Comparative study between bipolar electro-cautery and knot-tying technique in total thyroidectomy

RESULTS

This study was carried out at Al-Azhar university hospital on 60 patients all had thyroid diseases indicated for total thyroidectomy. Patients have been divided into 2 equal groups: 

Group A (knot-tying group): included 30 patients (3 males and 27 females) with a mean age 44.8 ± 9.7 years. Haemostasis was carried out by knot tying technique.

Group B (bipolar group):included 30 patients (4 males and 26 females) with a mean age 44 ± 8.9 years. Haemostasis was carried out by bipolar electro-cautery.

Indications for total thyroidectomy in both groups was;

Simple multi-nodular goiter in 43 patients (71.7%).

Graves disease with non compliance to medication in 5 patients (8.3%).

Secondary toxic goiter in 5 patients (8.3%).

Nodular goiter on top of thyroiditis in 2 patients (3.2%).

Solitary thyroid nodule with suspicious FNA in 5 patients (8.3%)

Bilateral vocal cord mobility has been confirmed in all patients by pre-operative indirect laryngoscope.

Uneventful total thyroidectomy has been carried out to all patients in both groups with no mortality, no permanent complications and no patients required redo surgery.

Statistical analysis of collected operative and post-operative data showed the following results.

Table 1: operative and post-operative results.

Significantly reduced operative time in group B than in group A with significant p value < 0.001.

Bipolar (suturless) thyroidectomy was associated with less blood loss than ordinary knot-tying technique.

Recorded operative and post-operative morbidity in both groups showed non-significant P value (>0.1). All complicated cases has been recovered within 6 weeks without permanent effect.

There was significant difference between both group regarding post-operative pain severity with significant P value (<0.001) has been recorded according to visual analogue scale (VAS).

Despite of reduced post-operative drainage per suction drain in group (B) and early removal of suction drain in the first day post-operative, no significant difference in hospital stay.

One patient in knot tying group developed post-operative laryngeal spasm which was attributed to laryngeal odema secondary to repeated trial of difficult intubation with good response to steroids and oxygen therapy with no need for prolonged intubation or ICU admission.

From all patients in both groups, 5 patients only developed post-operative transient hypo-parathyroidism. 4 patients diagnosed by laboratory low serum calcium in early post-operative period without hypocalcaemic manifestations. Only one patient developed manifestations of hypocalcemia in the form of circumoral numbness tingling and numbness in both hands.       All cases of hypocalcemia were transient with good response to oral Ca and Vit D supplementation.

No cases for permanent RLN injury or permanent hypo-parathyroidism were recorded.

DISCUSSION

Safe and successful surgical procedure necessitates carful dissection with good haemostasis for proper identification and preservation of important structures. Knot-tying technique is the standard haemostatic method in general surgical practice. Vessel sealing devices has been used to save more time but associated with extra coast.⁸

Thyroid gland has been considered to have the richest blood supply, approximately 80 ml \100 g \s. This blood supply doubled in case of hyper thyroidism.⁹

Being one of richest blood supplied organs, improper haemostasis could lead to serious consequences like re-operation, laryngeal nerve damage and devitalization of parathyroid glands.¹⁰

In general surgical practice, the incidence and type of complications are closely related to type of surgery, surgeon experience, nature of used materials, underlying pathology and other patient’s factors. Electro-cautery can safely and effectively seals vessels up to 2 mm, however, lateral thermal dispersion cannot be precisely estimated and prevented. Classic suture haemostasis has been proved be safe and effective but associated with more time, more dissection, retained foreign body at operative site with prolonged tissue reaction, extensive fibrosis with late and scar complications.¹¹

In a comparative study, Manouras et al found reduced operative time by about 15-20% if bipolar or vessel sealer has been used in comparison with classic technique. Longer operative time in other studies has been attributed to learning curve.¹²

Monopolar electro-cautery was safe and effective in achieving haemostasis in thyroidectomy, as reported by Sandonato L et al, without increased risk of laryngeal nerve injury or hypo-parathyroidism.¹³

However, most surgeons don’t prefer its use in thyroidectomy specially near important structures to avoid damage by lateral thermal effect.  

In this study, 30 patients underwent total thyroidectomy by conventional knot-tying technique and another 30 patient suturless thyroidectomy has been carried out by bipolar electro-cautery. Patients with other pathologies (retrosternal extension), co-morbidities (previous neck surgery) or indicated for another procedure (like neck dissection) that may affect the outcome of surgery was excluded from the study.

In this study, statistically significant reduction in operative time (P-value <0.001) with bipolar electro-cautery (103.9±7.8 minutes) versus conventional knot-tying group (124.7±5.2 minutes). That result was comparable to other studies reported shortened operative time with use of bipolar electro-cautery or with use of harmonic and ligasure.

Recorded blood lose in bipolar group was also statistically significant (P value <0.001) in comparison with conventional group. Athough it was not associated with any clinical effect on the patients ( as blood loss in thyroid surgery is usually minimal to mild ) but matched with other studies conducting that use of electro-cautery and vessel sealing device was associated with less blood lose and better haemostasis.

There was significant difference in pain severity and need for post operative analgesia between both groups (P Value <0.001). Bipolar group had less post operative pain (3.8 ±1.2) compared to conventional Knot-tying group (5.8 ±0.9). Similar study recorded less narcotic analgesia was required in case of bipolar electro-cautery and attributed that to less tissue dissection and absence of residual suture material with subsequent inflammatory tissue reaction.¹⁴

Per this study the incidence of recurrent laryngeal nerve injury was 3.3% in bipolar group. Incidence of nerve injury was reported to be 1.85% by using bipolar electro-cautery in another study carried out by Govindaraj et al.¹⁴

In this study the incidence of hypoparathyroidism was 3.3% in bipolar group. Bove et al reported increased incidence of transient hypo-parathyroidism 24.5%.¹⁵

In this study no recorded cases of reactionary or tertiary haemorrhage. A similar study carried out by Challa et al on 40 patients in whom haemostasis was achieved by bipolar electro-cautery no recorded cases of post operative bleeding.¹⁶

In this study non significant P value (>0.1) was observed between both groups regarding hospital stay. Despite of less post operative drainage volume per suction drain and early drain removal in bipolar group, most patients were kept in the hospital till second post operative day for recording and detection of post operative hypocalcaemia which usually occurs in second post operative day.

Alherabi A et al, reported that bipolar thyroidectomy was associated with less need for drain, less hospital stay and early patient discharge.¹⁷

Less hospital stay was recorded by Petrakis et al,in case of thyroidectomy by using vessel sealing device (2.3± 1.7) compared to2.8 ± 1.3 days in conventional knot-tying group with significant P Value P18-21

Comparative study between bipolar diathermy and other vessel sealing devices, carried out by Challa S, Surapaneni S et al, showd that vessel sealing devices were associated with increased coast and limited use at higher centers only. Bipolar electro-cautery was available at all centers without extra coast and with same efficacy of vessel sealing devices.¹⁶

In this study, there was no mortality no permanent morbidity in both studied groups.

CONCLUSION

Suturless thyroidectomy using bipolar electro-cautery was proved to be safe and effective without increased risk of operative, post-operative complications and without increased coast. Bipolar electro-cautery associated with less operative time, less blood loss, less post-operative drainage, decreased pain and may be less hospital stay.