Conventional clamp-and-tie hemostasis versus energy-based hemostasis devices in total thyroidectomy: a systematic
Baraa Awad1,2,3, Moheb A Ashi4, Rena Y Abualjamal2,3
1Department of Otolaryngology - Head & Neck Surgery, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia.
Introduction:
Total thyroidectomy, a procedure for various thyroid pathologies, is traditionally performed using conventional clamp-and-tie hemostasis (CH). Advanced high-energy devices (HEDs), including the Harmonic Scalpel (HS) and LigaSure (LS), offer energy-based vessel sealing with potential efficiency gains, but safety concerns and cost implications remain. This systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs) was conducted to compare the efficacy and safety of energy-based hemostasis devices versus CH in total thyroidectomy.
Methods:
This Systematic review included 22 prospective RCTs, published between 2005 and 2022, enrolling 3,824 patients. The primary outcomes included operative time (OT), intraoperative blood loss (IOBL), and transient recurrent laryngeal nerve (RLN) injury and hypocalcemia. Secondary outcomes were postoperative hematoma (POH), postoperative drain output (POD), and length of hospital stay (LOS). Intervention rankings were determined using the Surface Under the Cumulative Ranking Curve (SUCRA), SUCRA values reflect the probability that an intervention ranks higher relative to others for a given outcome and do not indicate a clinical or statistical superiority; therefore, they should be interpreted alongside effect estimates and credible intervals.
Results:
In comparison with CH, both HS and LS were statistically significantly superior, reducing OT by approximately 22 min (HS: SUCRA 0.76, LS: SUCRA 0.73). HS demonstrated further significant superiority over CH, reducing LOS by -0.37 days (SUCRA 0.93) and POD output by -24 mL (SUCRA 0.87). While HS showed a numerical reduction in IOBL, this difference did not reach statistical significance, yet HS ranked highest for this outcome (SUCRA 0.91). Importantly, no significant differences were detected among HS, LS, and CH for key safety outcomes, including transient RLN palsy, transient hypocalcemia, and POH.
Conclusion:
Energy-based hemostasis devices, particularly HS, were associated with shorter operative time and reduced postoperative fluid output and hospital stay compared with conventional clamp-and-tie hemostasis. However, the certainty of evidence for most outcomes was moderate to low, the analysis was underpowered to establish equivalence for rare safety events, and the modest clinical gains should be weighed against device costs and local operating-room efficiency. These findings support conditional, context-dependent use of HEDs rather than routine preference for any single device.
