Comparison between conventional and harmonic techniques in bleeding control during Thyroidectomy

Methodology: This randomized control trial was conducted in Surgery Department, Bahawal Victoria Hospital Bahawalpur. This study was completed in 5 months (August 2018 to January 2019) and all the patients under trial were asked for informed consent. A total number of 100% (n=62) were taken in this trial and online source Openepi.com was used for calculating sample size. Patients were selected by lottery method. Computer software SPSS version 23.2 was used for complete data entry and analysis. All the descriptive variables like onset of action and age were presented as SD and mean. Statistical test ANOVA was applied to find the significance among all groups. Chi square test was applied for analysis of continuous stats among groups. P value 0.05 was to be considered as significant.

Thyroidectomy is, in essence, devascularization of thyroid by double ligation and dividing the branches of thyroid vessels followed by excision of the gland, and done when a patient is suffering from thyroid cancer, goiter or hyperthyroidism , the endocrine surgeons often perform the procedure of thyroidectomy. Since time spent in the operative room is expensive, this will reduce both time and cost of operation [6] . From the experience, we can conclude that during thyroid surgery, the use of harmonic scalpel reduce the time duration much more, and also report initial case controlled study results by comparing the use of conventional suture tying to the harmonic scalpel in patient undergone by total thyroidectomy or lobectomy [7] .
The procedures included in thyroidectomy have many complications like massive bleeding, injury and infection to the surrounding organs and structures [8] . Similarly, all of the complications are directly related to mortality and morbidity rates of 40% app [9] .
That's why thyroid surgery is considered as barbaric and called as "horrid butchery".
The previous studies shows that blood volume and surgery time by using harmonic scalpel method is less as compared to conventional knots method , but we want to compare blood volume and time of surgery by using both harmonic and conventional methods on local level [10] .

Method and material:
After taking the ethical approval from the ethics committee of the institution, this randomized control trial was conducted in Surgery Department, Bahawal Victoria Hospital Bahawalpur. This study was completed in 5 months (August 2018 to January 2019) and all the patients under trial were asked for informed consent. Patients were also completely briefed about their participation in study, its procedure and its purpose also. A total number of 100% (n=62) were taken in this trial and online source Openepi.com was used for calculating sample size. Those patients, who had to undergo total thyroidectomy for multinodular disease, were in inclusion criteria and those patients who were suffering from toxic disease, intrathoracic goiter, malignant disease and wanted central or lateral lymphadenectomy were excluded from the study. Patients were selected by using lottery method.
For this process, a total number of 100% (n=62) patients were used and these patients were divided into two groups and each group consists of 50% (n=31) patients, in 62 member there were 65% male and 35% females. All patients were given routine preoperative measures for their disease and same type of anesthesia and hospital care was applied but surgical instruments used were different .All the patients for operation were admitted in morning and they were kept there for 23 hours. During the procedure anesthesia used was endotracheal general anesthesia. During operation conventional methods was used to position and cover or drapes the body of patient. Usually depends upon the size of thyroid of patient a cut of 4 to 6cm was made with help of scalpel which is also called incision, exactly over the level of thyroid isthmus. The strap muscles that surround the thyroid gland laterally and on midline were separated .Either by using conventional knot tying or harmonic knot tying the superior, inferior and middle thyroid vessels were categorized separately. During process different vessels are displaced, suppose first thyroid lobe is medially rotated and then the vessel of ligament of berry, after that the nerves that are visible or present near the lobe is clamped and tie together. The same mechanism is repeated on lobe of counter side. Finally when the ligation gets completed the wound is closed by using the interrupted 3-o polyglactin suture to give accurate position to strap muscles which were displaced before the operation. Then Michel clips are used to close the skin which was removed before operation on day 1.
Computer software SPSS version 23.2 was used for complete data entry and analysis. All the descriptive variables like onset of action and age were presented as SD and mean. Statistical test ANOVA was applied to find the significance among all groups. Chi square test was applied for analysis of continuous stats among groups. P value 0.05 was to be considered as significant.
The main outcome variables of this study were the time of procedure (minutes) and blood loss volume (ml). The mean time of procedure was 98.80±16.52minutes and 119.81±9.95 minutes for the harmonic scalpel and conventional knot groups respectively. Significant difference was found for the time of procedure in groups (t=-6.060, p-value = 0.000). (table. 2) The mean blood loss volume was 454.52±22.73 ml and 850.68±23.79 ml for the harmonic scalpel and conventional knot groups respectively. Significant difference was found for the blood loss volume in groups (t=-67.025, p-value = 0.000). (table. 2)

Discussion:
As we know that bleeding control during thyroidectomy plays very important role during the whole surgical procedure. Uncontrolled blood loss during the process can cause disturbance in homeostatic stability and even could lead to death of patient. To find out which method either use of conventional knot tying or harmonic scalpel is useful for bleeding control in thyroidectomy [3] . But the results of current studies show that harmonic scalpel is much better than the conventional knot [11] .
Many studies has conducted in the past, but almost no one study shows that conventional knot method is better comparative to harmonic but recent studies done with highly advanced technology shows that harmonic scalpel is much better than ligation [12].
It was thought that technique of harmonic scalpel is beneficial as compare to conventional procedure .By using harmonic scalpel two major changes occur, first of all the time duration is reduced and second the risk of hypocalcaemia and recurrent laryngeal nerve paresis is reduced. From the beginning of this century a large number of persons did research on advantageous use of harmonic scalpel [13]. Some important studies are given below in this regard.
A study done in 2015 by Cheng et al, total number of 100% (n=86) patients were used to observe the reduction in time, or indirectly observe the significantly faster operative time (-23.1 min, p<0.001), and less transient hypocalcaemia (RR0.69, p=0.01). The result of this study support our results.
Even after few years later another group of scientists did 11 studies , Zhang found significantly even more faster time (-22.4 min ,p= 0.001), time period is very necessary during thyroid gland surgery because the thyroid gland is highly vascularized gland that's why effective and meticulous homeostasis is required to decrease over bleeding. Finally the most recent study is done few year earlier by Blanchard et al, they use 25 patients during this study 11 male and 14 female were included , female and male were of equal age [14] . They found the operative time as (-18.7 min, p<0.001) [15] .