Total thyroidectomy: conventional suture ligation technique versus sutureless techniques

Mahmoud N. M. Ali, Ahmed Abdelkahaar Aldardeer, Ayman M. A. Ali, Alaa A. Radwan


Background: Since the introduction of successful thyroidectomy no change occurred in the technique but with the innovation of sutureless surgery, sutureless thyroidectomy becomes a competitor for the conventional technique. In this study we tried to analyze the outcomes of each.

Methods: This was a prospective cross armed uncontrolled randomized study included 65 patients suffering from non-malignant goiter who underwent total thyroidectomy, admitted to Sohag University Hospital from September 2017 to October 2018. Patients were randomly allocated into two groups; Group (S) managed with sutureless thyroidectomy, and Group (C) managed with conventional knot tying technique. The data of the patients were gathered and analyzed considering the operative and post-operative outcomes. All patients were followed-up for 6 -12 months.

Results: We found a significantly shorter operative time (p=0.001), also the amount of intra-operative blood loss was highly significant less in Group S (p=0.001). There was higher incidence of post-operative pain in Group C (p<0.001), post-operative drainage volume was highly significantly less in Group S (p=0.001). Regarding post-operative complications; the incidence of recurrent laryngeal nerve paralysis (RLNP) was insignificant between both groups (p=0.38), in the same time the incidence post-operative transient hypocalcaemia was significantly more in Group C (P=0.025). The overall post-operative complication rate was significantly more in Group C (p=0.002). The duration of hospital stay was highly significant shorter in Group S (p=0.0001).

Conclusions: The use of Harmonic FOCUS® is beneficial for both patient and surgeon; it is efficient and a trustable safe substitute to the conventional knot tying technique.


Thyroidectomy, Harmonic focus, Hemostasis

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Cannizzaro MA, Bianco SL, Borzi L, Cavallaro A, Buffone A. The use of FOCUS Harmonic scalpel compared to conventional hemostasis (knot and tie ligation) for thyroid surgery: a prospective randomized study. Springer Plus. 2014;3:639.

Wiseman S, Tomljanovich P, and Rigual N. Thyroid lobectomy: operative anatomy, technique, and morbidity. Operative Techniques Otolaryngol Head Neck Surg. 2004;15:210-9.

Ferri E, Armato E, Spinato G, Spinato R. Focus harmonic scalpel compared to conventional haemostasis in open total thyroidectomy: a prospective randomized trial. Int J Otolaryngol. 2011;2011:357195.

Delbridge L. Total thyroidectomy: the evolution of surgical technique. ANZ Journal of Surgery. 2003;73:761-8.

Cosenza G, Morano C, Cilurso F, Cavaniglia D, Cesare TD, Scarinci A, et al. LigaSure small jaw vs. harmonic focus and clamp-tie technique in total thyroidectomy for benign disease: A prospective randomized trial. Clin Surg. 2018;3:2038.

Cordon C, Fajardo R, Ramirez J, Herrera MF. A randomized, prospective, parallel group study comparing the Harmonic Scalpel to electrocautery in thyroidectomy. Surgery. 2005;137:337-41.

Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel S, Nikiforov Y, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133.

Lombardi CP, Raffaelli M, Cicchetti A, Marchetti M, De Crea C, Di Bidino R, et al. The use of "harmonic scalpel" versus "knot tying" for conventional "open" thyroidectomy: results of a prospective randomized study. Langenbecks Arch Surg. 2008;393:627-31.

Nenkov R, Radev K, Marinova E, Cvetkov N, Semkov A, Petrov B. The harmonic scalpel application in thyroid surgery. JIMAB. 2013;19:408-11.

Aziz W, Khan MS, Assad S, Siddique G. Suture-less thyroidectomy using harmonic scalpel versus conventional thyroidectomy: A randomized controlled trial. JPMS. 2016;6:48-51.

Siperstein AE, Berber E, Morkoyun E. The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery. Arch Surg. 2002;137:137-42.

Miccoli P, Materazzi G, Miccoli M, Frustaci G, Fosso A, Berti P. Evaluation of a new ultrasonic device in thyroid surgery: comparative randomized study. Am J Surg. 2010;199:736-40.

Sista F, Schietroma M, Ruscitti C, De Santis G, De Vita F, Carlei F, et al. New ultrasonic dissector versus conventional hemostasis in thyroid surgery: a randomized prospective study. J Laparoendosc Adv Surg Tech A. 2012;22:220-4.

Ecker T, Cavalho AL, Choe JH, Walosek G, Preuss KJ. Hemostasis in thyroid surgery: Harmonic scalpel versus other techniques-a meta-analysis. Otolaryngology–Head and Neck Surgery. 2010;143:17-25.

Huang J, Yu Y, Wei C, Qin Q, Mo Q, Yang W. Harmonic scalpel versus electrocautery dissection in modified radical mastectomy for breast cancer: a meta-analysis. PLoS One. 2015;10(11):e0142271.

Mishra N, Samal D, Kar IB, Sharma G, Baig SA, Kar R, et al. Bipolar vessel sealing system versus suture ligation in selective neck dissection. J Maxillofac Oral Surg. 2018;17:495-501.

Prgomet D, Janjanin S, Bilic M, Prstacic R, Kovac L, Rudes M, et al. A prospective observational study of 363 cases operated with three different harmonic scalpels. Eur Arch Otorhinolaryngol. 2009;266:1965-70.

Park J, Koh J. Era of bloodless surgery: spotlights on hemostasic materials and techniques. Hanyang Med Rev. 2018;38:3-15.

Cirocchi R, Boselli C, Guarino S, Sanguinetti A, Trastulli S, Desiderio J, et al. Total thyroidectomy with ultrasonic dissector for cancer: multicentric experience. World J Surg Oncol. 2012;10:70.

Vach B, Fanta J, Velenská Z. The harmonic scalpel and surgery of the thyroid gland. Rozhl Chir. 2002;81(Suppl 1):S3-7.

Currie A, Chong K, Davies GL, Cummins RS. Ultrasonic dissection versus electrocautery in mastectomy for breast cancer—a meta-analysis. Eur J Surg Oncol. 2012;38:897-901.

Miccoli P, Berti P, Dionigi G, D’Agostino J, Orlandini C, Donatini G. Randomized controlled trial of harmonic scalpel use during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2006;132:1069-73.

Ortega J, Sala C, Flor B, Lledo S. Efficacy and cost-effectiveness of the Ultracision harmonic scalpel in thyroid surgery: an analysis of 200 cases in a randomized trial. J Laparoendosc Adv Surg Tech A. 2004;14:9-12.

Contin P, Goossen K, Grummich K, Jensen K, Schmitz-Winnenthal H, Buchler MW, et al. ENERgized vessel sealing systems versus conventional hemostasis techniques in thyroid surgery --the ENERCON systematic review and network meta-analysis. Langenbecks Arch Surg. 2013;398:1039-56.

Yildirim O, Umit T, Ebru M, Bulent U, Belma K, Betul B, et al. Ultrasonic harmonic scalpel in total thyroidectomies. Adv Ther. 2008;25:260-5.

Javaid A, Khurshaidi N, Habib Z, Soomro R. Comparison of mean duration of drain removal in quilting vs non quilting wound closure in modified radical mastectomy. Med. Forum. 2018;29:15-9.

Pardal-Refoyo JL. Hemostatic Systems in Thyroid Surgery and Complications. Acta Otorrinolaringol. 2011;62:339-46.

Chen C, Kallakuri S, Vedpathak A, Chimakurthy C, Cavanaugh JM, Clymer JW, et al. The effects of ultrasonic and electrosurgery devices on nerve physiology. Br J Neurosurg. 2012;26:856-63.

Witt RL. Recurrent laryngeal nerve electrophysiologic monitoring in thyroid surgery: The standard of care? J Voice. 2005;19:497-500.

Steurer M, Passler C, Denk Dm, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope. 2002;112:124-33.

Marchesi M, Biffoni M, Cresti R, Mulas MM, Turriziani V, Berni A, et al. Ultrasonic scalpel in thyroid surgery. Chir Ital. 2003;55:299-308.

Voutilainen PE, Haglund CH. Ultrasonically activated shears in thyroidectomies: a randomized trial. Ann Surg. 2000;231:322-8.

Emam TA, Cuschieri A. How safe is high-power ultrasonic dissection? Ann. Surg. 2003;237:186-91.

Cordón C, Fajardo R, Ramírez J, Herrera MF. A randomized, prospective, parallel group study comparing the harmonic scalpel to electrocautery in thyroidectomy. Surgery. 2005;137:337-41.

Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, et al. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg. 2004;28:271-6.

Sitges-Serra A, Ruiz S, Girvent M, Manjón H, Dueñas JP, Sancho JJ. Outcome of protracted hypoparathyroidism after total thyroidectomy. Br J Surg. 2010;97:1687-95.

Zehra S, Parveen S. Post-operative hypocalcaemia following open thyroidectomy for benign multinodular goiters using FOCUS Harmonic Scalpel versus conventional suture ligation technique for hemostasis: a Prospective, singleblind, randomized controlled trial J Endocr Surg. 2018;18:132-41.

Miccoli P, Berti P, Raffaelli M, Materazzi G, Conte M, Galleri D. Impact of harmonic scalpel on operative time during video-assisted thyroidectomy. Surg Endosc. 2002;16:663-6.

Del Rio P, Bezer L, Palladino S, Arcuri MF, Iotti E, Sianesi M. Operative time and postoperative pain following minimally invasive video-assisted parathyroidectomy. G Chir, 2010;31:155-8.

Cheng H, Clymer JW, Qadeer RA, Ferko N, Sadeghirad B, Cameron CG, Amaral JF. Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis. Clinico Economics Outcomes Res. 2018;10:399-412.

Graff AT, Miller FR, Roehm CE. Predicting hypocalcemia after total thyroidectomy: parathyroid hormone level vs. serial calcium levels. Ear Nose Throat J. 2010;89:462-5.