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| Ultrasonic energy based device. Harmonic Focus+ (HF+) (Ethicon, Johnson and Johnson, Cincinnati, OH, USA). The HF+ is widely used in open thyroid surgery. Its curved and tapered tip has bare blades on one side and a non-active tissue pad on the opposite side.
Source publication
Technological advances in thyroid surgery have rapidly increased in recent decades. Specifically, recently developed energy-based devices (EBDs) enable simultaneous dissection and sealing tissue. EBDs have many advantages in thyroid surgery, such as reduced blood loss, lower rate of post-operative hypocalcemia, and shorter operation time. However,...
Context in source publication
Context 1
... a Harmonic device is used for transecting and sealing tissue, contact between the blade and the tissue pad of the device causes a rapid temperature increase. (Figure 4) A Harmonic device can seal vessels up to 7 mm in diameter. Notably, ultrasonic EBDs such as the Harmonic enable sealing at lower temperatures compared to monopolar electrocautery equipment (30,36). ...
Similar publications
Introduction: There are a number of thyroid gland diseases that require surgical treatment. Therefore, it is important to improve the surgical approaches and treatment tactics in patients that need such surgery.
Aim: To provide an algorithm to prevent parathyroid gland damage during surgery.
Materials and methods: This work was based on treatment...
Citations
... 134 patients in two groups were enrolled between December 2021 to December 2022, which 68 patients underwent ET and 66 accepted OT to achieve dissection of unilateral lobectomy and lymph node in neck central area by the same medical team. In addition, all patients completed assessment using QOL-C30 [15], SCL-90 [16]; VIS [17], SIS [18], NIS [19], and SCAR-Q scale [20][21][22][23]. In this study, we conducted a prospective evaluation of DTC patients for the first time by combining multiple questionnaire scales to compare the impact of different surgical approaches on quality of life. ...
Background
The relationship between different surgical treatments and quality of life remains uncertain for differentiated thyroid carcinoma (DTC). The aim of this study is to compare the gasless endoscopic thyroidectomy trans-axillary approach (ET) and traditional open thyroidectomy (OT) through a prospective cohort study focusing on the rate of the efficacy, and quality of life (QoL).
Methods
This prospective observational longitudinal cohort study enrolled 134 female patients diagnosed with DTC from December 01/2021 to December 31/2022. Multiple scales were applicated to evaluate the differences in quality of life, effectiveness, safety, etc. between the two groups during preoperative and postoperative follow-up periods, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 3.0 (QOL-C30), Symptom Checklist (SCL-90), Scar Cosmesis Assessment and Rating (SCAR-Q), voice impairment score (VIS), swallowing impairment score (SIS), and neck impairment score (NIS).
Results
Among them, 68 accepted ET and 66 patients underwent OT. To enhance comparability between the two groups, the patients enrolled in this study are female. Compared with the OT group, the ET group performed significantly better postoperative physical quality of life, including sound (p = 0.036), swallowing (p < 0.001), and neck function (p = 0.010). The ET group was also associated with significantly better cosmetic satisfaction (p < 0.001), and relatively faster recovery in psychological and emotional situation.
Conclusions
Gasless endoscopic thyroidectomy through an axillary approach leads to good cosmetic and psychological effects, improves postoperative QoL, and could be recommended for rapid postoperative recovery and involvement in daily and social activities.
... The rates of postoperative hypoparathyroidism and other complications, the levels of postoperative on-Tg and on-TgAb, and the number of cases who received 131 I treatment were evaluated. In addition, all patients completed assessment using the Short From (SF)-36 scale [5] , Voice Impairment Score (VIS) [14] , Swallowing Impairment Score (SIS), Neck Impairment Score (NIS) [15] , and Scar questionnaire (SCAR-Q) scale [16,17] . Surgical costs, total hospitalization costs, and other aspects were also analyzed statistically for all patients (Fig. 1). ...
... Gradual coagulation and closure of the vascular branches between the true capsule and parenchyma of the thyroid gland were undertaken against the thyroid gland, and preservation of all PGs and all their vascular components was carried out (Fig. 3). A safe distance ( > 2 mm) to the RLN was needed when freeing and cutting the berry ligament at the entrance of the RLN into the larynx [14] . This method was effective in preserving compact A1 (Video 1) and embedded A2 (Video 2) PGs. ...
Objective
To compare robot-assisted thyroidectomy (RT) and open thyroidectomy (OT) through a prospective cohort study focusing on the rate of postoperative hypoparathyroidism, efficacy, and quality of life (QoL).
Summary Background Data
Hypoparathyroidism is a frequent complication after thyroidectomy. Reducing the risk of hypoparathyroidism after total thyroidectomy is a crucial and difficult task for thyroid surgeons.
Methods
We prospectively enrolled 306 patients with papillary thyroid carcinoma(PTC) into an RT group and OT group. The former used “super-meticulous” capsular dissection (SMCD) and the latter used traditional meticulous capsular dissection. Patients were evaluated by scales [Short Form (SF)-36, Visual Impairment Scale (VIS), Swallowing Impairment Scale (SIS), Neck Impairment Scale (NIS), Scar questionnaire (SCAR-Q)].
Results
The rates of transient hypoparathyroidism, permanent hypoparathyroidism, and transient hypocalcemia after surgery in the OT group and RT group were significantly different ( P <0.001). SIS and VIS scores in the two groups were significantly different ( P <0.001). SF-36 showed significant differences ( P <0.001) in the subsections of “physiological function”, “body pain”, “general health”, “vitality”, “social function”, “role emotional”, and “mental health” between the two groups. SCAR-Q showed that the length and appearance of scars showed significant differences between the two groups.
Conclusions
Robot-assisted thyroidectomy with Super-meticulous capsular dissection can protect parathyroid function and improve postoperative QoL, and could be a new option for robot-assisted surgery against thyroid cancer.
... It is important to emphasize that some studies in the literature found an increased RLN thermal injuries and palsy in the EBD group, mainly because of the thermal spread around the device and the tissue contraction. Therefore it is important to underline that the EBDs must be used with caution especially in non-expert hands, and in any case at a safe distance from structures considered noble, such as RLN and parathyroid glands, to preserve their functionality [41][42][43]. ...
Thyroid cancer is the fifth most common cancer in the USA, with differentiated subtype accounting for more than 95% of neoplasm. Surgery remains the mainstay of treatment, either with lobectomy or total thyroidectomy. In the last decades, many technological innovations have been introduced in this field. The aim of this review is to illustrate the most recent advances regarding the classical surgical approach, particularly regarding hemostatic devices, parathyroid identification with fluorescence systems, intraoperative identification of lymph node metas-tases, and intraoperative neuromonitoring.
... Efficient hemostasis is a very important issue in thyroid and parathyroid surgery. In recent decades, one of the most major advances in thyroid and parathyroid surgery has been the development of surgical energy devices (SEDs) 1 . SEDs provide more efficient hemostasis than the conventional clamp-and-tie technique in areas with rich blood supply, which reduces intraoperative blood loss and operation time 2 , postoperative hypocalcemia 3 , and life-threatening postoperative hematoma 4 . ...
... Efficient hemostasis is a very important issue in thyroid and parathyroid surgery. In recent decades, one of the most major advances in thyroid and parathyroid surgery has been the development of surgical energy devices (SEDs) 1 . SEDs provide more efficient hemostasis than the conventional clamp-and-tie technique in areas with rich blood supply, which reduces intraoperative blood loss and operation time 2 , postoperative hypocalcemia 3 , and life-threatening postoperative hematoma 4 . ...
... Those two steps will ensure the achievement of the real baseline EMG-amplitude. The use of an energy-based device can result in the paralysis of RLN, which can cause hoarseness after the operation [13]. The precise definition of those stimulation points is of great importance for both novices in thyroid surgery and new users of intraoperative neuromonitoring. ...
The aim of this study was to evaluate the diagnostic accuracy of a neuromonitoring protocol-the Abu Dhabi Neural Mapping protocol (ADNM)-using a new device, Nim-Vital™, during minimally invasive thyroidectomy in the early identification of non-recurrent laryngeal nerve (n-RLN) problems and the preservation of its function.
Method:
Patients with thyroid disorders that required thyroid resection, who were admitted to the Department of Surgery at Burjeel Hospital, Abu Dhabi, between January and July 2022, were included in the study. The data were extracted from a prospective database and were analyzed retrospectively. All nerves at risk were identified and exposed at seven precisely defined anatomical points, with strict adherence to the intraoperative technical steps of neuromonitoring. These were sequentially applied to the vagal nerve (VN), the superior laryngeal nerve (SLN), and the recurrent laryngeal nerve (RLN). In the next step after the creation of the skin-platysma flap, the strap muscle's lateral border was moved from the medial limb of the sternocleidomastoid without using any electrical device and without any manipulation of the thyroid gland. The VN was exposed in the carotid sheath and then stimulated using a monopolar probe at a precisely defined point above the clavicle, using anatomical landmarks.
Results:
In total, 136 women with a mean age of 40 years (range 18-74) and 36 men with a mean age of 42 (range 21-66), demonstrating 270 nerves at risk, were included in the analysis. Indications for surgery were malignancy in 70 cases, toxic goiter/Graves in 23 cases, retrosternal goiter in 21, and symptomatic multinodular goiter in 64 cases. Of these, 100 patients received a total thyroidectomy, 46 received a right lobectomy, and 24 received a left lobectomy only. For a total thyroidectomy, the median skin-to-skin surgery duration was 52 min (range 24-104 min) and the median hospital stay was 2 days (range 1-4 days). In 4 cases (4/146; 2.74%) the pre-dissection stimulation of the vagal nerve (VN1) at the ADNM's precisely defined point did not create any signal or proper EMG-curve that indicated the existence of the non-RLN. Proximal dissection of the right VN at a precisely defined point by the ADNM's level of incisura of the larynx created a positive signal. The separation point of the right non-RLN from the VN was discovered in all four patients. The postoperative video-laryngoscopy confirmed bilateral mobile vocal cords in all cases.
Conclusions:
Following the ADNM protocol during thyroid surgery minimizes the risk of a non-laryngeal nerve injury and prevents voice dysfunction.
... There was no case of RLN injury in the MDTN group while the rates were 0.87% and 7.14% in the HS group and CE group, respectively, but all recovered within three months after surgery. Since EBD can cause injury to RLN due to their thermal effect, numerous researches have been dedicated to exploring the thermophysical properties and safety capability of various EBD to establish standardized guidance for scrupulous and safe utilization of EBD (31). Most of the related studies showed that HS can achieve a good hemostatic effect without increasing the incidence of injury to adjacent nerves (9,11,15). ...
Background
Energy-based devices (EBD) have been popularized in thyroidectomy worldwide. Microdissection tungsten needle (MDTN) is characterized by the ultra-sharp tip providing safe and meticulous dissection with effective hemostasis. However, little study has applied MDTN in thyroidectomy.Methods
This retrospective study compared clinical data of the patients who underwent total thyroidectomy (TT) with central neck dissection (CND) using MDTN, harmonic scalpel (HS), and conventional electrocautery (CE). We assessed outcomes related to surgical efficacy and safety. The injury degree of tissue was assessed by biochemical indicators and early-stage inflammatory factors in the drainage fluid. Histological sections of the thyroid specimens were evaluated to compare levels of thermal damage by the three EBD.ResultsThere was a significant decrease in the intraoperative blood loss, operation time and 24-hour drainage volume in the MDTN group compared to the CE group. The total drainage volume, duration of drainage, and average length of stay of the MDTN group were less compared to the CE group though they did not reach statistical significance. No disparity was observed between the MDTN group and HS group in these variables. Total costs were not significantly different among these groups. The incidence of recurrent laryngeal nerve (RLN) injury was the lowest using MDTN compared to the CE (P = 0.034) and HS (not significant). No statistical differences were observed among these groups regarding postoperative wound pain and infection, hypoparathyroidism, and postoperative hemorrhage. Analysis of biochemical indicators showed a lower level of hemoglobin in the MDTN and HS group than the CE group (P = 0.046 and 0.038, respectively) and less triglyceride in the HS group than the MDTN and CE group (P = 0.002 and 0.029, respectively) but no significant difference in cholesterol level in these groups. Early-stage inflammatory factors including TNF-α and IL-6 showed significantly higher concentration in the CE group than the MDTN and HS group. Histological sections of thyroid specimens revealed that MDTN caused the lowest degree of thermal damage followed by HS then CE.
ConclusionMDTN exhibited comparable surgical efficacy and safety outcomes as HS in thyroidectomy. Therefore, MDTN is a safe and viable alternative for hemostasis in thyroidectomy.
... Hemostasis of the blood-rich thyroid gland is an important issue during thyroid surgery, and postoperative hematoma is a lifethreatening complication that should be avoided as much as possible (1). As an equipment to assist hemostasis, many energybased devices (EBDs) have been developed in the past 30 years and are widely used in thyroid surgery (2). High temperatures are unavoidable when using EBDs, and direct or indirect thermal energy can transfer to the recurrent laryngeal nerve (RLN) and result in thermal injury (3)(4)(5). ...
... Activation study was performed in 8 RLNs of 4 piglets (animal No. [1][2][3][4]. No adverse EMG events (amplitude decrease or latency increase) were observed when the QMR BS and QMR MU were activated at distances of 5 and 2 mm. ...
... The application of EBDs during thyroid surgery has increased worldwide due to significantly reduced intraoperative blood loss, operating time, and postoperative hematoma rates (2,17). In addition, the risk of thermal injury to nerves during thyroid surgery continues to increase (18). ...
Objectives
Quantum molecular resonance (QMR) devices have been applied as energy-based devices in many head and neck surgeries; however, research on their use in thyroid surgery is lacking. This study aimed to investigate the safety parameters of QMR devices during thyroidectomy when dissection was adjacent to the recurrent laryngeal nerve (RLN).
Methods
This study included eight piglets with 16 RLNs, and real-time electromyography (EMG) signals were obtained from continuous intraoperative neuromonitoring (C-IONM). QMR bipolar scissor (BS) and monopolar unit (MU) were tested for safety parameters. In the activation study, QMR devices were activated at varying distances from the RLN. In the cooling study, QMR devices were cooled for varying time intervals, with or without muscle touch maneuver (MTM) before contacting with the RLN.
Results
In the activation study, no adverse EMG change occurred when QMR BS and MU were activated at distances of 2 mm or longer from the RLNs. In the cooling study, no adverse EMG change occurred when QMR BS and MU were cooled in 2-second intervals or immediately after MTM.
Conclusion
QMR devices should be carefully used when performing RLN dissection during thyroid surgery. According to the activation and cooling safety parameters in this study, surgeons can avoid RLN injury by following standard procedures when using QMR devices.
... With the modernization of thyroid surgery, advances have included the use of energy-based devices (EBD) as an extension from the "clamp-and-tie" technique that Theodore Kocher fathered in the 19th century. Today, hemostasis can be achieved in multiple ways: clamp-and-tie, electrocautery (monopoloar or bipolar), with hemostatic clips, and more advanced EBD that use thermal, ferromagnetic, or ultrasonic energy to ligate, seal and dissect tissue (36). Even though more advanced techniques with EBD have demonstrated reduced pain, wound drainage, decreased rates of neck hematoma and even hypocalcaemia (37)(38)(39)(40), the results for EBD are inconsistent in terms of rates of RLN injury compared with conventional approaches (41,42). ...
... Several studies have demonstrated that traction and thermal injury are the first and second most common causes of iatrogenic RLN injury during thyroidectomy (39,43,44). As one would expect, the use of EBDs can generate high temperatures that can spread to critical structures such as the RLN causing indirect thermal spread or direct thermal injury (36). Thus, various guidelines are published to ensure that surgeons maintain a safe distance between the activated EBD tip and the surrounding soft tissue (36). ...
... As one would expect, the use of EBDs can generate high temperatures that can spread to critical structures such as the RLN causing indirect thermal spread or direct thermal injury (36). Thus, various guidelines are published to ensure that surgeons maintain a safe distance between the activated EBD tip and the surrounding soft tissue (36). It is also recommended that enough time lapses for the tip or blade to cool sufficiently before using the device to dissect tissue or work close to the RLN. ...
The field of endocrine surgery has expanded from the traditional open neck approach to include remote access techniques as well as minimally invasive approaches for benign and malignant thyroid nodules. In experienced hands and with careful patient selection, each approach is considered safe, however complications can and do exist. Post-operative dysphonia can have serious consequences to the patient by affecting quality of life and ability to function at work and in daily life. Given the significance of post-procedural dysphonia, we review the surgical and non-surgical techniques for minimizing and treating recurrent laryngeal nerve injury that can be utilized with the traditional open neck approach, remote access thyroidectomy, or minimally invasive thermal ablation.
... Furthermore, the "liquid-gas flow" generated by EBDs can also be a risk factor for RLN thermal injury (9,14). RLN thermal injury is severe and can lead to paralysis of the VC (15,16). Notably, it would be quite effective to isolate the RLN with lateral thermal spread and liquid-gas flow. ...
Background
Energy-based devices (EBDs) increase the risks of thermal nerve injuries. This study aimed to introduce a surgical strategy of intraoperative neural tunnel protecting (INTP) for evaluating the effect in reducing the incidence of recurrent laryngeal nerve (RLN) damage in open, trans breast, and transoral endoscopic thyroidectomy.
Methods
INTP strategy was introduced: a tunnel was established and protected by endoscopic gauze along the direction of the nerve. A total of 165, 94, and 200 patients with papillary thyroid carcinoma (PTC) were to use INTP in respectively open, trans breast, and transoral endoscopic thyroidectomy as the INTP group. Additionally, 150, 95, and 225 patients who received the same methods without INTP were enrolled in the control group. Ipsilateral thyroidectomy or total thyroidectomy, and central compartment dissection were performed on the enrolled patients.
Results
Clinicopathologic characteristics, surgical outcomes, and surgical complications were similar between the INTP group and the control group in open, trans breast, and transoral endoscopic thyroidectomy. The incidences of electromyography (EMG) changes in the INTP group were lower as compared to the control group in trans breast endoscopic thyroidectomy (p < 0.05). The incidence of postoperative hoarse in the INTP group was lower as compared to the control group in open and transoral endoscopic thyroidectomy (p < 0.05). Postoperative calcium levels (p < 0.01) were significantly higher, and the white blood cells (p < 0.05) and C-reactive protein levels (p < 0.01) were significantly decreased in the INTP group compared with the control group in transoral endoscopic thyroidectomy.
Conclusions
This was the first instance of the INTP strategy being introduced and was found to be an effective method for protecting the RLN in open, trans breast, and transoral endoscopic thyroidectomy. Additionally, INTP helped protect other important tissues such as the parathyroid glands in transoral endoscopic thyroidectomy as well as in reducing postoperative inflammatory responses.
