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Invited Critique
December 21, 2009

Sutureless Thyroidectomy—Technological Advance or Toy?Comment on “Prospective Clinical Trials of Thyroidectomy With LigaSure vs Conventional Vessel Ligation”

Arch Surg. 2009;144(12):1174-1175. doi:10.1001/archsurg.2009.199

In this meta-analysis of the use of LigaSure during thyroidectomy, the authors conclude that sutureless thyroid operations are safe, effective, and reduce operative duration. So what? Other than the arguable cost-effectiveness of reduced operating time, there is no difference between LigaSure thyroidectomy and standard open techniques. So is sutureless thyroidectomy really a significant advance, or just another expensive technological toy? Are we to abandon our surgical heritage and training and stop tying knots during thyroidectomy just for the sake of a few minutes saved in operating time? Well, I believe the answer to that question is an unequivocal yes. Sutureless techniques have been an invaluable advance for laparoscopic operations, and we are now entering a new sutureless era in open surgical procedures. It is fitting that this meta-analysis of sutureless thyroidectomy is now being published because thyroidectomy is one of the hallmark surgical procedures—the first Nobel Prize ever to be awarded to a surgeon was given to Theodor Kocher in 1909 for his pioneering work in relation to thyroidectomy and its follow-up.1 The ability to offer thyroid procedures with an acceptable mortality rate was the cornerstone upon which many of the major surgical clinics in the United States established their reputations. It remains one of the most commonly performed surgical procedures worldwide and is considered fundamental to surgical training. Of interest, surgical techniques for thyroidectomy have, until recently, changed little from those used by Kocher in Switzerland; Dunhill in Melbourne, Australia; and the Mayo brothers in Minnesota early last century. Sutureless thyroidectomy represents the next major advance, but not just for thyroid procedures. Because the new generation of sutureless devices fit neatly into the surgeon's hand, acting as a virtual extension of the fingers but also capable of dissecting and vessel sealing, I have no doubt that, in a short time, all open procedures will be performed using such sutureless techniques, and the surgical tie will be relegated to history museums. In my own unit, we have been performing sutureless thyroidectomy for more than 3 years and now have a series of 1163 total thyroidectomies. The technique is as safe as the traditional open procedure but with a significant time saving. I have not tied a knot in all that time. In the operating room, instead of teaching surgical residents to dissect, clip, cut, and tie, I now teach them to dissect, seal, divide, and protect patients from thermal injury. Welcome to the new age of surgery; farewell to the surgical tie. It is only fitting that thyroidectomy should be at the forefront of that change.

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