Blood loss and Procedure Time in Major Salivary Glands Benign Tumors Resection Using Harmonic Scalpel

Carrillo Rivera Jorge Arnulfo , Quiñones Ravelo René , Martínez Pérez José Ricardo , Gallardo Huerta Víctor Omar , González López Annel Ivonne , Radilla Flores Mariana del Carmen , Ramírez Landeros Joshua , Gamboa Ramírez Fernando , Torrejón Hernández Carlos Adrián , Hidalgo Delgado Jesús Nicolás 5 Oral and Maxillofacial surgeon at General Hospital “Dr. Darío Fernández Fierro” ISSSTE. México. Dentist General Practice Third year resident in Oral and Maxillofacial Surgery. Second year resident in General Surgery. First year resident in General Surgery. *Corresponding author: Jorge Carrillo Rivera. Dpto. de Cirugía Maxilofacial Hosp. Gral. Dr. Darío Fernández. ISSSTE. Consultorio particular.


Introduction
The hemostasis systems applied in surgery are based on the production of endothermic heat as a result of an interaction between energy and tissue [1]. Progressively more sophisticated electrocoagulation systems such as the ultrasonic scalpel based on the protein's destructiveness have been developed of the cell membrane as a result of ultrasonic vibration, generating significantly low temperatures (50 to 100 ° C) compared to the electro cautery (100 to 150 ° C) . 3 It is an apparatus that uses mechanical energy to cauterize the vessels and dissect the tissues; It consists of three components, a generator that provides electricity, this is transformed into energy through a system of piezoelectric crystals that vibrate in an amplitude between 50 to 330 µm, at a constant frequency between 23 to 55.5 kHz, the expansion and contraction of These crystals are sent by means of a handpiece that attaches to the active tip either to a scalpel or to scissors [2,3]. Figure 1. Ultrasonic coagulation is similar to that of the electrocautery, however, the mechanism by which the protein is denatured is due to the transfer of mechanical energy, breaking the tertiary hydrogen bonds, the protein tissue is transformed into a viscous collagen that cauterizes the small and medium diameter vessels [3,4].
There are two mechanisms by which tissues are dissected, one is by means of cavitation fragmentation and the second by mechanical cutting at temperatures below 63 ° C; Vibration defragments proteins with the breakdown of hydrogen bonds (tertiary hydrogen bonds). It can be used simultaneously for cutting and coagulation, since it transfers the neuromuscular current and produces a minimal lateral thermal effect (1 to 3 mm). After cutting and coagulation, it causes minimal intraoperative bleeding, which allows the surgeon a better view of the operative field, so the surgery lasts less time than with other techniques and causes minimal tissue damage, which leads to scarring of faster wounds, lower postoperative morbidity and decreased postoperative pain [2, 4 and 5]. The surgical time is known as the time in minutes used in the surgical procedure obtained from the anesthesiology report sheet, from the beginning of the surgical incision in the skin to the closure of it. The transsurgical bleeding defined as the volume of bleeding in milliliters reported on the anesthesiology sheet resulting from the count in the aspiration manifold and the estimation by gauze used. Over the years, various methods have been reported for the quantification of intraoperative bleeding, some of these methods are considered impractical and obsolete. According to current literature, visual estimation is the most widely used method despite its low accuracy [6]. The quantification of bleeding by the weight of textiles is considered the most practical and accurate method to determine the amount of blood not captured in the containers, which is obtained by subtracting the dry weight of absorbent textiles and the weight of textiles with blood material, using the conversion of 1g = 1ml [6].

Clinical case 1
This is a 54-year-old male patient, with a 3-year hemifacial asymmetry of evolution in the right buccal region of slow growth, asymptomatic, soft consistency and well-defined edges, not hyperemic or hyper thermic. \ With a history of uncontrolled systemic arterial hypertension, osteoarthritis and gonartrosis of the left lower limb, on treatment based on pregabalin and etoricoxib 1 tablet every 24 hours. In the simple tomography, a hypo dense area was observed in the circumscribed right oral space of 6 x 5 centimeters. Figure    Tumor resection was performed under balanced general anesthesia with orotracheal intubation, through a preauricular approach with submandibular extension of approximately five centimeters, dissection by planes and coagulation of small and medium caliber vessels through the use of ultrasonic vibration scissors until reaching the lesion, respecting the integrity of the parotid gland, as well as the marginal branch of the facial nerve, the tumor was removed, the hemostasis of the surgical bed was verified and it was sutured by planes.

Case report 2
A 58-year-old female patient with a history of controlled type II diabetes, with a two-year increase in volume in the left parotid region of slow growth, firm consistency, subject to deep planes, with a diameter of four centimeters, not painful to palpation Requesting preoperative studies, salivary gland ultrasonography, reporting hypercoic area dependent on the left parotid gland, with presence of adjacent nodes and increased vascularity. Simple and contrasted computed tomography observing a hyper dense area of soft tissue with proximity to the carotid sheath and lymph nodes present, with a diagnostic impression of parotid gland tumor of the superficial lobe, lymphadenopathy and increased vascularity ( Fine needle aspiration biopsy (BAAF) was performed, reporting polymorphonuclear cells with metaplastic changes in the epithelium, with a positive diagnostic interpretation of Whartin tumor. Under balanced general anesthesia orotracheal intubation, prior asepsis and antisepsis, a three-centimeter submandibular approach was designed with pre and retroauricular extension, dissection of superficial cervical fascia and coagulation of small and medium-sized vessels with ultrasonic vibration scissors, appreciating tumor in Left parotid space approximately four centimeters in diameter, respecting the marginal branch of the nerve and facial vein, tumor resection is performed, sending tissue to a pathological study with a diagnosis of Whartin's tumor, observing a surgical bed without bleeding data, suturing by planes. (Figure 6).  gland tumor (33.3%), followed by cervical lymphadenopathy (25%), the results obtained were captured in an Excel spreadsheet and evaluated through the SPSS program to know measures of central tendency. Of the twelve patients included in the study, 3 (25%) were male and 9 (75%) female, the most frequent diagnosis was benign submandibular submandibular sialoadenitis (25%), parotid lymphadenopathy (8.3%), and lipoma (8.3%), the most frequently performed surgery was submaxilectomy (50%), followed by superficial parotidectomy (33.3%) and lymph node resection ( 16.6%). There is no significant correlation between bleeding presented by the 12 patients with the time of the surgical procedure. There was greater bleeding in patients undergoing parotidectomy, in relation to those of submaxilectomy. Graphic 1.

Graphic 2.
Histogram of frequency in minutes of the 12 procedures performed.

Graphic 3.
Histogram of frequency in milliliters of the 12 procedures performed.

Discussion
Ultrasonic coagulation is a surgical tool, implemented in head and neck surgery since 1991. The ultrasonic vibration scissors, consist of a vibrating blade that oscillates at a frequency of 55.5 kHz and a temperature that does not exceed 100°C [8,9].
Fan et al. demonstrated the use of ultrasonic vibration scissors for the resection of benign lesions at the base of the tongue through the transoral approach, reducing surgical duration and Tran's operative hemorrhage [10]. Koh et al mentioned less damage to nerve structures in neck dissections using ultrasonic vibration than with the use of electrosurgery [11].

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Learn more www.auctoresonline.org/journals/clinical-medical-reviewsand-reports The coagulation of the tissue originates through the denaturation of proteins, breaking the hydrogen bonds due to the high vibrational energy transferred to the tissue with the ultrasonic energy. Due to the absence of high temperatures, the tissue does not boil or carbonize, it simply bleaches and coagulates [12,14]. Currently, a decrease in operative time has been reported in the world literature, as well as a significant decrease in hemorrhagic complications in the Trans and postoperative period through the use of ultrasonic vibration instruments in head and neck surgery [15,19].

Conclusions
the harmonic scalpel (HS) (Ethicon, Somerville, NJ), an instrument that uses ultrasonic vibrations to induce tissue cutting and immediate coagulation, was introduced in the early 1990s [7, 10]. A low power setting allows for greater hemostasis and a slower cut, while a high power setting offers less hemostasis but a faster cutting capacity. Ultrasonic vibration has been shown to reduce operative time and intraoperative blood loss in a range of procedures including from thyroidectomy, parotidectomy, glosectomy and neck dissection [15,18]. According to the data obtained, it can be concluded that the time and trans operative bleeding decrease considerably with the use of ultrasonic vibration, coinciding with that reported by the articles reviewed [19,20].