Abstract
Technological advances in thyroid surgery have rapidly increased in recent decades. Specifically, recently developed energy-based devices (EBDs) enable simultaneous dissection and sealing tissue. EBDs have many advantages in thyroid surgery, such as reduced blood loss, lower rate of post-operative hypocalcemia, and shorter operation time. However, the rate of recurrent laryngeal nerve (RLN) injury during EBD use has shown statistically inconsistent. EBDs generate high temperature that can cause iatrogenic thermal injury to the RLN by direct or indirect thermal spread. This article reviews relevant medical literatures of conventional electrocauteries and different mechanisms of current EBDs, and compares two safety parameters: safe distance and cooling time. In general, conventional electrocautery generates higher temperature and wider thermal spread range, but when applying EBDs near the RLN adequate activation distance and cooling time are still required to avoid inadvertent thermal injury. To improve voice outcomes in the quality-of-life era, surgeons should observe safety parameters and follow the standard procedures when using EBDs near the RLN in thyroid surgery
Highlights
Thyroidectomy is one of the most common head and neck surgeries
The specific purpose of using energybased devices (EBDs) in thyroid surgery is to achieve hemostasis, the mechanism through which EBDs achieve hemostasis differs from one devices to another [3]
Tissue contraction during EBD activation increases the risk of thermal injury because it reduces the distance from the recurrent laryngeal nerve (RLN) at which an EBD can be safely used [6]
Summary
Thyroidectomy is one of the most common head and neck surgeries. In the United States, more than 150,000 thyroidectomies were performed annually, and the case number of thyroid surgery is increasing each year [1]. Most intraoperative thermal injuries to the RLN result from thermal spread during use of high-temperature electrocautery devices and EBDs. Tissue contraction during EBD activation increases the risk of thermal injury because it reduces the distance from the RLN at which an EBD can be safely used [6]. Activation studies assess the distance from the RLN at which an EBD can be safely used without causing thermal injury; cooling studies assess the time (after activation) needed for the EBD tip or blade to cool sufficiently for use of the EBD in performing a dissection close to or in contact with the RLN (Figure 2). FMsealer has a significantly lower peak temperature (92.1°C) and enables faster transection of tissue bundles [41] In their activation study, Huang et al reported that the safe distance is 2 mm for a single 3-second activation. No adverse EMG events occurred after a 3-second cooling time or after muscle touch maneuver [40]
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