|Year : 2021 | Volume
| Issue : 2 | Page : 80-87
Sutureless technique for thyroidectomy: Systematic review of literature
Nitin Khunteta, Jaspreet Singh Badwal
Department of Surgical Oncology, Sri Ram Cancer and Super speciality Centre, Mahatma Gandhi Medical College and Hospital, Mahatma Gandhi University of Health Sciences and Technology, Sitapura, Jaipur, Rajasthan, India
|Date of Submission||06-Aug-2021|
|Date of Acceptance||18-Aug-2021|
|Date of Web Publication||17-Dec-2021|
Dr. Nitin Khunteta
508, Fountain Square, Behind the Lalit, Jagatpura Road, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
The purpose of the present systematic review is to compare the outcomes and complications of two techniques of thyroidectomy: the surgical technique for thyroidectomy performed by a sealing device (LigaSure small jaw) versus conventional clamp-and-tie technique (CAT). Clinical studies were retrieved from the electronic databases of PubMed, EMBASE, and Scopus. One-hundred and five articles provided information in relation to outcomes of thyroidectomy performed with the use of sealing device versus that performed using traditional CAT technique. Of these, 27 articles were selected for final inclusion. A thorough review of available literature shows that sealing device provides better results in terms of intraoperative and postoperative blood loss, postoperative drain volume, incidence of transient or permanent palsy of recurrent laryngeal nerve and external branch of superior laryngeal nerve, postoperative transient or permanent hypocalcemia, and length of hospital stay.
Keywords: Clamp and tie technique, goiter, hemithyroidectomy, LigaSure small jaw, thyroid cancer, thyroid nodule, thyroid surgery, thyroidectomy
|How to cite this article:|
Khunteta N, Badwal JS. Sutureless technique for thyroidectomy: Systematic review of literature. J Head Neck Physicians Surg 2021;9:80-7
|How to cite this URL:|
Khunteta N, Badwal JS. Sutureless technique for thyroidectomy: Systematic review of literature. J Head Neck Physicians Surg [serial online] 2021 [cited 2022 Aug 17];9:80-7. Available from: https://www.jhnps.org/text.asp?2021/9/2/80/332720
| Introduction|| |
Thyroidectomy is the most commonly performed endocrine surgery and is the treatment of choice for many thyroid disorders. A problem unique to the surgery of the thyroid gland is the high vascularity of this organ because of the numerous blood vessels lying in close apposition to the gland. Furthermore, intraoperative bleeding leads to further serious complications such as the injury of recurrent laryngeal nerve (RLN) or the external branch of superior laryngeal nerve (EBSLN). Inadvertent damage to the parathyroid glands leads to prolonged periods of hypocalcemia, which if not managed within limited time, can lead to life-threatening tetany. Hence, it can be incurred that most of the complications related to surgery of the thyroid gland are a consequence of uncontrolled hemorrhage, both intraoperatively and postoperatively. The sealing device (LigaSure small jaw [LSJ]) helps to prevent these complications by dissecting the tissue in planes, coagulating, and cutting the vessels with minimum lateral damage to adjacent critical anatomic structures, such as the RLN, trachea, larynx, and pharynx.
The purpose of the present study is to compare the outcomes and complications of thyroidectomy performed by sealing device (LSJ) versus conventional clamp-and-tie technique (CAT) on basis of evidence derived from a systematic review of available literature, with the aim of providing recommendations for reducing complications of thyroidectomy.
| Materials and Methods|| |
A sealing device can seal vessels of up to 7 mm in diameter,,,, with lateral thermal spread limited to 1–3 mm, as reported in various studies. It helps to achieve simultaneous sealing and division of vessels through the application of high current (4A) and low voltage (<200 V). The sealing action is brought about by denaturation of collagen and elastin in the vessel wall. The pressure applied through the application of scissor action apposes the vessel walls to allow proteins to make a seal. At a microscopic level, the internal elastic lamina is preserved and collagen bundles form across the previous lumen.
An electronic search was conducted using the PICO critical appraisal tool for systematic reviews [Table 1]. The search terms used to search the articles were : goiter OR thyroid cancer OR multinodular goiter AND thyroidectom* AND hemithyroidectom* AND ligasure AND operat* time OR hypocalcemia OR drain OR RLN paralysis OR RLN palsy.
The search blocks used are shown in [Table 1].
Clinical studies were retrieved from the electronic databases of PubMed, EMBASE, and Scopus. A total of 3124 articles had been published till May 2021 in English and other languages which included retrospective studies, prospective studies, randomized controlled trials (RCTs), SEER Database surveys, multicenter studies, and smaller descriptive studies. 105 articles provided information in relation to outcomes of thyroidectomy performed with use of sealing device versus that performed using traditional CAT technique. Of these, 26 articles provided details of surgical techniques, methods used to assess complications and outcomes as per the treatment modality. References of the selected studies were further searched for important relevant studies. Apart from this, a search over the Google search engine was conducted to obtain related studies. To identify and remove heterogeneity, strict selection criteria were employed as per the recommendations mentioned by the working committee on PRISMA guidelines, such that only the studies on the use of sealing device (LSJ) for thyroidectomy were included in the systematic review.
Inclusion and exclusion criteria
All 105 articles were reviewed by two independent authors and final studies were included by consensus of both authors. Studies were included if they had reported specific parameters in relation to the use of sealing device for thyroidectomy, such as operating time, intraoperative or postoperative hemorrhage, drain volume, transient or permanent postoperative hypocalcemia, transient or permanent postoperative paralysis of RLN or EBSLN, period of follow-up, hospital stay, mode of measurement used, and groups of patients studied. A total of 26 articles were selected for final inclusion. Exclusion criteria can be stated as studies focussed on the use of harmonic scalpel for thyroidectomy, studies including cases of recurrence, articles concentrating on medullary or anaplastic thyroid carcinoma, and studies involving resection of adjacent critical anatomic structures such as trachea and larynx.
Risk of bias
The quality of studies was assessed using Cochrane collaboration's risk of bias tool. Most of the RCTs had a low risk of bias. The non-RCTs were included if they had a low risk of bias.
| Results|| |
A plethora of articles have been published in the last two decades, reporting the results for use of sealing device for thyroidectomy. Many of these were well-designed RCTs that compared the outcomes of thyroidectomy performed using traditional CAT technique. A thorough review of available literature shows that sealing device provides better results in terms of intraoperative and postoperative blood loss, postoperative drain volume, incidence of transient or permanent RLN palsy, postoperative transient or permanent hypocalcemia, and length of hospital stay.
[Table 2] shows the design of various studies from recent to early years, parameters that were evaluated, along with number of subjects, type of study, and outcomes. Furthermore, meta-analyses of published data have been conducted by Yao et al. and Zhang et al., which confirm that the sealing device provides superior outcomes as compared to traditional CAT technique for thyroidectomy. It must be stressed that the comparatively short period of hospital stay and low incidence of associated temporary and permanent complications prove sealing device to be a cost-effective alternative to traditional CAT technique for thyroidectomy.
|Table 2: Tabulation of studies on outcomes for sutureless technique from recent to early years, which includes randomized controlled trials, retrospective, prospective, casecontrol studies|
Click here to view
| Discussion|| |
A thorough review of literature was done & the outcomes of thyroidectomy using LSJ versus CAT technique in relation to operative time, hospital stay, pain and postoperative complications was assessed. Reduction in operative time was a parameter included in almost all the studies, such as Chiang et al., Cosenza et al., Ramouz et al., Aljuraibi et al., Coiro et al., and many others. These studies have confirmed without doubt that the operative time is significantly shortened when thyroidectomy is performed using LSJ as compared to CAT technique [Table 2]. With regard to intraoperative blood loss, studies by Chiang et al., AlJuraibi et al., Coiro et al., Cakabay et al., and Youssef et al. have provided evidence that the quantity of blood loss is lesser for LSJ technique. This is due to the superior vessel sealing mechanism of LSJ which blocks the lumen of blood vessels by its sealing action. Similarly, Cosenza et al. and Ramouz et al. proved that postoperative blood loss is reduced with LSJ technique. Aljuraibi et al. reported reduction in postoperative drain volume with LSJ technique. The results for postoperative hypocalcemia have been reported as widely different in various studies due to differences in the extent of surgery, i.e., total, subtotal, or hemithyroidectomy. Studies by Liu et al., Chiang et al., and Ramouz et al. provided reliable data confirming that the incidence of hypocalcemia is significantly lower in LSJ technique versus CAT technique. Liu et al., Ramouz et al., and Cosenza et al. reported a lower incidence of postoperative hematoma/hemorrhage in LSJ technique.
With regard to incidence of postoperative palsy of RLN, Zhang and Cosenza et al. reported no significant difference between outcomes in LSJ group versus CAT group. However, other authors such as Ramouz et al., Aljuraibi et al., Coiro et al., Singh et al., Scilletta et al., and Parmeggiani et al. have exhibited a lower incidence of RLN palsy with LSJ technique. Manouras et al. reported a significantly lower incidence of injury to EBSLN with LSJ. Reduction in hospital stay is a major factor in reducing the costs of surgery. Chiang et al., Cosenza et al., Molnar et al., Marrazzo et al., and Barbaros et al. reported reduction in hospital stay using LSJ technique. Postoperative pain is another important factor that affects the quality of life after thyroidectomy. Youssef et al. and Khafagy et al. have confirmed in their studies that postoperative pain is significantly lesser in LSJ group as compared to CAT technique.
Cosenza et al. conducted a prospective RCT to assess the safety and efficacy of LSJ versus harmonic focus (HF) and CAT technique (CAT) in total thyroidectomy for benign disease. The strength of this study was that it was a well-designed RCT where the three groups were homogeneous in terms of age, gender, BMI, and pathology. One hundred and twenty-six patients with benign disease undergoing total thyroidectomy were randomly assigned into three groups: CAT group (42 patients); LSJ group (42 patients); and HF group (42 patients). Perioperative and postoperative data were compared between the groups. In LSJ and HF groups, the mean operative time was 20 min shorter than the CAT group (P < 0.001; 95% CI). The postoperative complication rates as well as the mean hospital stay were similar between the three groups. It is pertinent to emphasize that the study included benign cases only.
Ramouz et al. published a randomized controlled trial to compare the postoperative complications of LSJ instrument with CAT method in thyroidectomy patients. All patients with the diagnosis of multinodular goiter, thyroid cancers, retrosternal goiter, and other indications for thyroid surgeries were enrolled. This study included a large sample size of 550 patients, of which 261 were randomly assigned to the conventional Group (A) and 274 patients to LSJ Group (B). There was no significant difference regarding demographic data between Groups A and B. During total thyroidectomy, intraoperative blood loss was 64.42 ± 20.72 and 49.64 ± 17.92 ml in Groups A and B, respectively (P 0.043; 95% CI). Operative time was significantly lower in LSJ group compared to the conventional group in total and subtotal thyroidectomy (P 0.002; P 0.001; 95% CI). There was no significant difference between techniques regarding RLN injury (P 0.134). Decrease in total and ionized serum calcium was more severe in patients with conventional thyroidectomy (total calcium, P < 0.0001; 95% CI) (ionized calcium, P 0.005; 95% CI). The authors concluded that LSJ device decreases operative time and intraoperative bleeding compared to conventional technique. Besides, changes in total and ionized calcium levels in patients with LSJ thyroidectomy are subtle compared to CAT technique. The major weakness of this study was inclusion of a heterogeneous group of histological types of thyroid pathology. The strength of this was that it was an RCT with a large sample size. Besides, the results of this study confirmed that LigaSure has better treatment outcomes even in a heterogeneous group of study population including multinodular goiters, thyroid cancers, and retrosternal goiters.
Zhang et al. (2017) published a meta-analysis to compare the outcomes of LSJ versus CAT technique or HF Scalpel in thyroidectomy in terms of operative time, intraoperative blood loss, postoperative blood loss, length of hospital stay, and complications including temporary/permanent hypocalcemia, temporary/permanent RLN palsy, seromas, hematomas, and infection. The greatest virtue of this study design was the assessment of quality of studies using Cochrane collaboration's risk of bias tool. Four out of seven studies selected for final inclusion were RCTs, thus generating a high level of evidence. There was significant reduced operative time in LSJ group compared with CAT group (mean difference [MD] = −17.49, 95% CI, P < 0.00001) or HF group (MD = −2.29, 95% CI, P < 0.00001). Besides, results in relation to other perioperative outcomes such as intraoperative and postoperative blood loss were in favor of LSJ group compared with CAT group. In terms of complications, significantly less temporary hypocalcemia rate was observed in LSJ group compared with CAT (odds ratio [OR] = 0.49, 95% CI, P = 0.02), although no significant difference was detected in comparison to HF scalpel (OR = 0.47, 95% CI, P = 0.22). There was no significant difference between the three groups in relation to incidence of other complications such as length of hospital stay, permanent hypocalcemia, temporary or permanent RLN palsy, and hematomas. Zhang et al. concluded that the use of LSJ is more favorable than the CAT technique in thyroidectomy.
Uludag et al. (2017) published a prospective study was to evaluate the impact of sutureless total thyroidectomy performed with energy-based devices (EBDs) on objective voice quality (VQ) of patients without RLN and/or EBSLN injury. Sixty patients were randomly assigned to three groups – Group L (LigaSure), Group H (harmonic), or Group C (conventional technique). In all groups, the EBSLN and RLN were dissected. For analysis of change in VQ, digital videolaryngostroboscopy, voice handicap index (VHI), multidimensional voice program, and electroglottography were used. On comparison of VHI scores at postoperative 1st week and 2nd month to preoperative values for each group, Groups L and H demonstrated an increase in VHI in the early postoperative evaluation (P = 0.731), but there was no significant increase for Group C. No significant increase was found in the late postoperative period compared to preoperative period for any of the groups. In the early postoperative period, VQ was found to be better with the conventional technique than EBDs, but in the late postoperative period, VQ was detected better in EBDs (especially in Group L) than the conventional technique. However, no statistical difference was observed (P = 0.703). The results thus showed that VQ for EBDs is not significantly different from that of conventional technique and EBDs provide an acceptable VQ after thyroid surgery.
AlJuraibi et al. conducted a prospective analytic study to compare the outcomes of LigaSure versus CAT technique in total thyroidectomy. The greatest strength of this study was a large sample size of 200 patients who underwent surgery for bilateral benign multinodular goiter. Subjects were randomized into two groups of 100 patients each. Group A underwent surgery using LigaSure sealing device, whereas Group B underwent surgery by traditional CAT technique. No statistical difference was found between the two groups regarding age, sex, and body mass index. The operative time was 115.54 ± 15.35 min in Group A compared to 127.1 ± 7.95 min in Group B (P ≤ 0.0001; 95% CI). The intraoperative blood loss was 62.06 ± 7.34 ml in Group A versus 75.84 ± 9.21 ml in Group B (P ≤ 0.0001; 95% CI). Incidence of temporary RLN injury was 3% in Group A versus 5% in Group B. Transient hypoparathyroidism was seen in 2% of patients of both groups, while permanent hypoparathyroidism was found in only one patient of Group B. Postoperative drain volume was 54.16 ± 9.21 ml in Group A and 66.28 ± 8.99 ml in group B (P ≤ 0.0001; 95% CI). Furthermore, the authors concluded that the use of LigaSure is associated with better functional preservation of laryngeal nerves and parathyroid glands. It must be noted that the study included only cases of benign thyroid disease. Although results were reported in relation to incidence of RLN palsy, there was no comment on postoperative palsy of EBSLN.
Khafagy et al. presented a prospective study to evaluate the outcomes of LigaSure-assisted total thyroidectomy versus conventional thyroidectomy as regards feasibility, intraoperative and postoperative complications, postoperative pain, and hospital stay. A total of 30 patients suffering from multinodular goiter, toxic goiter, and Graves' disease suspicious for malignant nodules were randomized into Group L (LigaSure, 15 patients) and Group C (conventional, 15 patients). The incidence of temporary hypoparathyroidism, temporary RLN palsy, postoperative bleeding, and wound complications was 6.7%, 6.7%, 0%, and 6.7% in Group L versus 20%, 13.3%, 13.3%, and 13.3%–20% in Group C, respectively. Postoperative pain was analyzed according to the visual analog scale (VAS). The VAS scores were significantly lower for Group L throughout the first 3 postoperative days. The authors concluded that LSJ improved surgical outcomes with significantly reduced operative time, wound drainage duration, and hospital stay. In addition, the use of LigaSure significantly reduced wound pain scores. Majority of the patients included in this study suffered from benign thyroid disease. The sample size was rather small for drawing conclusions which could guide treatment decisions.
Yao et al. (2009) reported their results of a meta-analysis that included four randomized trials and five nonrandomized trials including 467 patients in LigaSure group and 460 patients in CAT group. Only studies which had a prospective controlled design were included. The primary outcomes were reported in terms of operative duration and amount of intraoperative blood loss, while the secondary outcomes were reported in relation to length of hospital stay and any postoperative complications, including postoperative hypocalcemia and RLN palsy. The operative time was significantly reduced in the LigaSure group (weighted MD [WMD], −11.97 min; 95% CI; P < 0.001) as compared to the CAT group. No significant difference was found between LSJ group and CAT group for an overall incidence of postoperative complications (OR, 0.91; 95% CI, 0.61–1.36; P = 0.65). The authors concluded that LSJ is a safe alternative to CAT technique which reduces operative time without increasing complications and morbidity. However, the authors cautioned toward heterogeneity among the included studies when interpreting the results of this meta-analysis.
| Conclusion|| |
Sealing device is a safe and effective alternative to traditional CAT technique for thyroidectomy. It reduces the operating time, intraoperative and postoperative hemorrhage, postoperative drain volume, incidence of transient and permanent postoperative hypocalcemia, and incidence of transient and permanent paralysis of superior and RLNs. From the results of various studies cited above, it can be inferred that in countries with high volume of thyroid surgeries, such as India, sutureless technique of thyroid surgery is better as it will help to reduce the operative time, associated complications, and hospital stay.
Financial support and sponsorship
Conflict of interests
The authors declare that there is no conflict of interests that could influence this work.
This material has never been published and is not currently under evaluation in any other peer-reviewed publication.
The permission was obtained from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study. Not applicable as this is a review article with no patients involved.
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[Table 1], [Table 2]