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  Table of Contents  
COMMENTARY
Year : 2018  |  Volume : 55  |  Issue : 4  |  Page : 359-360
 

Harmonic scalpel versus conventional diathermy: Is one really better than the other?


Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication28-Feb-2019

Correspondence Address:
Suhani
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_551_18

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How to cite this article:
Suhani. Harmonic scalpel versus conventional diathermy: Is one really better than the other?. Indian J Cancer 2018;55:359-60

How to cite this URL:
Suhani. Harmonic scalpel versus conventional diathermy: Is one really better than the other?. Indian J Cancer [serial online] 2018 [cited 2019 May 21];55:359-60. Available from: http://www.indianjcancer.com/text.asp?2018/55/4/359/253297




Breast cancer is on the rise and so are the surgeries done for the same. Mastectomy and breast conservation surgery remain the common surgical modalities practiced for treatment of primary tumor. Axillary lymph node dissection and sentinel lymph node biopsy are the commonest surgical modalities used for the treatment of axilla. Flap necrosis, seroma, wound infection, and postoperative neuralgia as well as numbness over the lateral aspect of arm are the common postoperative complications. All these lead to increased patient morbidity and hospital stay, and development of techniques that lead to reduction of these have remained common areas of research. One such modality is the use of ultrasonic energy of harmonic scalpel in surgeries of the breast and axilla done for breast cancer.

The English literature has number of studies and meta-analysis [1] done to compare the use of harmonic scalpel and conventional technique in breast cancer surgeries. The conventional methods mentioned in the studies include the use of surgical blade, scissors, and diathermy. However, the last decade saw comparative studies that draw comparisons between diathermy and harmonic scalpel (HS) only, which is indirect evidence that most of the surgeons worldwide have adapted to the preferential use of diathermy over scissors and scalpel.

Before adopting or shifting from one technique to another, one must, however, perform an in-depth analysis of the published literature. Many of the studies published in the English literature have shown superiority of HS over diathermy in breast cancer surgeries by reducing the rates of seroma, flap necrosis, wound infection, and duration of axillary drain dwelling time.[1],[2],[3] However, several aspects still remain unanswered. I wish to highlight few of these here.

Two of the important considerations for optimizing surgical outcomes in the surgery for breast cancer are raising proper flaps and ligating major lymphatics in the axilla. Adhering to surgical principles here reduce the number of aforementioned complications. Preservation of dermal vascular plexus and raising flaps after identifying the premammary fascia leads to well-vascularized flaps during mastectomy and minimizes blood loss as well.[4] Sealing of the lymphatics in the axilla with sutures, clips, or energy devices is extremely important in decreasing postoperative seroma. Many of these skills are mastered with experience, the so-called learning curve for a procedure. The experience of surgeon in doing a particular procedure as well as operating with a particular energy source [5] is important in estimating the operative time for a procedure. It would not be wrong to say that as the learning curve is attained, there is a better precision to raise flaps and perform the surgery faster leading to a decrease in the operative time with either of the modalities used. Most of the studies have not taken these points into consideration (experience of surgeon in performing breast cancer surgeries as well as experience in operating with HS or diathermy), which may lead to a bias in interpreting the results.

An important area not touched upon in most studies is the subgroup analysis of various confounding variables, which may lead to bias in result interpretation. The rate of seroma formation is much less after breast conservation procedures as compared with mastectomy. Also, adoption of sentinel lymph node biopsy has led to significant reduction in the number of axillary dissections, and hence, the risk of seroma formation and prolonged axillary drainage has come down significantly.[6]

Various studies have pointed out that surgeries of the axilla done for heavy nodal disease with large number of positive nodes, extra-nodal soft tissue deposits, and level 3 lymph node involvement are associated with prolonged axillary drainage and seroma formation.[3] This also holds true for axillary dissections done in patients after neoadjuvant chemotherapy. Higher body mass index is associated with increased drainage and seroma.[7] The rate of complication of flap necrosis and wound infections are also increased with mastectomy done for larger tumors, which may be because of closure of wound under tension. The seroma formation may also depend upon the extent of mastectomy with the risk increasing as the radicality of the procedure increases. Also, performing a simultaneous breast reconstruction is known to decrease the seroma formation.[8]

Although there are ample number of studies in the English literature comparing HS and diathermy, most of these have more often than not failed to compare the outcomes by performing these subgroup analyses. Hence, further well-designed studies are warranted to address these concerns. Also, adhering to surgical principles is the foremost factor leading to safe surgical outcomes, irrespective of the energy source being used.



 
  References Top

1.
Zhang Z, Li L, Pang Y, Li Q, Guo C, Wang Y, et al. Comparison of harmonic scalpel and conventional technique in the surgery for breast cancer: A systematic review and meta-analysis. Indian J Cancer 2018; 55:348-58.  Back to cited text no. 1
  [Full text]  
2.
Deo SV, Shukla NK, Asthana S, Niranjan B, Srinivas G. A comparative study of modified radical mastectomy using harmonic scalpel and electrocautery. Singapore Med J 2002;43:226-8.  Back to cited text no. 2
    
3.
Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. Seroma formation after breast cancer surgery: Incidence and predicting factors. Am Surg 2000;66:444-50.  Back to cited text no. 3
    
4.
Purkait B, Srivastava A, Kataria K, Seenu V, Das P, Hari S, et al. Measurement of depth of premammary fascia and breast parenchyma by sonography and histological quantitation. Indian J Surg 2018. [doi.org/10.1007/s12262-018-1791-7].  Back to cited text no. 4
    
5.
Selvendran S, Cheluvappa R, Tr Ng VK, Yarrow S, Pang TC, Segara D, et al. Efficacy of harmonic focus scalpel in seroma prevention after axillary clearance. Int J Surg 2016;30:116-20.  Back to cited text no. 5
    
6.
Purushotham AD, Upponi S, Klevesath MB, Bobrow L, Millar K, Myles JP, et al. Morbidity after sentinel lymph node biopsy in primary breast cancer: Results from a randomized controlled trial. J Clin Oncol 2005;23:4312-21.  Back to cited text no. 6
    
7.
Burak WE Jr., Goodman PS, Young DC, Farrar WB. Seroma formation following axillary dissection for breast cancer: Risk factors and lack of influence of bovine thrombin. J Surg Oncol 1997;64:27-31.  Back to cited text no. 7
    
8.
Aitken DR, Hunsaker R, James AG. Prevention of seromas following mastectomy and axillary dissection. Surg Gynecol Obstet 1984;158:327-30.  Back to cited text no. 8
    




 

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