Total thyroidectomy is a commonly performed surgical procedure for benign thyroid disorders such as multinodular goiter, Graves’ disease, and toxic goiter. Achieving secure hemostasis is critical due to the gland’s rich vascular supply and proximity to vital structures. Conventional ligature, although effective, may prolong operative time. Bipolar diathermy allows precise vessel sealing with minimal thermal spread and may improve surgical efficiency. The application of different diathermy techniques has been widely advocated to minimize intraoperative blood loss and reduce the need for perioperative blood transfusion. Among these techniques, advanced electrothermal bipolar tissue sealing systems, such as LigaSure, have been increasingly utilized across various surgical specialties. The LigaSure device operates by delivering high-current, low-voltage bipolar radiofrequency energy, allowing tissue to be grasped and compressed within the instrument jaws. A microprocessor-controlled feedback mechanism continuously monitors tissue impedance and automatically terminates energy delivery once an effective seal is achieved. This technology relies on the body’s intrinsic collagen and elastin fibers to form a permanent fusion zone, enabling secure sealing of blood vessels up to 7 mm in diameter, as well as lymphatic channels and tissue bundles, with an average sealing time of approximately two to four seconds in most surgical settings [1-4]. Total thyroidectomy represents the definitive surgical treatment for a wide range of benign and malignant thyroid disorders. Nevertheless, the extent of glandular resection has been associated with an increased risk of postoperative complications [5]. Intraoperative bleeding during thyroidectomy can significantly impair visualization of the surgical field, potentially increasing the risk of recurrent laryngeal nerve (RLN) injury, complicating parathyroid gland identification and preservation, and prolonging operative duration. Given the rich vascular network and extensive venous plexuses within the thyroid parenchyma, thyroid surgery necessitates meticulous devascularization of numerous vessels prior to gland removal. Consequently, achieving effective and reliable hemostasis is a critical step in ensuring operative safety and efficiency [6]. Hemostasis during thyroidectomy may be accomplished using either conventional suture ligation (CSL) or advanced vessel-sealing technologies such as the LigaSure system [7]. Notably, postoperative hemorrhagic complications and neck hematoma formation have been reported more frequently following total thyroidectomy compared with subtotal thyroidectomy, primarily due to the wider extent of dissection and tissue manipulation involved [5,8-9]. The aim of this study was to compare operative and postoperative outcomes between bipolar diathermy and conventional ligature techniques in patients undergoing total thyroidectomy.

Patients and Methods

This prospective comparative study was conducted in the Department of General Surgery, Al-Kindy Teaching Hospital, Baghdad, Iraq, with recruitment starting on 1 February 2024 and continuing for 6–12 months. Adult patients (≥18 years) scheduled for total thyroidectomy due to benign thyroid disease (including multinodular goiter, Graves’ disease, and toxic goiter) were enrolled after clinical assessment and informed consent. Patients were excluded if they had suspected or confirmed thyroid malignancy, prior neck surgery (revision thyroidectomy), bleeding disorders or unmodifiable anticoagulation, previous neck irradiation, major systemic conditions affecting surgical risk assessment, or incomplete perioperative data.

All patients underwent a standardized preoperative evaluation including history and examination, thyroid investigations as indicated (e.g., thyroid function tests, ultrasonography, and fine-needle aspiration when needed to exclude malignancy), baseline laboratory assessment, and anesthesia fitness evaluation. Total thyroidectomy was performed under general endotracheal anesthesia using a standard collar incision, subplatysmal flap elevation, midline strap muscle separation, and extracapsular dissection, with meticulous identification and preservation of the recurrent laryngeal nerve (RLN) and parathyroid glands. The key difference between groups was the hemostatic method: in the bipolar diathermy group, vessel control and thyroid pedicle sealing were achieved primarily using bipolar diathermy, whereas in the conventional ligature group, hemostasis was achieved using clamp-and-tie suture ligation, with additional sutures applied when necessary.

Postoperatively, patients were monitored for airway safety, wound status, voice changes, and calcium-related symptoms, and they received standardized analgesia and routine postoperative care. Drain insertion was applied selectively based on intraoperative assessment of oozing and dead space. Study outcomes were recorded using predefined measures including operative time (≤90 minutes vs >90 minutes), intraoperative blood loss (<100 mL vs ≥100 mL), drain insertion, intraoperative field quality (clear field, episodes of obscuration), need for additional hemostatic sutures, conversion to another method if required, postoperative complications (transient hypocalcemia, RLN injury, hematoma, wound infection), recovery indicators (hospital stay ≤2 days, early oral intake), and pain outcomes (VAS categories and analgesic requirement duration). Data were analyzed using SPSS, categorical variables were expressed as n (%), and statistical significance was considered at p<0.05.

Table 1 demonstrates that the two study groups were well matched regarding baseline demographic and clinical characteristics. The proportion of patients aged ≥40 years was comparable between the bipolar diathermy group 22 (55.00%) and the conventional ligature group 23 (57.50%). Females constituted the majority in both groups, accounting for 30 (75.00%) in the bipolar diathermy group and 29 (72.50%) in the conventional ligature group. Regarding clinical indications for surgery, multinodular goiter was the most common diagnosis in both groups 22 (55.00%) vs. 21 (52.50%), followed by Graves’ disease 12 (30.00%) vs. 13 (32.50%), while toxic goiter was observed at equal rates in the two groups 6 (15.00%) each. These findings indicate comparable baseline characteristics between the two groups.

Table 1: Baseline Demographic and Clinical Characteristics

Table 2 highlights clear differences in operative outcomes between the two techniques. A substantially higher proportion of patients in the bipolar diathermy group achieved an operative time of ≤90 minutes 28 (70.00%) compared with the conventional ligature group 14 (35.00%), indicating greater operative efficiency with bipolar diathermy. Similarly, intraoperative blood loss of 

<100 mL was more frequently observed in the bipolar diathermy group 30 (75.00%) than in the conventional ligature group 14 (35.00%). In contrast, the need for drain insertion was lower in the bipolar diathermy group 10 (25.00%) compared with the conventional ligature group 18 (45.00%), suggesting improved intraoperative hemostatic control.

Table 2: Operative Outcomes

Table 3 summarizes postoperative complications and shows comparable safety profiles between the two groups. Transient hypocalcemia occurred in 6 patients (15.00%) in the bipolar diathermy group and 7 patients (17.50%) in the conventional ligature group. Temporary recurrent laryngeal nerve (RLN) injury was rare and observed equally in both groups 1 (2.50%) each. Postoperative neck hematoma and wound infection were infrequent overall, with slightly higher rates in the conventional ligature group.

Table 3: Postoperative Complications

Table 4 demonstrates more favorable recovery outcomes in the bipolar diathermy group. A hospital stay of ≤2 days was recorded in 32 patients (80.00%) compared with 22 patients (55.00%) in the conventional ligature group. Early oral intake was also more frequent in the bipolar diathermy group [34 (85.00%) vs. 26 (65.00%)], indicating faster postoperative recovery.

Table 4: Recovery and Hospital Stay

Table 5 presents an overall comparison of surgical outcomes. A favorable overall outcome was achieved in a higher proportion of patients in the bipolar diathermy group 34 (85.00%) compared with the conventional ligature group 28 (70.00%). The incidence of any postoperative complication was slightly lower in the bipolar diathermy group 8 (20.00%) than in the conventional ligature group 10 (25.00%).

Table 5: Overall Outcome Summary

Table 6 illustrates notable differences in intraoperative technical performance. A clear operative field throughout surgery was achieved more frequently with bipolar diathermy 32 (80.00%) compared with conventional ligature 18 (45.00%). Occasional field obscuration and the need for additional hemostatic sutures were markedly higher in the conventional ligature group.

Table 6: Intraoperative Technical and Surgical Field Assessment

Table 7 demonstrates comparable parathyroid and nerve preservation outcomes between the two techniques. Preservation of all parathyroid glands and maintenance of normal postoperative calcium levels were high in both groups, with no cases of persistent hypocalcemia or permanent RLN injury.

Table 7: Parathyroid and Nerve Preservation Outcomes

Table 8 indicates improved postoperative pain control with bipolar diathermy. Mild pain and shorter analgesic requirements were more common in the bipolar diathermy group, whereas moderate to severe pain and prolonged analgesic use were more frequent in the conventional ligature group.

Table 8: Postoperative Pain and Analgesic Requirement

This comparative evaluation demonstrated that bipolar diathermy provided superior operative efficiency and improved intraoperative field conditions compared with conventional ligature, while maintaining a comparable safety profile regarding major thyroidectomy-related complications. The observed benefits—shorter operative time, reduced blood loss, fewer drains, clearer operative field, reduced need for additional hemostatic sutures, faster recovery, and improved postoperative pain control—are clinically important in thyroid surgery, where meticulous hemostasis is essential for protecting the recurrent laryngeal nerve (RLN) and parathyroid glands. In the present study, a significantly higher proportion of patients in the bipolar diathermy group achieved an operative duration of ≤90 minutes, accompanied by markedly lower intraoperative blood loss and reduced drain insertion rates. These findings support the concept that bipolar energy-based sealing enhances surgical efficiency by allowing rapid, reliable vessel sealing without repetitive clamp-and-tie maneuvers. Similar reductions in operative time and blood loss with bipolar vessel sealing systems have been documented in experimental and clinical studies across multiple surgical disciplines, highlighting the effectiveness of controlled bipolar radiofrequency energy in achieving hemostasis [10-15]. In thyroid surgery, where extensive devascularization of small vessels and venous plexuses is required, even minimal bleeding can obscure anatomical landmarks and prolong dissection. Several comparative thyroidectomy studies have reported improved operative efficiency and reduced bleeding with bipolar or LigaSure-based techniques compared with conventional suture ligation. [16-19]. Meta-analytical data further suggest that advanced hemostatic devices may offer procedural advantages depending on surgical context and operator experience [10,11,20]. A key practical advantage observed in this study was the significantly improved surgical field clarity in the bipolar diathermy group, with fewer episodes of field obscuration and a lower requirement for additional hemostatic sutures. Effective hemostasis is critical during thyroidectomy, as bleeding can compromise visualization of the RLN and parathyroid glands, increasing the risk of iatrogenic injury [6-7]. By maintaining a consistently dry operative field, bipolar diathermy facilitates precise capsular dissection and may reduce unnecessary tissue manipulation. RLN injury remains one of the most feared complications of thyroid surgery. In this study, temporary RLN injury was rare and identical in both groups, with no cases of permanent palsy. These findings are consistent with large multicenter audits and systematic reviews reporting low permanent RLN injury rates when thyroidectomy is performed by experienced surgeons [19-20]. Transient RLN dysfunction may result from traction, edema, or thermal spread rather than direct nerve transection, and typically resolves within months [21-23]. Importantly, the use of bipolar diathermy did not increase RLN morbidity, corroborating previous studies demonstrating similar nerve injury rates between energy-based and conventional techniques [24-27]. Postoperative hypocalcemia remains the most frequent complication following total thyroidectomy. In the present study, transient hypocalcemia rates were comparable between groups, and no persistent hypocalcemia occurred. These findings align with published reports indicating that hypocalcemia is more strongly related to parathyroid devascularization and extent of dissection than to the hemostatic method itself [23-25]. Early reports suggested that bipolar vessel sealing might reduce hypoparathyroidism by minimizing tissue trauma and preserving microvascular supply [26]. However, subsequent studies have produced mixed results, with many reporting similar calcium outcomes between bipolar and conventional ligature techniques [28-29]. Our findings support the view that bipolar diathermy does not increase hypocalcemia risk and may facilitate safer dissection through improved hemostasis. Postoperative neck hematoma is a potentially life-threatening complication following total thyroidectomy. In this study, hematoma and wound infection rates were low in both groups, with slightly higher frequencies in the conventional ligature group. Similar complication rates have been reported in multiple comparative series evaluating bipolar vessel sealing systems[30-32]. Reduced drain usage in the bipolar diathermy group further suggests improved intraoperative bleeding control, which may contribute to enhanced postoperative comfort and earlier mobilization. Patients undergoing bipolar diathermy demonstrated faster postoperative recovery, reflected by shorter hospital stay, earlier oral intake, and reduced postoperative pain severity with shorter analgesic requirements. Improved recovery metrics may be attributed to reduced operative time, less tissue trauma, and better intraoperative hemostasis. Previous studies have suggested that advanced energy devices may reduce postoperative pain by limiting excessive traction and dissection [17]. Although pain assessment is inconsistently reported across the literature, the present findings support a beneficial role for bipolar diathermy in enhancing patient comfort without compromising safety [10,14,33]. The heterogeneity of findings across studies comparing bipolar diathermy and conventional ligature likely reflects differences in surgeon experience, thyroid pathology complexity, operative technique, outcome definitions, and institutional discharge policies. While some authors have reported no significant differences in operative time or hospital stay [12,28], others have demonstrated meaningful advantages with bipolar sealing systems [13,15,27]. Meta-analyses emphasize that outcomes are context-dependent rather than universally superior for any single technique [10,14].

Study Implications and Conclusion

In summary, bipolar diathermy represents a safe and effective hemostatic technique for total thyroidectomy, offering improved operative efficiency, superior surgical field clarity, faster recovery, and reduced postoperative pain while maintaining complication rates comparable to conventional ligature. These findings are consistent with a substantial body of evidence supporting the safety of bipolar vessel sealing systems in thyroid surgery, provided they are used by experienced surgeons adhering to meticulous surgical principles [16,25].

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