Energy Devices in Minimally Invasive Thyroidectomy

  • Pier Francesco Alesina
  • Martin K. Walz


An accurate haemostasis is essential during any surgical procedure. This problem is well known for thyroid surgery since over one century when Billroth, considered one of the best surgeons in Europe, reported a mortality of 40% on a series of 20 patients in 1869. Few decades later, in the hands of Theodor Kocher, thyroidectomy developed into a safe operation with a mortality rate of 0.5% by 1898 (Richard 1990). The key for these extraordinary results was the technique he introduced which first ligated the major arteries and veins followed by identifying and isolating the recurrent laryngeal nerve (Kocher 1883). Since that time, suture ligation has continued to be the gold standard of obtaining haemostasis. The introduction of the minimally invasive thyroid surgery poses the problem to break this 100-year-old rule. The impossibility to ligate is obvious for the purely endoscopic operations such as the endoscopic neck, thoracic and axillary approach (Henry and Segab 2006; Strik et al. 2007; Kang et al. 2009), but also the video-assisted operation due to the limited working space permits conventional ligatures only after the extraction of the thyroid lobe through the skin incision (Miccoli et al. 2006). Many instruments are now available for this use and have been demonstrated to be at least as safe as the knot-and-tie technique.


Recurrent Laryngeal Nerve Thyroid Surgery Energy Device Cosmetic Satisfaction Axillary Approach 
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  1. Alesina PF, Rolfs T, Walz MK (2010) Bipolar thermofusion vessel sealing system (TVS) versus conventional vessel ligation (CVL) in thyroid surgery – results of a prospective study. Langenbecks Arch Surg 395:115–119PubMedCrossRefGoogle Scholar
  2. Bandi G, Wen CC, Wilkinson EA et al (2008) Comparison of blade temperature dynamics after activation of Harmonic Ace scalpel and the Ultracision Harmonic Scalpel LCS-K5. J Endourol 22:333–336PubMedCrossRefGoogle Scholar
  3. Barbaros U, Erbil Y, Bozbora A et al (2006) The use of LigaSure in patients with hyperthyroidism. Langenbecks Arch Surg 391:575–579PubMedCrossRefGoogle Scholar
  4. Barczyński M, Konturek A, Cichoń S (2008) Minimally invasive video-assisted thyroidectomy (MIVAT) with and without use of harmonic scalpel – a randomized study. Langenbecks Arch Surg 393:647–654PubMedCrossRefGoogle Scholar
  5. Cordón C, Fajardo R, Ramírez J et al (2005) A randomized, prospective, parallel group study comparing the Harmonic Scalpel to electrocautery in thyroidectomy. Surgery 137:337–341PubMedCrossRefGoogle Scholar
  6. Defechereux T, Rinken F, Maweja S et al (2003) Evaluation of the ultrasonic dissector in thyroid surgery. A prospective randomised study. Acta Chir Belg 103:274–277PubMedGoogle Scholar
  7. Di Rienzo RM, Bove A, Bongarzoni G et al (2010) Comparison of conventional technique, Ligasure Precise and Harmonic Focus in total thyroidectomy. G Chir 31:296–298PubMedGoogle Scholar
  8. Emam TA, Cuschieri A (2003) How safe is high-power ultrasonic dissection? Ann Surg 237:186–191PubMedGoogle Scholar
  9. Foreman E, Aspinall S, Bliss RD et al (2009) The use of the harmonic scalpel in thyroidectomy: ‘beyond the learning curve’. Ann R Coll Surg Engl 91:214–216PubMedCrossRefGoogle Scholar
  10. Fujita T, Doihara H, Ogasawara Y et al (2006) Utility of vessel-sealing systems in thyroid surgery. Acta Med Okayama 60:93–98PubMedGoogle Scholar
  11. Hallgrimsson P, Lovén L, Westerdahl J et al (2008) Use of the harmonic scalpel versus conventional haemostatic techniques in patients with Grave disease undergoing total thyroidectomy: a prospective randomised controlled trial. Langenbecks Arch Surg 393:675–680PubMedCrossRefGoogle Scholar
  12. Heniford BT, Matthews BD, Sing RF et al (2001) Initial results with an electrothermal bipolar vessel sealer. Surg Endosc 15:799–801PubMedCrossRefGoogle Scholar
  13. Henry JF, Segab F (2006) Lateral endoscopic approach for thyroid and parathyroid surgery. Ann Chir 131:51–56PubMedCrossRefGoogle Scholar
  14. Kang SW, Lee SC, Lee SH et al (2009) Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 146:1048–1055PubMedCrossRefGoogle Scholar
  15. Karvounaris DC, Antonopoulos V, Psarras K et al (2006) Efficacy and safety of ultrasonically activated shears in thyroid surgery. Head Neck 28:1028–1031PubMedCrossRefGoogle Scholar
  16. Kilic M, Keskek M, Ertan T et al (2007) A prospective randomized trial comparing the harmonic scalpel with conventional knot tying in thyroidectomy. Adv Ther 24:632–638PubMedCrossRefGoogle Scholar
  17. Kim FJ, Chammas MF Jr, Gewehr E et al (2008) Temperature safety profile in laparoscopic devices: Harmonic Ace (ACE), Ligasure V (LV) and plasma trisector (PT). Surg Endosc 22:1464–1469PubMedCrossRefGoogle Scholar
  18. Kirdak T, Korun N, Ozguc H (2005) Use of ligasure in thyroidectomy procedures: results of a prospective comparative study. World J Surg 29:771–774PubMedCrossRefGoogle Scholar
  19. Kiriakopoulos A, Dimitrios T, Dimitrios L et al (2004) Use of a diathermy system in thyroid surgery. Arch Surg 139:997–1000PubMedCrossRefGoogle Scholar
  20. Kocher T (1883) Ueber Kropfextirpation und ihre Folgen. Arch Klin Chir 29:254–335Google Scholar
  21. Koh YW, Park JH, Lee SW et al (2008) The harmonic scalpel technique without supplementary ligation in total thyroidectomy with central neck dissection: a prospective randomized study. Ann Surg 247:945–949PubMedCrossRefGoogle Scholar
  22. Koutsoumanis K, Koutras AS, Drimousis PG et al (2007) The use of a harmonic scalpel in thyroid surgery: report of a 3-year experience. Am J Surg 193:693–696PubMedCrossRefGoogle Scholar
  23. Lachanas VA, Prokopakis EP, Mpenakis AA et al (2005) The use of Ligasure Vessel Sealing System in thyroid surgery. Otolaryngol Head Neck Surg 132:487–489PubMedCrossRefGoogle Scholar
  24. Leonard DS, Timon C (2008) Prospective trial of the ultrasonic dissector in thyroid surgery. Head Neck 30:904–908PubMedCrossRefGoogle Scholar
  25. Lepner U, Vaasna T (2007) Ligasure vessel sealing system versus conventional vessel ligation in thyroidectomy. Scand J Surg 96:31–34PubMedGoogle Scholar
  26. Lombardi CP, Raffaelli M, Cicchetti A et al (2008) The use of “harmonic scalpel” versus “knot tying” for conventional “open” thyroidectomy: results of a prospective randomized study. Langenbecks Arch Surg 393:627–631PubMedCrossRefGoogle Scholar
  27. Manouras A, Markogiannakis H, Koutras AS et al (2008) Thyroid surgery: comparison between the electrothermal bipolar vessel sealing system, harmonic scalpel, and classic suture ligation. Am J Surg 195:48–52PubMedCrossRefGoogle Scholar
  28. Mantke R, Pross M, Klose S et al (2003) The harmonic scalpel in conventional thyroid surgery. Possibilities and advantages. Chirurg 74:739–742PubMedCrossRefGoogle Scholar
  29. Marchesi M, Biffoni M, Cresti R et al (2003) Ultrasonic scalpel in thyroid surgery. Chir Ital 55:299–308PubMedGoogle Scholar
  30. Marrazzo A, Casà L, David M et al (2007) Thyroidectomy with LigaSure versus traditional thyroidectomy: our experience. Chir Ital 59:361–365PubMedGoogle Scholar
  31. Meurisse M, Defechereux T, Maweja S et al (2000) Evaluation of the ultracision ultrasonic dissector in thyroid surgery. Prospective randomized study. Ann Chir 125:468–472PubMedCrossRefGoogle Scholar
  32. Miccoli P, Berti P, Raffaelli M et al (2002) Impact of harmonic scalpel on operative time during video-assisted thyroidectomy. Surg Endosc 16:663–666PubMedCrossRefGoogle Scholar
  33. Miccoli P, Berti P, Frustaci GL et al (2006) Video-assisted thyroidectomy: indications and results. Langenbecks Arch Surg 391:68–71PubMedCrossRefGoogle Scholar
  34. Miccoli P, Materazzi G, Miccoli M et al (2010) Evaluation of a new ultrasonic device in thyroid surgery: comparative randomized study. Am J Surg 199:736–740PubMedCrossRefGoogle Scholar
  35. Musunuru S, Schaefer S, Chen H (2008) The use of the Ligasure for hemostasis during thyroid lobectomy. Am J Surg 195:382–384; discussion 384–385PubMedCrossRefGoogle Scholar
  36. Ortega J, Sala C, Flor B et al (2004) 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 14:9–12PubMedCrossRefGoogle Scholar
  37. Oussoultzoglou E, Panaro F, Rosso E et al (2008) Use of BiClamp decreased the severity of hypocalcemia after total thyroidectomy compared with LigaSure: a prospective study. World J Surg 32:1968–1973PubMedCrossRefGoogle Scholar
  38. Papavramidis TS, Sapalidis K, Michalopoulos N et al (2010) UltraCision harmonic scalpel versus clamp-and-tie total thyroidectomy: a clinical trial. Head Neck 32:723–727PubMedCrossRefGoogle Scholar
  39. Parmeggiani U, Avenia N, De Falco M et al (2005) Major complications in thyroid surgery: utility of bipolar vessel sealing (Ligasure Precise). G Chir 26:387–394PubMedGoogle Scholar
  40. Petrakis IE, Kogerakis NE, Lasithiotakis KG et al (2004) LigaSure versus clamp-and-tie thyroidectomy for benign nodular disease. Head Neck 26:903–909PubMedCrossRefGoogle Scholar
  41. Pons Y, Gauthier J, Ukkola-Pons E et al (2009) Comparison of LigaSure vessel sealing system, harmonic scalpel, and conventional hemostasis in total thyroidectomy. Otolaryngol Head Neck Surg 141:496–501PubMedCrossRefGoogle Scholar
  42. Rahbari R, Mathur A, Kitano M et al (2010) Prospective randomized trial of ligasure versus harmonic hemostasis technique in thyroidectomy. Ann Surg Oncol. doi:10.1245/s10434-010-1251-5Google Scholar
  43. Richard B (1990) Welbourn: the history of endocrine surgery. Praegel, New YorkGoogle Scholar
  44. Richter S, Kollmar O, Neunhoeffer E et al (2006) Differential response of arteries and veins to bipolar vessel sealing: evaluation of a novel reusable device. J Laparoendosc Adv Surg Tech A 16:149–155PubMedCrossRefGoogle Scholar
  45. Saint Marc O, Cogliandolo A, Piquard A et al (2007) LigaSure vs clamp-and-tie technique to achieve hemostasis in total thyroidectomy for benign multinodular goiter: a prospective randomized study. Arch Surg 142:150–156; discussion 157PubMedCrossRefGoogle Scholar
  46. Sartori PV, De Fina S, Colombo G et al (2008) Ligasure versus ultracision in thyroid surgery: a prospective randomized study. Langenbecks Arch Surg 393:655–658PubMedCrossRefGoogle Scholar
  47. Sebag F, Fortanier C, Ippolito G et al (2009) Harmonic scalpel in multinodular goiter surgery: impact on surgery and cost analysis. J Laparoendosc Adv Surg Tech A 19:171–174PubMedCrossRefGoogle Scholar
  48. Siperstein AE, Berber E, Morkoyun E (2002) The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery. Arch Surg 137:137–142PubMedCrossRefGoogle Scholar
  49. Strik MW, Anders S, Barth M et al (2007) Total videoendoscopic thyroid resection by the axillobilateral breast approach. Operative method and first results. Chirurg 78:1139–1144PubMedCrossRefGoogle Scholar
  50. Takami H, Ikeda Y, Niimi M (1999) Ultrasonically activated scalpel for subtotal thyroidectomy in Graves’ disease. Am J Surg 178:433–434PubMedCrossRefGoogle Scholar
  51. Voutilainen PE, Haglund CH (2000) Ultrasonically activated shears in thyroidectomies: a randomized trial. Ann Surg 231:322–328PubMedCrossRefGoogle Scholar
  52. Yildirim O, Umit T, Ebru M et al (2008) Ultrasonic harmonic scalpel in total thyroidectomies. Adv Ther 25:260–265PubMedCrossRefGoogle Scholar
  53. Zarebczan B, Mohanty D, Chen H (2010) A comparison of the LigaSure and harmonic scalpel in thyroid surgery: a single institution review. Ann Surg Oncol. doi:10.1245/s10434-010-1334-1343Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Clinic for Surgery and Centre of Minimal Invasive Surgery, Kliniken Essen-MitteAcademic Hospital of the University of Duisburg-EssenEssenGermany

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