Harmonic Scalpel Tonsillectomy Versus Bipolar Electrocautery and Cold Dissection

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1 Med. J. Cairo Univ., Vol. 77, No. 3, June: , Harmonic Scalpel Tonsillectomy Versus Bipolar Electrocautery and Cold Dissection AHMAD M.M. AL-BASSIOUNY, M.D. The Department of ENT, Faculty of Medicine, Cairo University. Abstract Objective: The aim of this study is to compare total tonsillectomy by harmonic scalpel (TTH) with bipolar Electrocautary (TTE) and cold dissection in children with chronic tonsillar hypertrophy. Design: Patients were selected from Dar Al Shifa hospital, Kuwait, complaining of recurrent attacks of acute tonsillitis with possible snoring and obstructive sleep apnea. Material and Methods: Twenty children with chronic tonsillitis who underwent harmonic scalpel tonsillectomy (TTH) were compared with twenty children who underwent tonsillectomy with bipolar Electrocautary (TTE) and twenty children with cold dissection from January to December of The main parameters included: Surgical time, estimated blood loss, Postoperative pain, hospital stay and postoperative complications. Results: 60 children were evaluated in this study, 42 (70%) males and 18 (30%) females. TTH group had shorter operating time ((mean: 7.1 min), than the TTE group (mean 7.7 min) or the cold dissection group (mean 11.3 min). intraoperative bleeding is significantly reduced in TTH group (mean 6.3ml) than TTE group (mean 8.3 ml) or the cold dissection group (mean 10,7 ml). postoperative pain score reduced in the TTH group (1 st day: mean 3.6 & 1 st week: mean 2.4) than the TTE group (1 st day: mean 4.7 & 1 st week: mean 2.9) or the cold dissection group (1 st day: mean 4.1 & and 1 st week: mean 2.6). Postoperative bleeding reduced in the TTH group (0%), than the TTE group (10%) or the cold dissection group (5%). Conclusion: Use of the Harmonic scalpel for tonsillectomy may have several advantages over standard methods like electrocautery or cold dissection. Intraoperative blood loss and episodes of postoperative hemorrhages have been found to be minimal in patients in whom the Harmonic scalpel was used for tonsillectomy. The device also appears to be associated with a reduction in operating time and postoperative pain. Key Words: Harmonic scalpel Tonsillectomy Bipolar electrocautery Cold dissection. Introduction TONSILLECTOMY is one of the oldest and most commonly performed otolaryngology procedures, yet techniques continue to evolve. The original way of performing tonsillectomy was a tonsillectomy or subcapsular tonsillectomy, as described by Physick [1]. In 1914, Barnes described a trend toward the "radical operation of tonsillectomy, by which evolves complete removal of the tonsil in capsule". Despite refinements in surgical technique, instrumentation, and anesthetic delivery for tonsillectomy, two areas of concern "bleeding and postoperative pain" remain significant challenges for the surgeon and the patient. Certainly, otolaryngologists would want to investigate the feasibility of any new instrumentation that would decrease the morbidity of tonsillectomy, even if it were relatively expensive. The ultrasonic harmonic scalpel (Ethicon Endo- Surgery) has been used for a variety of surgical procedures, primarily intraabdominal and gynecologic [3,4]. The harmonic scalpel is equipped with a dissecting hook blade that is attached to a ceramic piezoelectric connector that converts electrical energy to mechanical energy and generates a longitudinal blade motion of 55,500 cycles per second. The rapid, low-amplitude motion of the blade's tip has a cavitational effect on tissue. The blade simultaneously cuts and coagulates tissue by breaking hydrogen bonds, denaturing protein and creating a sticky coagulum thus controlling the small blood vessels. This is accomplished at a relatively low temperature (50 [degrees] to 100 [degrees]c), which limits damage to adjacent tissue [5]. The harmonic scalpel has been used in tonsil surgery for several years. The comparison of harmonic scalpel tonsillectomy with other tonsillec- 141

2 142 Harmonic Scalpel Tonsillectomy Versus Bipolar Electrocautery tomy techniques has been the subject of many studies. The research results proved to be contradictory, particularly concerning postoperative complications and complaints. Most authors observed reduced intraoperative bleeding during harmonic scalpel tonsillectomy [6,7]. This study, have been conducted to determine if the harmonic scalpel had any advantages over conventional dissection with respect to the length of operating time, the amount of intraoperative blood loss, the degree of postoperative pain and the incidence of delayed postoperative hemorrhage. Adenoidectomy, if needed, was performed with an adenoid curette and hemostasis achieved with bipolar electrocautery after nasopharyngeal packing. The length of operating time and the estimated amount of blood loss were recorded for each. Material and Methods Between January to December of 2008, 60 children were evaluated in Dar Al Shifa hospital, Kuwait, complaining primarily from recurrent attacks of acute tonsillitis with possible snoring and obstructive sleep apnea. Twenty children who underwent harmonic scalpel tonsillectomy (TTH) were compared with twenty children who underwent tonsillectomy with bipolar Electrocautary (TTE) and twenty children with cold dissection. The TTH group were 13 (65%) males and 7 (35%) females. The patients age ranged from 3 to 12 years (mean age 5 years). The TTE group were 15 (75%) males and 5 (25%) females. The patients age ranged from 3-9 years (mean age 4.5 years). The cold dissection group were 14 (70%) males and 6 (30%) females. The patients age ranged from 3-11 years (mean age 5.5 years). The follow-up duration ranged from 3 to 6 months. The main parameters included: estimated blood loss, surgical time, postoperative pain, hospital stay and postoperative complications particularly delayed postoperative bleeding. Surgical technique: Operations were performed under general anaesthesia using orotracheal intubation with the patient in tonsillectomy position. The harmonic scalpel was set to power level 3 as recommended by the manufacturer. The blunt edge of the harmonic probe (Fig. 1), was used to dissect the tonsil from its bed. Homeostasis can be done by applying the blunt tip of the probe for the bleeding site for seconds until bleeding stops. Bipolar electrocautery was set to power level 8. Surgical removal of tonsil was similar in the 3 techniques. Tonsillectomy was performed by capsule identification and tissue plane dissection. Fig. (1-A): Harmonic probe. Fig. (1-B): Probe tip. Nurses in the day case word assessed each patient's degree of postoperative pain in the 1 st 3-4 hours postoperatively by means of a 10-point visual analog scale. All patients were discharged with an antibiotic, an analgesic (paracetamol) and diet instructions. All patients were reexamined 1 week postoperatively and their pain was reassessed by the same method. Any attack of postoperative bleeding were also noted and assessed. Results 60 children were evaluated in this study, 42 (70%) males and 18 (30%) females. Twenty children underwent harmonic scalpel tonsillectomy (TTH), they were 13 (65%) male and 7 (35%) females. Patients age ranged from 3 to 12 years

3 Ahmad M.M. Al-Bassiouny 143 (mean age 5 years). bipolar tonsillectomy (TTE) group were 15 (75%) males and 5 (25%) females. The patients age ranged from 3-9 years (mean age 4.5 years). The cold dissection group were14 (70%) males and 6 (30%) females. The patients age ranged from 3-11 years (mean age 5.5 years). Table (1), show demographic information. Table (1): Demographic information. All patients Harmonic scalpel Electrocautary Cold dissection No. of patients Age range (y) (mean) 3-12 ( 6) 3-12 (5) 3-9 (4.5) 3-11 (5.5) Sex: Male 42 (70%) 13 (65%) 15 (75%) 14 (70%) Female 18 (30%) 7 (35%) 5 (25%) 6 (30%) The conclusions drawn from this study were based on the operating time, intraoperative blood loss, postoperative pain, hospital stay and postoperative bleeding. Operating time: The length of operating time was ranging from 13 to 18 minutes (mean: 7.1) with the harmonic scalpel, from 12 to 16 minutes (mean: 7.7) with dissection-cautery and minutes (mean 11.3) for the cold dissections. Intraoperative blood loss: The estimated amount of blood lost during surgery was significantly less in the harmonic scalpel group. The estimated blood loss was 5-14 ml (mean 6.3) in the TTH group, 7-16 ml (mean 8.3) in TTE group and ml (mean 10.7) in cold dissection group. Hospital stay: All patients discharged in the same day except three cases that needed over night admission in the electrocautery/cold dissection groups. At 3 hours postoperatively, pain scores ranged from 1 to 10 (mean: 3.6) on the harmonic scalpel side, from 2 to 10 (mean: 4.7) on the dissectioncautery side and from 1 to 10 (mean: 4.1) on the cold dissection. At I week, pain scores ranged from 0 to 5 (mean: 2.4), from 1 to 6 (mean: 2.9) and from 1 to 6 (mean 2.6) respectively. Postoperative complications: There were no cases of postoperative hemorrhage or dehydration in any group except 3 case of mild to moderate 2ry hemorrhage in the electrocautery group which controlled with conservative treatment. Table (2), shows postoperative data. Table (2): Postoperative data. Harmonic scalpel Electrocautery Cold dissection Operating time (min) 13 to 18 minutes (mean: 7.1) 12 to 16 minutes (mean: 7.7) minutes (mean 11.3) Intraoperative blood loss (ml) 5-14 ml (mean 6.3) 7-16 ml (mean 8.3) ml (mean 10.7) Overnight admission 0% 2 case (10%) 1 case (5%) 1 st day 1 to 10 (mean: 3.6) 2 to 10 (mean: 4.7) 1 to 10 (mean: 4.1) 1 st week 0 to 5 (mean: 2.4) 1 to 6 (mean: 2.9) 1 to 6 (mean 2.6) 2ry hemorrhage 0% 2 case (10%) 1 case (5%) Discussion Otolaryngologists utilize every effort to make benefit from any instrumentation that would decrease the morbidity of tonsillectomy and increase its safety. Harmonic scalpel dissection is a relatively new approach to tonsillectomy. In view of the unique properties of the harmonic scalpel, namely, its ability to cut and coagulate with great precision, which results in minimal lateral thermal tissue damage and the fact that it provides better visibility

4 144 Harmonic Scalpel Tonsillectomy Versus Bipolar Electrocautery of the surgical field, some authors have concluded that harmonic scalpel tonsillectomy results in less postoperative pain and fewer complications. Although some studies have found this technique to be superior to other conventional methods, its use is still not very popular [8]. In this study, the harmonic scalpel was associated with a significant decrease in intraoperative blood loss, a slight decrease in early postoperative pain and an apparent increase in the risk of delayed bleeding. These results were matched with the results of other authors. Walker and Syed [9], prospectively evaluated 316 tonsillectomies, 155 of which were performed with the harmonic scalpel. They collected data on the outcome parameters, including the return to regular diet and activity and the use of pain medications. Compared with electrocautery tonsillectomy, harmonic scalpel tonsillectomy was associated with a significantly earlier return to normal diet and activity, a similar degree of perioperative blood loss and a lower rate of delayed bleeding. The authors called for additional studies to further evaluate this device for tonsillectomy. Kamal et al. [10], in their single-blinded prospective study showed that the mean operative time in the harmonic scalpel tonsillectomy (HST) group was not longer than the conventional steel tonsillectomy (CST) group, but the intraoperative blood loss was significantly less in the HST group. Postoperative pain was present in all patients in the HST group, but to a lesser extent than in the CST group. They concluded that HST has the advantage over CST when secondary hemorrhage after tonsillectomy is considered. Intraoperative blood: In this study intraoperative blood which was relatively less in the harmonic scalpel tonsillectomy than the bipolar tonsillectomy (6.3 vs. 8.3). Wiatrak & Willging [11], in their study to review recent studies comparing its use in tonsillectomy with standard dissection and electrocautery, concluded that Intraoperative blood loss and episodes of postoperative hemorrhages have been found to be minimal in patients in whom the Harmonic scalpel was used for tonsillectomy. Collison & Weiner [12], concluded that the only clearly demonstrable advantage that the harmonic scalpel had over cold dissection was that it caused less intraoperative blood loss. Operating time: In this study the operation time was less in the Harmonic scalpel tonsillectomy than the other 2 groups (7.1, 7.7 & 11.3 respectively). This result matches with the result of Shai et al. [8], in his study comparing Harmonic scalpel tonsillectomy versus hot electrocautery and cold dissection. They concluded that operating times were shortest for the harmonic scalpel procedure and longest for cold dissection. Even with our relative degree of inexperience with the harmonic scalpel, we were still able to perform surgery more quickly with it than we were with the more established modalities. On the other hand these results did not match with the results of other authors. Roth et al. [7], in their study comparing the Harmonic scalpel tonsillectomy with the monopolar diathermy tonsillectomy, concluded that the harmonic scalpel group experienced significantly less intraoperative bleeding (5.0 vs ml, p<0.0001) and there was no clinically significant difference between the groups with respect to the amount of operating time. Weiner [12], concluded that there was no difference regarding operating time in when comparing Harmonic scalpel versus conventional tonsillectomy. In this study, pain scores obtained in the 1 st day and after one week, showed that postoperative pain is less in the Harmonic scalpel group than the other 2 groups. This result matches with the results of Wiatrak B.J. & Willging J.P. [11], which concluded that the harmonic scalpel appears to be associated with a reduction in postoperative pain. On the otherhand, did not match with the results of Sheahan et al. [13], in their prospective, randomized, single-blind trial, comparing the ultrasonic scalpel with bipolar diathermy with respect to postoperative pain. They concluded that there was no difference between the two treatments regarding pain scores that obtained on postoperative days 1, 2, 7 and week 3. They also concluded that the use of the ultrasonic scalpel in adult tonsillectomy is likely to be limited by its substantial costs and difficulties with haemostasis. Postoperative bleeding: In this study the incidence of delayed postoperative bleeding with less in the harmonic scalpel group than the 2 groups. Mild to moderate postop-

5 Ahmad M.M. Al-Bassiouny 145 erative bleeding occurred in 3 patients in the other 2 groups. This results matches with the conclusion of Kamal et al. [10], that it may be safe to say that HST is superior to most other conventional methods in reducing secondary hemorrhage. Kurzynski et al. [6], concluded in their study that Harmonic scalpel tonsillectomy is an effective and safe alternative technique in tonsil surgery. In some cases however other hemostasis techniques may be necessary to control intense bleeding. This is matched with our study regarding need to use bipolar to control bleeding in some cases of harmonic scalpel tonsillectomy. References 1- PHYSICK P.S. and AM J.: Med. Sci., 1: 262-5, BARNES H.A.: The tonsils: faucial, lingual and pharyngeal. St. Louis (Mo): Mosby, TAN J.J. and SEOW-CHOEN F.: Prospective, randomized trial comparing diathermy and Harmonic Scalpel hemorrhoidectomy. Dis. Colon. Rectum, 44: 677-9, WINTER M.L., MENDELSOHN S.A.: Total laparoscopic hysterectomy using the harmonic scalpel. JSLS Journal of the Society of Laparoendoscopic Surgeons, 3: 185-6, Johnson and Johnson Gateway. (accessed Sept. 8, 2004). 6- KURZNSKI M., SZALENIEC J. and SKIADIEN J.: Harmonic scalpel tonsillectomy-personal experience and review of literature. Otolaryngol. Pol., 62 (5): 561-6, ROTH J.A., PINCOCK T., SACKS R., FORER M., BOUSTRED N., JOHNSTON W. and BAILEY M.: Harmonic scalpel tonsillectomy versus monopolar diathermy tonsillectomy: a prospective study. Ear. Nose. Throat J., 87 (6): 346-9, SHAI S., BRETT M., WALTER B., DAVID M. and MICHAEL H.: Harmonic scalpel tonsillectomy versus hot electrocautery and cold dissection: an objective comparison. Ear. Nose. Throat J., October, 1, WALKER R. and SYED Z.A.: Harmonic scalpel tonsillectomy versus electrocautery tonsillectomy. A comparative pilot study. Otolaryngol. Head Neck Surg., 125: , KAMAL S.A., BASU S., KULANDAIVELU G., TAL- PALIKAR S. and PAPASTHATIS D.: Harmonic scalpel for tonsillectomy: a prospective study. Eur. Arch. Otolrhinolaryngol., 263 (5): , WIATRAK B.J. and WILLGING J.P.: Harmonic scalpel for tonsillectomy. Laryngoscope, 112: 14-16, COLLISON P.J. and WEINER R.: Harmonic scalpel versus conventional tonsillectomy: a double-blind clinical trial. Ear Nose Throat J., October 1, SHEAHAN P., MILLER I., COLREAVY M., SHEAHAN J.N., McSHANE D. and CURRAN A.: The ultrasonically activated scalpel versus bipolar diathermy for tonsillectomy: a prospective, randomized trial. Clin. Otolaryngol., 29 (5): 530-4, 2005.