Harmonic Knife New Haemostatic Procedure In Thyroid Surgery

Al-Kindy College Medical Journal 2017: Vol.13 No. 1 142 www.kmjub.com ABSTRACT Background: Thyroid operation needs very meticulous haemostasis to have minimal morbidity and mortality. Objectives: Assessment of harmonic knife in open thyroid surgery as anew haemostatic procedure . Type of the study: Cross-sectional study. Methods: This study had been conducted at Alkindy teaching hospital in Baghdad city from the 1 st of May 2013 to the 1 st of January 2017 on 229 goiterous patients who needs thyroidectomy(36 males,193 females),divided in 2 groups according to the haemostatic procedure used during their operations, Group A (15 males,85females)using the usual conventional surgery(pick, tie &cut), Group B (21males,108 females) using harmonic knife as haemostatic procedure and compare the results according to time of surgery, amount of discharge in the drain during the first 24 hours post operatively ,the incidence of recurrent nerve palsy and the remote post operative hypocalcaemia (3months post operation) . Results: It shows that thyroid surgery (thyroidectomy) by using harmonic knife as haemostatic procedure is shorter in duration [mean67.22 minutes] with less blood loss in the drain [mean 64.96cc] and less incidence of hypocalcaemia in remote post operative period [3.8%] in comparison to the results of the usual conventional thyroidectomy procedures (mean duration 82.02 minutes, mean blood loss in the drain 111.13cc & incidence of hypocalcaemia is 7%}. Conclusions: Harmonic knife is very safe & beneficial haemostatic device in thyroid surgery. Key ward: Goiter, Homeostasis, Harmonic scalpel.

eticulous haemostasis is a very important point in thyroid surgery to decrease morbidity and mortality by identification and preservation of vital structures such as parathyroid glands, recurrent laryngeal nerve and the superior laryngeal nerve.Decreasing the incidence of reoperation for hematoma formation which compromised air way (1,2) , The harmonic scalpel is an ultrasonic system for endoscopic cutting and coagulation, the source of energy is vibrational frequency approaching 55500 cycle/second attached to power box to forceps or blade acting as a knife/scissor through tissue with coagulation and closure of blood vessels.
(3) Harmonic scalpel is a new technology in our work which needs evaluation of its benefits in open thyroid surgery.
Method: This study had been conducted at the specialized center for diabetes and endocrinology & alkindy teaching hospital Baghdad city during the 1 st of May 2013 to the 1 st of January 2017 on 229 patients (36 males, 193 females) who were scheduled to have thyroidectomy under general anesthesia for their goiter after usual routine outpatient work up, all the information were recorded in their case sheet on day of their elective thyroidectomy, the haemostatic procedures were identified to the patients before surgery in the operative consent.Their ages were ranging from 11 to 75 years with median of 38.86 years and their operations were done by two experienced surgeons.They were divided in two groups according to the haemostatic procedure used during thyroid surgery.The 2 groups were similar regarding patient age, sex, type of operation and thyroid pathology.
Group A 100 patients (15 males, 85 females of a median age of 40.57years) were having the usual conventional steps (picking, tying & cutting vessels) using vicryl 2/0 for the superior, middle and inferior thyroid vessels (leavening inferior thyroid artery without ligation with closure of thyroid capsule on its bed) and with the aid of electro-surgery as haemostatic procedure in their thyroid operation during (2013,2014) .
Group B 129 patients (21males, 108 females of median age of 37.78 years) were having their thyroid surgery by using harmonic knife as haemostatic procedures (adjusted at power 3-5 ) in middle thyroid ,inferior thyroid vessel with ligation of superior thyroid by 2/0 vicryl distally single knot and coagulation division by harmonic knife proximally and on cutting thyroid gland during (2015,2016).
In both groups the wound closed on radii-vac drain by vicryl 2/0 interrupted stitches for strap muscles and subcutaneous layer the skin closed by 3/0 nylon sub cuticle.Recording time of the procedure (defined as time from the minute knife on the skin till the last skin stitch), the amount of the discharge in the drain during the 1 st twenty four hours post operatively, measurement of serum calcium 3months post surgery and assessment of vocal cord mobility 2 weeks post operatively to assess the incidence of recurrent nerve injury as an outpatient follow up.All the patients discharged on 1 st post .
Table 4 shows that:-There is no significant difference between reading of preoperative thyroid function test of both conventional and harmonic operated patients.
Post operative hypocalcaemia is significantly presents among conventional surgery patients, p value <0.001.Duration of operation is significantly longer among conventional surgery patients, p value < 0.001.
Amount of post operative bleeding is significantly larger in conventional surgery patients, p value <0.001.
There is no significant association between vocal cord palsy and maneuver of operation as shown in table (5).
There was no post operative hematoma or bleeding that needs reoperation and no mortality in both groups.was regarded as thought of (fool hardy in Britain) (horrid butchery in America), but with many technical and scientific achievements by magnificent physician and scientists it becomes a safe procedure (5,6) .Before two decades the harmonic scalpel using mechanical vibration at 55.5 KH with its ability on tissue cutting and coagulation with advantages of less thermal tissue injury, lack of neuro-muscular transmission and the avoidance of electrical energy transmission through the patient body was adopted in modern surgery (7,8) .
The cooperation of the surgical team is the important factor in determining the operative time of thyroid procedure and in our study the same teams conduct the operation in the conventional and harmonic knife which decrease the bias in the both groups and explain the reduction in the time of the operation in the harmonic group (67  10,11,12) .www.kmjub.com There was no significant difference in the recurrent laryngeal nerve palsy in the two groups (p value 0.36) most cases of palsy can be attributed to excessive traction on the thyroid gland during the dissection.On reviewing other literatures we found reduction in time of operation and amount of loss with reduction in hypocalcaemia as in Calo P.G group (13) which show reduction in the post operative hypocalcaemia by (3.3% after 6months and 2.1% after 12 months post operatively) by harmonic scalpel in comparison to conventional group (12.98% after 6months and 5.96% after 12 months post operatively.On 2013 Rumen nenkove group show significant reduction in the time and drainage by harmonic scalpel and reduction in the length of the wound needed to perform thyroidectomy to 3-4cm in thyroid size of each lobe not exceeding 7x3.5cm (14) .Thomas Ecker group reviewed 72 literatures in their meta-analysis (1153 patients) conclude reduction of thyroidectomy time by 25% the operating theater time when use harmonic scalpel and reduction of post-operative discharge but without significant difference with conventional procedures (15) .Conclusion: Harmonic scalpel is very beneficial procedure in thyroid surgery ,it shorten time of the procedure and reduce blood loss during and in the post operative period, it also decrease the incidence of post operative hypocalcaemia in comparison to conventional thyroidectomy with the aid of other electro surgical devices.
Recomondation: Is to make this device available in our surgical theaters.

FigureFigure 2
Figure 1 cases distributed according to gender

Table 1
antibiotic, analgesics for 5 days and calcium supplement for 2-3 weeks to overcome the immediate hypocalcaemia that may occur during the first post operative weeks.The results of the two groups were compared by using the chi square test on SPSS M Harmonic Knife New ….Thamer T. Al-Ali et al Al-Kindy College Medical Journal 2017: Vol.13 No. 1 143 www.kmjub.comoperativedayon Results: Thyroidectomy was done for 229 patients, 100(43.7%)patientsasconventional thyroidectomy and 129(56.3%)harmonicmaneuver.Figure 1 shows that 193(84.3%)caseswerefemales and 36(15.7%)weremales.The mean age of patients was 39.12 ±11.09 years, males were significantly older than female (p v <0.001), table1

Table 2
distribution of patients according to duration of Table 4 independent two sample t test measured differences between means of different variables according to