Ann Thorac Surg 2009;88:1138-1141. doi:10.1016/j.athoracsur.2009.06.052
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Comparison of Ultrasonic Scalpel to Electrocautery in Patients Undergoing Endoscopic Thoracic Sympathectomy
Benny Weksler, MDa,*,
Mary Pollice, MSN, CRNPa,
Zemilson B.B. Souza, MDb,
Rodrigo Gavina, MDb
a Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
b Hospital Quinta D'Or, Rio de Janeiro, Brazil
Accepted for publication June 19, 2009.
* Address correspondence to Dr Weksler, Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, 1025 Walnut St, Ste 607, Philadelphia, PA 19107 (Email: benny.weksler{at}jefferson.edu).
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Abstract
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Background: Sympathectomy is an effective treatment for hyperhidrosis. The ultrasonic scalpel and electrocautery have been used for the procedure, but the use of the ultrasonic scalpel has been promoted as superior to that of electrocautery. This study explored whether a reusable electrocautery probe was equally as effective and safe as the ultrasonic scalpel for sympathectomy.
Methods: We retrospectively analyzed 140 consecutive patients. The ultrasonic scalpel (HDH 05, Ethicon Endo-Surgery, Cincinnati, OH) was used in 70 patients (group 1) and a reusable 5-mm cautery hook (Edlo, Canoas, Brazil) was used in 70 patients (group 2). End points were improvement in symptoms (% improvement score), length of stay, return to work, and complications. Data were analyzed using two-tailed t test and the 
2 (p = 0.05 was significant). Data are mean ± standard deviation.
Results: Follow-up was 27.2 ± 8.4 months. Groups were similar in demographics, disease site, and level of sympathectomy. There was no significant difference in improvement score by site. The feet had the least improvement score (36.5% ± 32.3%), and the hands the highest improvement score (97.0% ± 11.3%). Length of stay was similar, 11.4 ± 5.9 (group 1) vs 10.1 ± 5.4 hours (group 2). Return to work in group 1 was 4.8 ± 2.7 vs 5.7 ± 3.6 days (p = 0.09). Group 1 had 14 complications and group 2 had 7 (p = 0.16).
Conclusions: We could not demonstrate a clear advantage in the use of the ultrasonic scalpel.
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Introduction
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Primary hyperhidrosis is a common disease that affects men and women equally, with peak incidence in the late second and early third decades of life, and an incidence in the Western world of up to 2.8% of the population [1]. Most affected patients have palmar hyperhidrosis, and axillary and craniofacial hyperhidrosis are relatively common as well [2].
Endoscopic thoracic sympathectomy (ETS) became a popular treatment modality for hyperhidrosis in the early 1990s [3] and is a well-established treatment for this condition. The term sympathectomy is widely used without clear definitions and may be referred to as a resection of a portion of the sympathetic chain, transection of the chain, clipping of the sympathetic chain, or transection of the chain above and below the ganglia with ablation of the ganglia [4]. It is unclear if the results of the operation are affected by the different techniques used. Most surgeons who resect or transect the sympathetic chain (as opposed to clipping) use the monopolar cautery [5–7], but a few groups use the ultrasonic scalpel [8, 9].
The ultrasonic scalpel uses vibrations to 55.5 KHz to cut and coagulate simultaneously [10]. Compared with regular electrosurgical units, the ultrasonic scalpel is said to minimize lateral thermal tissue damage, produce less smoke, does not provoke neuromuscular stimulation, and no energy passes through the patient [11]. The ultrasonic scalpel gained quick acceptance in the surgical field and has been used in laparoscopic [12], head and neck [13], cardiac [14, 15], and thoracic surgery [16]. The ultrasonic scalpel would seem to be ideal for ETS, keeping thermal spread to minimum and avoiding injury to important nervous structures such as the stellate ganglia.
We have been operating on patients with palmar, axillary, craniofacial hyperhidrosis, and rubor facial. We perform a sympathectomy (transection of the sympathetic chain) at the level of T2 for facial symptoms (hyperhidrosis or rubor), T3 sympathectomy for palmar hyperhidrosis, and T3/T4 sympathectomy for axillary hyperhidrosis. To compare the ultrasonic scalpel with a monopolar cautery, we operated on 70 consecutive patients using the ultrasonic scalpel and then on 70 patients using a monopolar cautery and compared their outcomes.
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Material and Methods
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We conducted a retrospective study based on a prospective database of 140 consecutive patients operated on by a single surgeon (B. W.). Institutional Review Board approval was obtained, and all patients signed written informed consent. Patients were operated on between June 2003 and September 2006. All patients underwent ETS.
In July 2007, patients were contacted and interviewed by telephone. Patients were asked to score the resolution of their symptoms after the operation (complete resolution, 100% improvement; 0%, no improvement), the presence and grade of compensatory hyperhidrosis (10, unbearable; 0, no symptom), the site of compensatory hyperhidrosis, and the score of each site. Patients were also asked if they regretted undergoing ETS and why. We reviewed each patient's medical record for complications, hospital stay, and time from operation until the patient returned to work.
Surgical Procedure
We routinely perform a T2 sympathectomy for facial hyperhidrosis and rubor facialis, T3 sympathectomy for palmar hyperhidrosis, and T3 and T4 sympathectomy for axillary hyperhidrosis. In patients with multiple sites, we combine multiple levels of sympathectomy. The ETS was done with the patient under general anesthesia with a single lumen endotracheal tube in the supine position with the arms extended. Two 5-mm ports were inserted at the third and the fifth intercostal space at the midaxillary line. Carbon dioxide was insufflated to a pressure of 5 mm Hg.
After inspection of the pleural cavity, the first rib was identified. Usually, there is a fat pad on top of the first rib and it cannot be easily visualized. Palpation with an instrument facilitates proper identification. The sympathetic chain was recognized and identified at its crossing with the neck of each rib. Sympathectomy [4] was done transecting the sympathetic chain at the neck of the second, third, or fourth rib for a T2, T3, or T4 sympathectomy respectively. The periosteum of the rib was incised for approximately 2 cm laterally from the sympathetic chain to transect any rami communicans (Nerve of Kuntz).
After the sympathectomy was done, a small catheter was inserted into the pleura and all carbon dioxide and air removed from the pleural cavity. The catheter was removed while the lungs were being inflated to a positive pressure of 25 mm Hg. The contralateral side was operated on in the same fashion with the same level sympathectomy. Immediately after the operation, patients had a chest roentgenogram and were discharged to home if there was no pneumothorax. The initial 70 patients (group 1) were operated on with the ultrasonic scalpel 5-mm hook HDH05 (Ethicon Endo-Surgery, Cincinnati, OH). The last 70 patients (group 2) were operated on with a monopolar hook cautery (Edlo, Canoas, Brazil).
Statistics
All data are reported as mean ± standard deviation. Means were compared using two-tailed t test. Nominal variables were compared using Pearson 2 test. Significance was set at p 
0.05. Statistical analysis was done with SPSS 17 software (SPSS Inc, Chicago, IL).
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Results
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No deaths or conversions to open procedures occurred in either group. General demographics were similar in both groups (Table 1). Because the study was sequential, the follow-up was significantly longer for group 1 than for group 2 (34.2 ± 4.7 vs 20.2 ± 4.3 months; p < 0.01). There was no significant difference with regard to the level of the sympathetic chain operated on (Table 2).
Some form of postoperative complication occurred in 21 patients, comprising 14 in group 1 and 7 in group 2 (p = 0.15; Table 3). There were no reoperations for bleeding. Hospital stay was 11.4 ± 5.9 hours for group 1 vs 10.1 ± 5.4 hours for group 2, a difference that was not a statistically significant (p = 0.24). No statistically significant difference was noted between the groups in improvement scores, incidence of compensatory hyperhidrosis, compensatory hyperhidrosis score, time to return to work after the procedure, and the number of patients regretting the procedure. Results are summarized in Table 4.
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Comment
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ETS is highly effective in controlling primary hyperhidrosis in the hands, axillae, and face. Approximately 95% of our patients were satisfied with the result, and only a small fraction regretted having had operation. Patients with palmar hyperhidrosis were the most satisfied, with an improvement index close to 100%. The most frequent complications were neuritis, occurring in 6.4%, and pneumothorax requiring insertion of a chest tube, occurring in 4.3%. Horner syndrome can be a serious complication and reportedly occurs in less than 0.5% of patients. Temporary Horner syndrome occurred in 1 patient. Another important consequence of ETS is compensatory hyperhidrosis, which occurred in 77.1% of our patients.
The ultrasonic scalpel may offer several interesting advantages for surgeons performing ETS, such as less smoke in the operative field, less lateral thermal injury, and no neuromuscular stimulation. It is reasonable to assume that those characteristics would offer a clear clinical benefit. For instance, the incidence of Horner syndrome and neuritis should decrease with the use of the ultrasonic scalpel. The use and benefits of the ultrasonic scalpel have been well studied in thyroid surgery. The ultrasonic scalpel has been consistently shown to decrease operative time during thyroidectomies; however, other variables such as recurrent nerve injury, incidence of seroma or hematoma, and hospital stay have not been affected by the use of the ultrasonic scalpel [13, 17–19].
In cardiac operations, the ultrasonic scalpel was shown to reduce intraoperative complications such as major arrhythmias, bleeding, the need for transfusion, length of mechanical ventilation, and minor postoperative complications in patients undergoing redo procedures [14]. In harvesting radial artery, ultrasonic scalpel decreases vasospasm and intimal injury compared with electrocautery [20] but did not decrease complications, including long-term neurologic hand complications [15].
A recently published meta-analysis of the efficacy and advantages of ultrasonic instruments reveals that ultrasonic instrumentation is safe and may offer advantages in some procedures [21]. For instance, the ultrasonic scalpel decreases blood loss and lessens operative time in a general surgical population; however, hospital stay is unchanged. Safety outcomes reported for most operations, such as common bile duct injury for cholecystectomy, bleeding, or seroma for other procedures, did not differ significantly when the ultrasonic scalpel was compared with nonultrasonic instruments.
Our study is relatively small. A cohort of 140 patients and only 70 patients per group may not provide the power to clearly reject the null hypothesis (both methods are similar) and avoid a type II error. Still, the total number of complications did not statistically differ between the two groups, and advantages offered by the ultrasonic scalpel do not significantly affect patient's outcome.
We did not specifically measure operative time. Most of our procedures take less than 15 minutes per side, and this time did not appear to change when we used the ultrasonic scalpel. Because our technique of sympathectomy involves the simple transection of the sympathetic chain, dissection is minimal and the ultrasonic scalpel does not offer any advantage over a regular hook cautery. It appears to us that the extra cost of the ultrasonic scalpel (around US $200.00 per patient) is not justifiable for sympathectomy. The same instrument was used in the 70 patients operated on with electrocautery (list price of US $900.00 for a new instrument) vs 70 new disposable ultrasonic hooks in the group operated on with the ultrasonic scalpel.
In conclusion, we could not demonstrate any clear advantage for the use of the disposable ultrasonic scalpel in patients undergoing ETS. We believe that the use of a nondisposable electrocautery hook has as good a result as the ultrasonic scalpel and with a lower overall cost.
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References
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Abstract
Introduction
