDDT has the advantages of cold dissection while reducing diathermy to a minimum.     

Harmonic scalpel tonsillectomy using the curved shears instrument versus cold dissection tonsillectomy: a retrospective study

OBJECTIVES: We compared operating time, intraoperative blood loss, and rate of postoperative bleeding in harmonic scalpel (HS) tonsillectomy using the curved shears instrument to those in cold dissection (CD) tonsillectomy. METHODS: The charts of 560 patients who underwent tonsillectomy were retrospectively reviewed. Three hundred nineteen patients underwent CD tonsillectomy between the years 1998 and 1999, and 241 patients underwent HS tonsillectomy using the curved shears instrument between the years 2001 and 2005. For the purpose of evaluation of postoperative bleeding rates, the groups were further stratified by age (11 years of age or less versus 12 years of age or more). RESULTS: For the HS group, the mean operating time was shorter (7 minutes versus 17.57 minutes) and the intraoperative blood loss was lower (0 mL versus 42.12 mL). These differences were statistically significant (p < .05). There was no significant difference in the overall postoperative bleeding rates between the two groups. The postoperative bleeding rate in the HS patients 11 years of age or younger was lower than that in the equivalent age group in the CD group (0.56% versus 2%, respectively), although this difference did not reach statistical significance. The postoperative bleeding rate in the HS patients 12 years of age or older was significantly higher than that in the equivalent age group in the CD group (7.93% versus 1%, respectively; p < .05). CONCLUSIONS: Harmonic scalpel tonsillectomy using the curved shears instrument offers advantages over CD tonsillectomy regarding operating time and intraoperative blood loss. In our patients more than 12 years of age, HS tonsillectomy using the curved shears instrument was associated with an increased postoperative bleeding rate compared to CD tonsillectomy.     

Bipolar electrodissection tonsillectomy in children

The purpose of this study was to compare bipolar electrodissection tonsillectomy with traditional cold dissection tonsillectomy in the pediatric population. Forty children with recurrent tonsillitis and/or obstructive symptoms were included in the study. The study population was randomly divided into two groups, and the two techniques were compared with regard to operative time, intraoperative and postoperative bleeding and postoperative pain. There were 23 children in the bipolar electrodissection tonsillectomy group (mean age, 8.1 years; range, 5–12 years), and 17 children in the cold dissection tonsillectomy group (mean age, 6.7 years; range, 5–12 years). The average operative times were 15.2±8.5 min for bipolar electrodissection tonsillectomy and 29.06±13.5 min for cold dissection tonsillectomy (P<0.05). The blood loss in bipolar electrodissection tonsillectomy and cold dissection tonsillectomy was 5.0±4.2 ml and 32.1±11.3 ml, respectively (P<0.05). Postoperative hemorrhage was not observed. Bipolar electrodissection tonsillectomy was less painful the first 30 min postoperatively (P<0.05). Bipolar electrodissection tonsillectomy in children is a useful technique, with results comparable to traditional cold dissection tonsillectomy.     

Teenage and adult tonsillectomy: dose-response relationship between diathermy energy used and morbidity.

OBJECTIVE: To determine whether an increase in the use of bipolar diathermy energy to perform a tonsillectomy is associated with an increase in postoperative pain and haemorrhage. STUDY DESIGN: Prospective study. SETTING: District General Hospital. METHODS: In all, 101 patients above the age of 13 years who underwent a tonsillectomy that involved the use of bipolar diathermy during the study period were included. The cumulative amount of diathermy energy used to perform each tonsillectomy was calculated with the help of a digital stop clock timing device connected to the diathermy foot-pedal. MAIN OUTCOME MEASURES: Postoperative pain scores and the incidence of secondary haemorrhage were recorded for each patient at four points in time following surgery, up to the tenth postoperative day. The haemorrhage rates were categorised into three groups (no bleeding, minor bleeding and major bleeding) according to severity. Associations between the diathermy energy used to perform each tonsillectomy and the corresponding postoperative pain scores and secondary bleeding rates were investigated. RESULTS: There was a statistically significant positive relationship between the total amount of bipolar diathermy energy used per tonsillectomy and the pain scores at all the four recorded points in time (r(s) = 0.44-0.72, P < 0.001). When the median energy consumption in the three groups (no bleeding, minor bleeding and major bleeding) were compared using the Kruskal-Wallis test, we found that there was limited evidence of a difference between the groups, but this was not statistically significant at the 5% level [H (2) = 5.374, P = 0.065, 99% CI 0.058-0.071]. CONCLUSIONS: Increased use of bipolar diathermy during the performance of a tonsillectomy is associated with a statistically significant increased amount of postoperative pain. The dose-response relationship between diathermy energy and postoperative bleeding is less clear. This suggests that there could be other important factors such as surgical instrument characteristics and degree of tonsillar adherence that have an additional influence and are therefore possible areas for future research.     

Traditional tonsillectomy compared with bipolar radiofrequency thermal ablation tonsillectomy in adults: a pilot study

OBJECTIVES: To assess the morbidity and efficacy of bipolar radiofrequency thermal ablation tonsillectomy and compare it with traditional cold dissection tonsillectomy with diathermy hemostasis. DESIGN: Prospective, randomized, single-blinded, controlled clinical study. SETTING: Helsinki University Central Hospital, Department of Otorhinolaryngology-Head & Neck Surgery, Helsinki, Finland. PATIENTS: Forty healthy volunteer patients aged 18 to 65 years admitted for elective tonsillectomy with recurrent or chronic tonsillitis, obstructive tonsillar hypertrophy, or history of quinsy. Two patients were excluded from the study and 1 patient cancelled the operation. INTERVENTIONS: Nineteen patients underwent a traditional cold dissection tonsillectomy with diathermy hemostasis, and 18 patients underwent a bipolar radiofrequency thermal ablation tonsillectomy. There was no intergroup difference in age, sex, weight, and indications for tonsillectomy. The subjects were not informed of the type of procedure until the telephone interview 3 weeks after the operation. MAIN OUTCOME MEASURES: Operating time and intraoperative blood loss; need for anesthetics during the operation; different recovery indicators in the recovery room (ie, duration and medications administered), surgical ward (ie, medications administered, use of corticosteroids, general condition, and status of the uvula on the first postoperative day), and in the 2 weeks following surgery (ie, visual analog scale scores on 6 symptoms, medications needed, the day patients returned to work, use of antibiotics, and retreatment acceptance); and complications and certain laboratory parameters. RESULTS: There was a statistically significant but clinically insignificant difference in operating time and intraoperative blood loss in favor of the traditional tonsillectomy group. The other outcome measures showed no statistically significant differences. CONCLUSION: Bipolar radiofrequency thermal ablation and traditional tonsillectomy were associated with similar postoperative morbidity.     

Postoperative bleeding after diathermy and dissection tonsillectomy

OBJECTIVE: To analyze the incidence and pattern of bleeding after tonsillectomy performed by either cold dissection or diathermy. DESIGN: A prospective, nonrandomized cohort study of postoperative hemorrhage after tonsillectomy. METHODS: Monthly reporting of the number of tonsillectomies and postoperative bleeds from otolaryngologists working in rural areas of Victoria, Australia over a 2.5 year period. Criteria for bleeding were either 1) repeat anesthesia and surgery because of hemorrhage (including return to theater from the recovery room), or 2) readmission to hospital because of bleeding, or 3) blood transfusion to replace blood loss. Main outcome measures were the incidence, volume, and time course of postoperative hemorrhage. RESULTS: The number of bilateral tonsillectomies with removal by cold-blunt dissection was 3,087. In this group, there were 57 (1.85%) bleeds. The number of bilateral tonsillectomies with removal by diathermy dissection was 1,557. In this group, there were 37 (2.38%) bleeds. If cold dissection is taken as the "control" and diathermy tonsillectomy as the "treatment" group, the relative risk of bleeding after diathermy tonsillectomy is 1.30 (95% confidence interval 0.88-1.93). The pattern of bleeding after each technique differs significantly over time, with more reactionary bleeds in the dissection group and more bleeds between 4 to 7 postoperative days after diathermy. When bleeding occurred, it was in excess of 500 mL in 16% of dissection cases and 43% of diathermy tonsillectomies. CONCLUSIONS: The difference in the risk of bleeding after each technique did not reach statistical significance, but the temporal pattern of hemorrhage differed, and more bleeds exceeding 500 mL were seen in the diathermy group.     

超声刀在扁桃体肿瘤切除术中的应用体会

目的 探讨超声刀在扁桃体肿瘤切除术中的应用体会。 方法 选择70例成人单侧扁桃体形态异常考虑肿瘤的患者,随机分为超声刀组(35例)和电刀组(35例),记录患者的一般情况、手术时间、术中出血、术后咽痛及并发症等情况,将两组患者的资料进行比较。 结果 两组患者男性居多,扁桃体以肥大或增生多见,且多为Ⅱ°大小。两组患者术后病理均以良性病变为多,最常见为慢性炎症,其次为乳头状瘤;恶性病变主要为淋巴瘤。超声刀组在手术时间及术中出血量方面要优于电刀组(P<0.001),而在术后继发性出血、术后感染及住院时间方面并无明显优势。超声刀组无术后原发性出血发生,电刀组有5例患者出现术后原发性出血,但二者间差异并无统计学意义(P=0.054)。术后第1天疼痛VAS评分超声刀组优于电刀组(P=0.009),而在术后第2、5、10天比较,差异无统计学意义。 结论 对于扁桃体肿瘤患者行扁桃体切除术而言,超声刀是一个理想的手术器械。     

Standard bipolar diathermy forceps vessel ligation is safe in thyroidectomy

Bleeding is a major complication of thyroid surgery. A retrospective study was performed comparing the outcomes of patients undergoing thyroid surgery where bipolar diathermy with standard bipolar forceps was used for vessel ligation (n = 64) compared to clamp-and-tie (n = 89). Fewer drains were inserted and patients were discharged earlier when standard bipolar diathermy was used for vessel ligation in hemithyroidectomies (P < 0.001). Complication rates were similar. The use of bipolar diathermy with standard forceps for vessel ligation in thyroid surgery has been shown to be as safe and effective as the clamp-and-tie technique, while resulting in earlier patient discharge. This technique is cost-efficient as it provides the advantage of reduced inpatient stay reported using bipolar vessel sealing devices or the harmonic scalpel, but without the additional expense.     

Cochlear implants using the Ultracision harmonic scalpel

We have evaluated the utility, indications and disadvantages of the Ultracision harmonic scalpel, in the cochlear implants, and his advantages compare to other electrocoagulation's systems. These aspects were evaluated in 50 cases of cochlear implants, made along the last years. We concluded that the Ultracision harmonic scalpel is indicated, mainly, in the otology field, in these situations in wich the cochlear implant is in the cochlea, and is mandatory the use of an electrocoagulation system. In this situation, the Ultracision harmonic scalpel was quick, safe and sure, and with many advantages, over the traditional scalpel and the bipolar diathermy.     

The use of the bipolar microcoagulator for haemostasis in tonsillectomy

The use of the bipolar microcoagulator for haemostasis in tonsillectomy A two-part prospective trial of the use of bipolar diathermy for haemostasis in tonsillectomy was carried out. The first part of the trial showed that bipolar diathermy was as effective as conventional methods of dealing with bleeding, and has no additional undesirable effects. The second part showed that the method could substantially reduce operating time.     

Influence of intraoperatively applied current of coagulation on the postoperative course in tonsillectomy

BACKGROUND UND METHODS: Postoperative pain after tonsillectomy is greater using diathermy compared to the use of ligatures for hemostasis. In the present paper, the influence of coagulation current on the postoperative course is assessed quantitatively. The applied coagulation current was registered in Watt per second (Ws) in 63 patients. Intraoperative blood loss, operation time, experience of the surgeon, postoperative pain and the consumption of analgesics were registered. RESULTS: The mean intraoperative blood loss was correlated to the amount of applied coagulation current. Operation time was reduced with increased coagulation current. The energy of the applied coagulation current correlated significantly with pain in the late postoperative period. There was no influence in the amount of coagulation current on the consumption of analgesics or postoperative hemorrhage. Blood loss was less and operation time was shorter with more experienced surgeons. Six secondary postoperative hemorrhages were observed. Hemorrhage occurred more often with inexperienced surgeons. The applied coagulation current was, however, not dependent on the surgeon's experience but on his individual technique for intraoperative control of hemostasis. CONCLUSIONS: Pain following tonsillectomy is related to the amount of intraoperatively applied coagulation current, especially in the late postoperative course (days 10 - 14). This may be explained by tissue damage and increased eschar due to coagulation. Careful and reserved use of intraoperative coagulation will reduce postoperative pain.