METHODS OF HEMOSTASIS IN THYROIDECTOMY

Аннотация

Post-thyroidectomy neck hematoma represents a major concern for surgeons because it can result in severe and even life-threatening complications. In fact, postoperative hemorrhage may result in airway compression and respiratory distress, and therefore, effective hemostasis is an important goal in thyroid surgery. Postoperative hematoma occurs at a rate of approximately 0.1% to 1.1%. Almost all cases occur in the first 6 h after surgery and can be the result of several surgeon or patient factors. For many years the clamp-and-tie technique has been the most common way to divide the main vascular pedicles of the thyroid gland. Alternatively, bipolar electrocautery has been used for only very small vessels. Other hemostatic systems have been introduced and proved to be potentially very useful in neck surgery and, in particular, for thyroid surgery.[1] Treatment of hematomas really depends on the symptoms. Most hematomas need to be evacuated and reexplored, but only an unstable or progressively worsening hematoma in a patient requires immediate evacuation at the bedside. Reintubation in a controlled operating room environment is often possible. The most senior endoscopist should perform the intubation because significant epiglottis and arytenoid edema may be present. During surgical history, numerous technical advances have emerged in hemostasis, the suture ligatures, vessel ligating clips, electrocoagulation by mono- or bipolar instruments, and topical hemostatic agents, the use of which is mainly promoted in the last years in thyroid surgery as in other surgical disciplines. Key words:Neck hematoma, hemostasis, thyroid surgery, treatment. Wedecided to usethe hemostatic products that are currently available in ouroperating room, an equine collagen patch coated with human fibrinogen and human thrombin (CFTP) and oxidized regenerated cellulose gauze, following our favorable initial experience with these topical hemostatic agents in general surgery. So we proceeded to design a prospective study to compare the efficacy of CFTP and cellulose gauze to traditional procedures in patients undergoing thyroid surgery, in terms of blood loss and the incidence of hemorrhagic events, always in relation to other complications.[2] Several options exist for the intraoperative ligation of blood vessels. Conventional techniques include clamp, tie, and cut methods, with orwithoutcautery. Somesurgeons usemonopolar cautery; however, thiscauses asignificant amount of heat dispersion and puts adjacent structures at risk for injury. Bipolar cautery is more pinpoint and allows less dispersion of heat. For many years the clamp-and-tie technique has been the most common way to divide the main vascular pedicles of the thyroid gland. Alternatively, bipolar electrocautery has been used for only very small vessels. This coagulation system is still considered appropriate to thyroid surgery because it concentrates all of the electrical energy in one limited point, thus reducing the heat transmission to the critical structures. Electrocautery is not, however, effective to obtain hemostasis on larger vessels, and therefore, the clamp-and-tie technique cannot be avoided. Other hemostatic systems introduced in the last decade have proved to be potentially very useful in neck surgery and particularly for thyroid surgery. This new class of instruments is generally better known as “energy devices”, because they all use different forms of energy 98,7:ROTCAFTCAPMI.SECNEICSLACIDEM ,5202 ,lirpA,5emuloV gro.srehsilbupcimedaca.www such as radiofrequency or ultrasound. Although they all generate a significant elevation of temperature in the tissues, as in any form of energy, the temperatures reached by these instrumentsare never as high as thestandard monopolarelectrocautery. All surgeons have encountered the situation of minimal but persistent oozefrom the superior pedicle or from the area directly adjacent to the nerve during thyroid surgery. Use of any of the previously described techniques to control this type of bleeding can markedly increase the risk of nerve injury. Several studies have assessed the use of adjunctive hemostatic agents during thyroidectomy. Surgicel is an oxidized cellulose mesh that adheres to tissue especially in areas of bleeding and helps form a hemostatic clot. In 2013, Amit and colleagues performed a study of 190 consecutive subjects undergoing total thyroidectomy. They placed a 2 cm × 2 cm patch of surgicel in the thyroid bed and avoided placement on the recurrent laryngeal nerve. They found no difference in the hematoma rate between the two groups; however, they found significantly higher postoperative drain output (133 vs. 93 mL), delayed time of drain removal (1.87 vs. 1.4 days), and longer hospital stay (2.7 vs. 1.8 days)inthesurgicel group compared with thecontrol group.[3] Hemostasis in thyroid surgery continues to be the most important goal after preserving vital structures. The harmonic scalpel and LigaSure systems have