0304 Studio.docx

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0304 Studio.docx

0304Studio

UniversitàdegliStudidiPalermo

AziendaOspedalieraUniversitariaPoliclinicoP.Giaccone

DipartimentodiChirurgiaGenerale,d’UrgenzaedeiTrapiantid’Organo(GENURTO)

UnitàOperativaComplessadiChirurgiaGeneraleed’Urgenza(Direttore:

Prof.G.Gulotta)

ViadelVespro,129–90127PALERMO

Earlyapplicationsofanewtissuesealingsysteminthyroidsurgery

GregorioScerrino,NunziaCinziaPaladino,GiudittaMorfino,ValentinaDiPaola,GiuseppeSalamone,GaspareGulotta

ThispaperwaspresentedattheIIIbiennalCongressofEuropeanSocietyofEndocrineSurgeons,Barcelona,April24–26,2008

CorrespondingAuthor:

GregorioScerrino

ViaA.DeGasperi,53–90146PALERMO(Italy)

Tel.00390916552807/6552814/515892

Mobilephone:

00393288105607

Fax:

00390916552831/6552814

ieronimus141160@yahoo.it

gregorio.scerrino@tiscali.it

Summary

BackgroundandAims:

.Werecentlyperformedmanythyroidectomiesusingadevicethatsimultaneouslyusesheatandpressureforweldingandcuttingtissue.Weevaluatepreliminaryresultsusingthistoolinthyroidsurgery.

Patients/Methods:

Aperspectiverandomizedstudywasconductedon68patientssubjectedtototalthyroidectomyforbenignnodularnontoxicgoiter:

34patients(groupA)usingthermocautery,34withclamp-and-tietechnique.Thetwogroupswerecomparabletoaverageage,sex,thyroidalvolume(25-50ml),incision(<35mm).Weevaluatedsurgicaltime,complications,postoperativeserumcalciumlevels,drainage,complications.ThecomparisonhasbeendonebytStudenttest.

Results:

Theaverageoperativetimewas52.85minutesinGroupAand60.26minutesinGroupB(p<0.0001).Thedifferenceamongcalciumlevelswassignificantly(p=0.02).Nocomplicationwasfoundinthetwogroups.Theaverageamountofdrainagewas60.9cc.(GroupA)and63.8cc(GroupB).

Conclusions:

Thermocauteryhasprovedsafeandeffectivetoreduceoperativetimeandtheincidenceofpostoperativehypocalcaemiaminimizingnecrosisandthermaldiffusion.Maniples‘costforeverypatientisalsooffsetbyreduceduseofligatures.TheapplicationinMIVATispossible.Furtherinvestigationsarerequiredtoconfirmasafehemostasisandthereducedheatspread.

Keywords:

electrosurgery;thermalspread;hemostasis;thyroidectomy;thermocautery

Introduction

Todaythyroidsurgery,whichstartedoutbetweentheendoftheXIXandthefirstdecadeoftheXXcentury,isbeingdiscussedespeciallyasfarastheextentoftheresectionisconcerned(lobectomy,sub-totalortotalthyroidectomy)andtheindicationtomini-invasivetechniques.

Nevertheless,thereisawideconfrontationaboutthenewtechnologiestoincreasesurgery’ssafetyand,atthesametime,toreduceitsimplementationprocedures.

Amongthetechnologieswhichhaveprobablyinfluencedthyroidsurgeryresultsbothonthereductionofrisksandthecomplicationsderivingfromthereductionofsurgeryduration,theremustbeincludedthesocalled“energybasedsurgicalinstruments”(ESI).Theyaredifferentequipments,whichtransformelectricenergyintootherformsofenergy(ultrasounds,radio-frequencies,etc.)whicharethentransformedintoheat(1-2).Generally,weesteemthattheESIavailableatthemomentwasteenergyinthesurroundingtissuesinanextremelylimitedwayand,inanycase,remarkablyinferiortotheelectro-surgerytraditionalinstruments(3).

Theuseofheatwiththeaimtodetermineasafehaemostasisisacontroversialpoint,whichconcernsespeciallytwotopics:

thetrueefficacyofthedeviceinuse,whichideallyshouldproduceahealingofthevesselsinordertoresisttopressurevaluesmuchhigherthanthoseattainabledirectly“invivo”(1-4),andtheriskthata“thermalspread”excessivelyextendedbeyondthelimitsofitsapplicationmaycauseamoreorlessreversibledamagetoparathyroidglandsandlaryngealnerves(4-5-6-7).

Ourexperiencewithsuchkindofsurgeryinstrumentsisextendedtoallthemainvarietiesavailableonthemarket.

Inthelastperiod,atourunitwehavebeenusinganinstrumentbasedontheexclusiveanddirectheatproduction,StarionTissueWeldingSystem®,endowedwithahandtoolTLS2140mmlong,producedbyStarionInstruments(Sunnyvale,California).Theheatissuppliedbyadistributorequippedwithaknobforthepowerregulation,anditisconcentratedonthetopofthetoolhavingtheshapeofforceps,withahandleconstitutedofatworingholder,astem,andlittlethinjawscontainingtheactivepart,astainlesssteelfilament,responsiblefortheheatproduction.

Thissystemenablesustousetwodifferentpowers,whichcanbechosenthroughadifferentpressureappliedonaspeciallyprovidedbuttoninsertedintheholder:

theinferiorpower,onthefirstrelease,canberegulatedbyhand,whilstthehighestpowerproductiontakesplaceonthesecondbuttonrelease.

Thecharacteristicsdeclaredontheinstrumentare:

*thecapacitytodeterminehaemostasisandtodissecttissues;

*theabsenceofapassageofelectricitythroughtissues;

*thelowestthermalspread;

*thelowestwatervapourandsmokeproduction.

Thecapacitytodeterminehaemostasisanddissectionsimultaneously,determinesundoubtedlyapracticaladvantage,especiallyifcomparedwithotherenergybasedinstrumentswhich,thoughproducinganextremelysafeandsuccessfultissuesynthesis,needasubsequent“cutting”,whichcanbedoneormanuallydirectlybythesurgeon,oralthoughthroughthesameinstrument,byanadditionalmechanictool.

Theelectricspreadmightberesponsibleforcarbonizationphenomena,producingaminorhaemostasisefficacy,especiallyfortheformationofaneschar,exposedtoadetachmentandconsequentreopeningofthehaemorrhagichotbedaccompaniedbypainproduction.

Thepossibledamagederivingfromthermalspreadevenafteralongspanoftime,hasalreadybeenmentioned.

Smokereductionrendersresortingtofurthermini-invasivetechniquessafer.

Theavailabilityofthisequipmenthasledustocheckitscharacteristics,qualitiesandflawsdirectlyintheatre.

Materialsandmethods

Applicationofthermaltechnology,firstofallisbasedonverifyingoftheoreticassumptions,bothonitssecurityanditsactualuse.

Measurementsconcerningtheelectricspreadofthesystemhavebeenmadeatourcentreafteranappropriatetrainingonhowtousethenewtechnology.Besidessomehistologicalcompoundshavebeenmadetoshowthechangesthatthisapplicationmaycauseonthevessels.Intheendwehavecarriedoutarandomizedperspectivestudy,on68patients,alloffemalesex,sufferingfromnon-toxicmultinodulargoitre,forwhomatotalthyroidectomyhasbeenplanned.

Thefinalcriteriawere:

-presurgicaldiagnosisofamultinodulardisease,showingnosignofmalignancy;

-thyroidsizeincludedbetween25and50ml.;

-nocoagulationalteration;

-notherapyinterferingonhaemostasis;

-nopreviousanti-thyroiddrugs;

-noanti-thyroidantibodies;

-nomalignancysuspicionafterFNAB.

Inthe12-18hoursbeforethesurgicaloperationcalcitriolhasbeengiveninaone50mcgdose.

Allthepatientshavebeensubjectedto“traditional”totalthyroidectomy,withanincisioninferiorto35mm.Attheendofthesurgeryasinglesmallsize(10Ch.)suctiondrainagetubehasbeenapplied,incorrespondencewiththethyroidcavity,where,ahaemostaticpatch(Collagen-Thrombin)hadpreviouslybeenapplied.

Thepatientsrecruitedforthisstudyhavebeendividedintotwogroupsof34people,A(inwhichthyroidectomyhasbeenwhollyconductedwiththermocautery)andB(inwhichthesurgeryhasbeenconductedwhollythroughthe“clampandtie”classicaltechnique)comparablewitheachotheraccordingtotheirage(groupA:

average=47,2,range27-61;groupB:

average=51,09,range24-60)andthesizeoftheirthyroid(groupA:

average=32,45ml,range25-47;groupB:

average=30,72ml,range25-50)measuredinthepre-operativetimeaccordingtotheultrasoundcriteria:

dlXdtXsX0,5,where:

dlisthelongitudinaldiameterofthelobe,dtisthetransversaldiameter,sisthelobethickness;0.5isacorrectionfactorusedtoassimilatetheobtainedamount(onavirtuallevel,thatofaparallelepiped)intheellipsoid.Thecalculationofthelobesizehasbeenmadeseparatelyandthevalueshavebeenaddeduplater.

IngroupAthermocauteryhasbeenusedstartingfromtheseparationofthepre-thyroidalmusclesalongthe“lineaalba”.Thesectionoftheupperpedicleshasbeenexecutedsystematicallythroughthedeviceandthehigherthecalibreofthevesselstreatedwas,thelessthepowerusedwas(generally,inthisphaseaquitelowpowerlevelwasused,whichrenderedthesynthesisphaselonger,keepinghowever,gratersecuritylevels)(fig.1).Besidesthedissectionofthemediumandofthesubistmicveinshasbeencarriedoutatamediumpower.Thedissectionbetweenmusclesandthyroidtogetherwiththemedianligamenthasbeengenerallyperformedathighpower.Somebindings(2-3foreachlobe)wereappliedonlywhenthedistanceoftherecurrentnervevisiblewasnotguaranteedabsolutelybyathermalspread.

TheBgrouppatientsweretreatedthroughtheclassicaltechnique:

themusclesectionalongthe“lineaalba”hasbeenmadewithaunipolarelectrosurgicalknife,whilstinpractiseallthedissectionoperations,startingfromthepreparationoftheupperpedicles,totherecurrentlaryngealnervedissectionphaseandtothedetachmentoftheglandfromitssite,hasbeenmadewithoutheating,ifnecessarywiththeapplicationofbindings.Theupperpedicleshavebeentreatedwithadoubleresorptionbinding.

Allthepatientshaveundergoneafibreopticlaryngoscopeduringthe24hoursafterthesurgicalprocedure,andtheyhavebeendischar

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