Sutureless FOCUS harmonic scalpel versus clamp-and-tie techniques for thyroidectomy: a meta-analysis of 43 randomized controlled trials

Background:One of the most important surgical steps during thyroidectomy is the safe ligation of vessels. In fact, it is crucial to avoid postoperative bleeding and nerves' injury. The "clamp and tie" technique was first introduced in the 19th century. Since then, a lot of other techniques have been adopted to facilitate the safe ligation and sectioning of thyroidal vessels; however, one of the most relevant advances is the introduction of energy-based devices (EBDs), which occurred three decades ago.Purpose:The aim of this systematic review and meta-analysis is to evaluate the safety and effectiveness of sutureless FOCUS harmonic scalpel (second-generation EBDs) versus conventional clamps-and-tie technique) in total thyroidectomy.Results:This systematic review and meta-analysis represent the largest comparison in the literature between the thyroidectomy procedure with the second-generation advanced harmonic scalpel ultrasonic focus (UAS FOCUS) versus the conventional clamp-and-tie (CT) technique: as a matter of fact, it includes 43 randomized controlled trials (RCTs) and a total of 10 361 patients. The incidence of transient recurrent laryngeal nerve palsy was statistically lower in patients undergoing UAS (3.99%) rather than CT (5.23%) (RR 0.79, 95% CI 0.63-0.99). The incidence of transient hypocalcemia was 11.3% in patients who underwent thyroidectomy with UAS FOCUS and 15.4% in those who underwent thyroidectomy with CT.Conclusion:Sutureless EBD is associated with a lower risk of damage to the laryngeal nerves and parathyroid glands. The rate of hypocalcemia and nerve paresis is indeed lower due to less thermic damage. Sutureless EBD can also diminish the rate of postoperative bleeding and cervical hematoma, a rare but potentially fatal complication.