Total thyroidectomy, as it is known today, began in the late 19th century, when Theodor Kocher [608476]

Introduction
Total thyroidectomy, as it is known today, began in the late 19th century, when Theodor Kocher
underwent a meticulous thyroidectomy, reducing the mortality of this surgery by less than 1%.
(Intechopen)
Although the technique of thyroidectomy has changed very little over the years, different
techniques for hemostasis have been developed, in addition to conventional methods [2].
The desire for a perfect hemostasis has led the medical equipment industry to produce that
“ideal” instr ument for safe thyroidectomy. Thus, hemostasis / sealing instruments such as
LigaSureTM Small Jaw, ThunderbeatTM Open Fine Jaw and HarmonicTM Focus have been
indicated with thyroid surgery [3,4,5].
The purpose of this study is to present the initial result s using the 3 surgical instruments for
performing the monobloc thyroidectomy, also reported in the literature.
Material and methods
We performed a prospective study, performed in the General Surgery Clinic 1 of the Emergency
Clinical County Hospital of Târ gu Mureș, between 01.01.2014 until now, in which I introduced
45 successive patients divided into groups of 15 in which the thyroidectomy was performed
using different sealing devices. For the first group LigaSureTM Small Jaw was used, for group 2
the Thun derbeatTM Open Fine Jaw was used and for group 3 the HarmonicTM Focus was used.
All patients underwent a complete evaluation preoperatively including: biochemical parameters,
fine needle biopsy puncture, otology examination and women were evaluated gynecol ogically.
The post -operative examination was performed by the otologist only if there were phonation
disorders or signs of respiratory failure. Patients known to have neck surgery and / or radiation
therapy, those with dysphonia and a patient undergoing tr eatment with TNF -alpha inhibitor
(adalimumab) having elevated eosinophils [6] were excluded from the study. The groups were
statistically compared following the following parameters: duration of surgery and
hospitalization, early postoperative complication s as well as voice alteration or acute respiratory
failure.
All patients were informed about the characteristics of these devices and implicitly of the
possible complications.

Surgical technique
The surgery was performed by a single surgeon with experienc e in endocrine surgery following
the same operative steps, the only difference being given by the use of sealing -hemostasis
devices. The surgery starts with a Kocher -type arched incision in the anterior cervical region of
about 3 -5 cm, located about 1 cm b elow the cricothyroid cartilage. The subcutaneous cell tissue,
the platysma muscle are sectioned and then the 2 flaps are prepared. The upper flap is suspended
using a thread to the chin then we divide the median raf of the muscles and enter into the thyro id
lodge.
The monobloc thyroidectomy is performed like "pulling a Lego piece", from left to right as " you
browse the tabs of a book" by sealing the inferior thyroid pedicle (Figure 1).

Figure 1. Sealing the inferior pedicle
The surgical intervention co ntinues with the sealing of the middle and posterior pedicles. We
continue the dissection from left to right, cutting the posterior ligaments of Berry (Figure 2),
detach ing the isthmus and enter into the right thyroid lodge (Figure 3).

Figure 2. Sectioning of the suspensory ligaments and
further dissection towards the upper pedicle
To facilitate the mobilization of the thyroid lobe we use a traction thread .

Figure 3. Entering into the right thyroid lodge
Following the same intraoperative steps, we practice the dissection of the right lobe, the last step
being the sealing of the superior thyroid pedicle of the right lobe (Figure 4). In this way we
obtain the monobloc thyroid specimen that is sent to the histopathological exam ination (Figure
5).

Figure 4. Sealing of the upper thyroid pedicle of the right lobe

Figur e 5. Thyroid monobloc specimen
We drain the thyroid lodge , suture of the median raf, resorbable suture of the subcutis and
intradermal skin suture.
Monoploar cautery is used as an auxiliary method of hemostasis in all patients .
Results:
Monobloc thyroidectomy was performed in all patients without reporting deaths or infections of
the wound.
Quantitative data were expressed as mean ± standard deviation , while qualitative data (sex,
biopsy puncture result) were expressed as percentages.
The demographic and clinical data of the 3 patient groups were similar and are represented in
table number 1.
Table 1: Clinical and demographic data
LigaSureTM Gr. Thund erbeatTM Gr. HarmonicTM Gr.
Vârsta medie 58,26±8,18 61,66±9,65 64,6±9,84
Women/Men 14/1 13/2 12/2
Preoperative histopathological diagnosis
Nodular goitre 11 11 10
Malignancy 2 3 4
Basedow -Graves disease 2 1 1

The operative time was measured from the incision to the sikn suture, without significant
statistical results. The results are represented in Table 2.
Tabele 2: Operative time
Operative time LigaSureTM Gr. ThunderbeatTM Gr. HarmonicTM Gr.
Mean 67,66 79,13 76,66
Minimum 40 55 45
Maximum 110 100 110
Standard deviation 22,5 13,38 18,58

The hospitalization period was similar . All 3 groups of patients having a minimum of 2 days, and
the maximum number of days was 7 and 6 respectively (Table 3). After applying the ANOVA
test to compar e the means of the 3 groups, we did not obtain a statistically significant result (p =
0.1998).
Tabele 3: Hospitalization
Mean±standard
deviation 3,06±1,53 4±1,41 3,6±1,24
Minim um 2 2 2
Maxim um 7 7 6

There were no manifestations of permanent hypocalcemia in the studied groups. The transient
disturbances of the balance of calculation were countered by the administration of calcium
intravenously and then orally.
In those 3 groups of patients there were some phonation complications and some postoperative
haematoma and the results are exemplified in table 4.
Tabele 4: Early postoperative complications
LigaSureTM Gr. ThunderbeatTM Gr. HarmonicTM Gr.
Răgușeală 3 3 2
Acute respiratory
failure 0 1 0
Haematoma 2 1 2
Discussions
Total monobloc thyroidectomy can be performed safely with a low complication rate, having a
good command of the surgical technique, knowing the local anatomy and implicitly by ensuring
a rigorous hemostasis.
The use of the LigaSureTM Small Jaw device in complete total thyroidectomy has been shown to
be safe and effective in reducing operative time, intraoperative blood loss and in reducing
postoperative drainage fluid. The sealing device is accompanied by better results regarding the
function of the recurrent laryngeal nerves and the condition of the parathyroid glands .
ThunderbeatTM Open Fine Jaw is the only device currently available in the world, capable of
simultaneously providing frictional thermal energy through ultrasound and bipolar power
generated [31].
Years of study on this device have shown that this combination of bipolar energy and ultrasonic
energy is more beneficial in surgery compared to devices using only ultrasound (Harmonic
FocusTM) or devices using only bipolar energy (LigaSureTM Small Jaw) .
The efficiency and versatility offered by this device are very useful nowadays and represent an
important step towards achieving perfection in modern surgery.

The average duration of the operating time was not signif icantly different from the statistical
point of view and is included in the data from the specialized literature, where the average time is
86 minutes. This operative time is greatly influenced by the operator's experience, as shown in
the article publishe d by Arnaud Patoir and colleagues. However, it seems that the group that had
been using LigaSureTM Small Jaw had a shorter operating time of approximately 11.47 compared
to ThunderbeatTM and 9 minutes respectively compared to HarmonicTM.
Regarding the leng th of hospitalization, the average within the groups included in the study was
similar. Th e mean value is higher compared to the literature data suggesting that the average
hospitalization period is 2 days. Recent studies suggest that thyroidectomy should be performed
under day hospital conditions, this attitude being dependent on the surgeon, patient and hospital.
In the studied batches, the use of sealing devices was effective. All vascular structures were
successfully sealed without the need for other h emostasis adjuvants during surgery.
Regarding the appearance of the phenomena of dysphonia or acute respiratory failure,
unfortunately a patient belonging to group 2 whose postoperative evolution was apparently
favorable, presented on the second day acute respiratory failure that did not recover
conservatively. The patient was transferred to the Otology department where a tracheostomy was
performed.
From our point of view, the LigaSureTM Small Jaw device has an advantage due to its
ergonomics as well as its easy handling compared to the other devices.
Conclusions :
Monobloc total thyroidectomy is a feasible therapeutic method for the surgical treatment of
thyroid disorders.
The use of new surgical instruments is beneficial, being a real help through their properties.
Shortening the operative , maintaining a clean operating field but also the small amount of smoke
released during the operation are just some of the facilities provided by these instruments.
The ergonomics of the sealing instruments used i n this study as well as the fact that they should
not be changed during surgery bring an added bonus for surgical comfort.