Acta Oto-Laryngologica, 2010; 130: 11801184

ORIGINAL ARTICLE

Ligasure versus diathermy scissors tonsillectomy: A controlled

randomized study

PER ATTNER1, CLAES HEMLIN2 & ANNE-CHARLOTTE HESSN SDERMAN1

1

Department of Otolaryngology, Head and Neck Surgery, Karolinska University Hospital and 2Department of
Otolaryngology, Sabbatsberg Hospital, Karolinska Institute, Stockholm, Sweden

Abstract
Conclusions: Ligasure tonsillectomies took longer than bipolar diathermy scissors tonsillectomies. Peroperative haemostasis was
comparable in the two groups. Postoperative haemorrhage was higher than expected, which needs to be further investigated.
A new handpiece, specically designed for tonsillectomy, could probably improve surgical performance regarding operative
time. Objective: To compare tonsillectomy using Ligasure with bipolar diathermy scissors with regard to operative time, blood
loss and complications. Methods: This was a prospective study; 150 patients (> 15 years of age) undergoing tonsillectomy were
randomized to tonsillectomy using either Ligasure or bipolar diathermy scissors. Operative time, peroperative blood loss,
postoperative pain and complications were recorded and evaluated. Results: A total of 149 cases were included, 75 randomized
to Ligasure tonsillectomy and 74 to bipolar diathermy scissors tonsillectomy. Peroperative blood loss was similar in both
groups. On average the operative time was 8 min longer in the Ligasure group. Postoperative pain was similar in the two groups.
Twenty patients (13%) experienced postoperative haemorrhage, which is higher than our previous material. Slightly fewer
patients experienced postoperative haemorrhage in the Ligasure group compared with the diathermy scissors group but the
difference was not signicant. Two of the 20 patients that experienced postoperative haemorrhage required a return to theatre
to stop the bleeding, fewer than previously observed. No other complications were seen.

Keywords: Haemhorrhage, haemostasis, peroperative blood loss

Introduction
Tonsillectomy is one of the most common surgical
procedures performed in the world. A multitude of
techniques have been introduced to minimize complications and improve safety and speed. Even though
it is a common procedure, a universal technique with
a minimum of complications has yet to be developed.
Common complications or side effects after surgery
include: peroperative bleeding, postoperative pain
and postoperative haemorrhage, which can be more
or less severe. Fatality after tonsillectomy is a rare but
well described complication [1].
At the day surgery unit at the ENT Department,
Karolinska University Hospital, the standard method
for tonsillectomy in recent years has been bipolar

diathermy scissors. As a combined cutting, dissecting

and haemostatic device, it has proven to be a safe and
effective method. As with all forms of electrosurgical
devices, diathermy scissors use heat to denature proteins, leading to haemostasis. The disadvantage of
using thermal energy is heat spreading in the surgical
eld, leading to damaged structures and delayed
wound healing, possibly even increased postoperative
pain. The haemostatic effect can also vary as there is
no sure way of knowing that the thermal seal will hold
as blood pressure rises postoperatively.
The Ligasure vessel sealing system (Valleylab,
Boulder, CO, USA) is a bipolar electrosurgical device
with active feedback control and minimal thermal
spread, which has been used in tonsillectomy and
has proven effective and safe for this procedure [2].

Correspondence: Per Attner MD, Department of Otolaryngology, Head and Neck Surgery, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
Tel: +46 8 517 715 39. Fax: +46 8 517 762 67. E-mail: per.attner@karolinska.se
(Received 5 January 2010; accepted 9 February 2010)
ISSN 0001-6489 print/ISSN 1651-2251 online  2010 Informa Healthcare
DOI: 10.3109/00016481003702544

Ligasure versus diathermy scissors tonsillectomy

1181

Ligasure has been compared to other surgical techniques in tonsillectomy in previous studies and has
been found to provide sufcient haemostasis and few
adverse events [35].
The aim of this study was to compare Ligasure
tonsillectomy to tonsillectomy using bipolar diathermy
scissors, with regard to operative time, peroperative blood loss, postoperative pain and postoperative
haemorrhage.

Material and methods

We conducted a prospective study at the day surgery
unit at the ENT Department, Karolinska University
Hospital. Only patients older than 15 years of age
undergoing tonsillectomy were included. Patients
undergoing simultaneous adenoidectomy, patients
with bleeding disorders and patients with a history
of peritonsillar abscess were excluded from the study.
Indications for surgery included recurrent tonsillitis
and tonsillar hypertrophy. All patients gave their
signed consent before being randomly assigned to
one of the two surgical techniques. The Ethical Committee of the Karolinska University Hospital approved
the research protocol. (Nr 2007/177-31/2).
All surgeries were performed under general anaesthesia by three senior surgeons. Patient care, pre- and
postoperative information and analgesia were identical in the two groups. Patients were discharged on the
day of surgery with a follow-up telephone interview
the day after surgery from the attending nurse (standard procedure in the department). Both at admission
and discharge from the daycare unit, patients were
given strict information verbally and in writing to
contact the ENT Emergency Room if there was any
suspicion of bleeding from the throat.
Surgeries were performed using a similar set-up in
both groups; a mouth gag was inserted and each tonsil
was grasped with a Blohmke forceps and pulled
towards the midline.
With the Ligasure, the precise instrument was
used both as a dissection device and as a haemostatic
device. The Ligasure system consists of an electrosurgical generator, a handpiece and a foot switch
(Figure 1). The tissue is grasped in the handpiece,
clamped, and the generator senses the density of the
grasped tissue and automatically adjusts the delivered
amount of energy that is released when the foot pedal
is pressed. A tone from the generator indicates completion of the pulse. The delivered energy denatures
collagen and elastin within vessel walls and forms a
seal that is said to withstand three times normal
systolic pressure [6,7]. Vessels up to a diameter of
7 mm can be sealed in this fashion. This also leads to

Figure 1. The Ligasure precise handpiece.

more limited thermal spread to surrounding tissue

[6].
No mucosal incision was made, the mucosa surrounding the tonsil was grasped and coagulated and
the same instrument was then used in tissue dissection. In this manner the tonsil was dissected and
removed.
With the bipolar diathermy scissors, the Power-Star
bipolar scissors (Ethicon) set on 20 W was used
(Figure 2). They comprise of a pair of modied
18 cm Metzenbaum scissors where the cutting blades
have a partial ceramic isolation in order to act as
electrodes in the bipolar instrument. Vessel bleeding
was usually stopped by the bipolar scissors but if
necessary with the more effective bipolar diathermy
forceps.
Operative time was measured from the time of
insertion of the mouth-gag until tonsils were removed
and haemostasis (when necessary) was completed.
Peroperative blood loss was measured by weighing
the cottonoid sponges after surgery and by measuring
the contents in the suction bottle.

Figure 2. Ethicon bipolar diathermy scissors.

1182

P. Attner et al.

Postoperative pain was measured using a visual

analogue scale (VAS) where the patient was asked
to provide an estimate of pain ranging from no pain at
all (=0) to worst pain imaginable (=10). All patients
were given a standardized regime of analgesic intake
three times per day. The values were recorded on
questionnaires before and after every time the patients
took their analgesic medication for 14 days postoperatively. The questionnaires were then recorded after
the period for analysis.
Postoperative haemorrhage was dened as any
incidence of dripping/spitting blood from the mouth
that occurred within 20 days after surgery and that led
to an unscheduled visit to the ENT Emergency
Room. These episodes were recorded using the
Departments computerized patient charts. Patients
also returned 14 days after surgery to hand over their
questionnaires and were then simultaneously questioned about haemorrhage.
All patient data, including operative time, peroperative blood loss, postoperative pain and postoperative haemorrhage were recorded in a database for
further analysis.
Statistical analysis was carried out using Statistica
software. Students t test was used for comparison
between groups and Mann-Whitney U test was used
to analyze pain levels. p values < 0.05 were considered
statistically signicant.

were operated due to recurrent tonsillitis and 37 due

to tonsillar hypertrophy. No difference in the distribution between the indications in the two groups was
seen (data not shown). No patients were lost to
follow-up; however, 42 patients did not completely
ll in and/or return their pain assessment questionnaires. A listing of all patient characteristics is shown
in Table I. No signicant differences were seen
regarding age or gender.

Peroperative blood loss

For all patients the mean peroperative blood loss was
9 ml (range 0100 ml). No signicant difference was
found between the groups.

Operative time
The mean time for completion of the surgery was
14.5 6.9 min (range 331.5 min). In the Ligasure
group the mean time was 18.3 5.4 min (range
831.5 min) and for diathermy scissors it was
10.3 6.1 min (range 330.75 min). The difference
between groups was signicant (p < 0.001).

Postoperative pain
Results
A total of 150 patients were included in this study.
One was excluded due to ongoing peritonsillar
abscess during surgery, leaving 149 patients for evaluation (59 males and 90 females). Ages ranged from
16 to 52 years, with a mean age of 27. The Ligasure
group comprised 75 patients and the diathermy scissors group comprised 74 patients. In all, 112 patients

A total of 107 patients completed the pain assessment

questionnaire; 62 in the Ligasure group and 45 in the
diathermy scissors group. Figure 3 shows the daily
percentage of patients in the two groups that recorded
pain over 5 on the VAS scale before the analgesic
intake in the evening. Registrations over 5 indicate
moderate to severe pain. No signicant difference
between the groups was found (Mann-Whitney
U test).

Table I. Patient characteristics.

Ligasure group
(n = 75)

All patients (n = 149)

Characteristic
Male

n
59

40

28

Diathermy scissors
(n = 74)
%

37

31

%
42

Female

90

60

47

63

43

58

Mean age (years)

26.8

...

26.9

...

26.7

...

Mean operating time (min) (X SD)

14.4 ( 6.9)

...

18.3 ( 5.4)

...

10.3 ( 6.09)

...

Mean preoperative blood loss (ml) (X SD)

8.8 ( 18.5)

...

8.9 ( 17.2)

...

8.4 ( 19.2)

...

Postoperative bleeding*

20

13

11

12

16

SD, standard deviation.

*Includes all patients that contacted the hospital due to a history of bleeding from the throat.

Ligasure versus diathermy scissors tonsillectomy

1183

Postoperative pain
80%
Diathermy scissors
Ligasure

70%

Pain score 5

60%
50%
40%
30%
20%
10%
0%
1

10 11

12

13

Days after surgery

Figure 3. Postoperative pain, percentage of registrations of VAS 5.

Postoperative bleeding
During the study, a total of 20 patients (13%) suffered
postoperative bleeding: 8 (11%) in the Ligasure
group and 12 (16%) in the diathermy scissors group
(no signicant difference, p = 0.3731). All of these
patients experienced secondary haemorrhages, no
primary haemorrhages (within the rst 24 h after
surgery) were seen. Of these 20 patients, only 2
needed to return to theatre (1 patient from the Ligasure group and 1 from the diathermy scissors group),
4 were treated with diathermy of small bleeds in the
ENT Emergency Room and the remaining 14 were
treated with overnight observation with systemic
administration of desmopressin and/or tranexamic
acid to stop and to reduce the risk of further bleeding
(data not shown).

Discussion
Compared with the diathermy scissors, the most
evident difference was that tonsillectomy with the
Ligasure devise took 8 min longer as a mean
(18.3 min vs 10.3 min). However, there seems to
be a learning curve: on average, the rst 10 Ligasure
surgeries took 19.6 min and the last 10 Ligasure
surgeries took 16.0 min. As expected, no difference
in operative time regarding the rst and last group
of 10 patients was shown in the diathermy scissors
group (data not shown). It was also noted that
the maximum operative time in both groups was
similar (31.5 min). Operative time in the Ligasure
group was close to what others have noted in earlier
studies [3].

In both groups the frequency of postoperative haemorrhage was distinctively higher than was seen in our
groups recent follow-up at our department, where the
frequency of postoperative haemorrhage was 7.5%.
This might be explained by the fact that patients
included in this study were made extra cautious
regarding postoperative haemorrhage with additional
written information and contacted the ENT Emergency Room more often because of this. Perhaps this
is demonstrated in that only 10% of the patients with
postoperative haemorrhage had to return to theatre to
stop the bleeding (2/20), compared with 19% in our
previous study. The fact that none of the postoperative haemorrhages were primary could perhaps also
explain why so few needed treatment in the operating
theatre. In our earlier study half of the patients with
primary bleeding needed return to theatre [8].
This higher rate of postoperative haemorrhage is
unacceptable and has led to an increased awareness
with more regular follow-up after tonsillectomies to
determine our postoperative haemorrhage rate. Other
authors have also discussed whether the general use of
hot techniques in tonsillectomies will lead to an
increased risk of postoperative haemorrhage [9,10],
while others have seen no such differences in prospective studies [11]. Further studies are needed and
possibly the technique used as our standard method in
tonsillectomies needs to be changed.
With regard to postoperative pain, no difference
was seen between the groups. Theoretically a reduction in pain would have been expected in the Ligasure
group, as the heat spreading in the surgical eld is
supposed to be limited by the measured amount of
energy produced by the devise. However, the
prolonged time for surgery is probably mirrored in

1184

P. Attner et al.

the pain scores in the Ligasure group. As many as

42 patients did not complete their questionnaires,
13 from the Ligasure group and 29 from the
diathermy scissors group, which might have affected
the result in making it more uncertain.
Peroperative bleeding was minimal in both groups,
in contrast to studies on tonsillectomy using cold
techniques, where mean peroperative blood loss normally measures more than 100 ml [5].
The Ligasure handpiece is disposable, in contrast to
the bipolar diathermy scissor, which is reusable. This
could be of interest since reusable instruments in
tonsillectomy could theoretically transmit CreutzfeldtJakob disease (CJD) [12] and are prohibited in some
countries. In the UK, only disposable instruments
have been used in tonsillectomies since 2000, but
lately many centres have started using reusable
instruments again since the risk of transmission
seems to be minimal.
When performing tonsillectomy with the Ligasure
method using the precise instrument, it should be
noted that this handpiece is not specically developed
for this procedure; a handpiece that is a little bit longer
and with a more sleek prole in the jaws of the
instrument should facilitate the dissection in the inferior pole of the tonsils and perhaps even make the
procedure go a little bit quicker.

Conclusions
In this study, tonsillectomies with Ligasure took a
longer time than in the diathermy scissors group. In
both groups, there was little to no peroperative blood
loss and a higher frequency of postoperative haemorrhage than expected. More studies are needed to see if
any of the techniques provides enough safety against
postoperative haemorrhage. Fewer postoperative haemorrhages required return to theatre compared with
our earlier data. As a disposable instrument, Ligasure
provides adequate safety against CJD transmission.
A new handpiece, specically designed for tonsillectomy, could probably improve surgical performance
regarding operative time.

Acknowledgments
The authors would like to thank Helena wferberg
and Marianne Granstrm for invaluable help with
data collection.
Declaration of interest: Dr Attner is a consultant to
Covidien Energy-based Devices, Boulder, CO, USA.

References
[1] Windfuhr JP, Schloendorff G, Baburi D, Kremer B. Lifethreatening posttonsillectomy hemorrhage. Laryngoscope
2008;118:138994.
[2] Prokopakis EP, Lachanas VA, Benakis AA, Helidonis ES,
Velegrakis GA. Tonsillectomy using the ligasure vessel
sealing system. A preliminary report. Int J Pediatr Otorhinolaryngol 2005;69:11836.
[3] Karatzanis A, Bourolias C, Prokopakis E, Panagiotaki I,
Velegrakis G. Thermal welding technology vs ligasure tonsillectomy: a comparative study. Am J Otolaryngol 2008;
29:23841.
[4] Lachanas VA, Hajiioannou JK, Karatzias GT, Filios D,
Koutsias S, Mourgelas C. Comparison of ligasure vessel
sealing system, harmonic scalpel, and cold knife tonsillectomy. Otolaryngol Head Neck Surg 2007;137:3859.
[5] Lachanas VA, Prokopakis EP, Bourolias CA, Karatzanis AD,
Malandrakis SG, Helidonis ES, et al. Ligasure versus cold
knife tonsillectomy. Laryngoscope 2005;115:15914.
[6] Heniford BT, Matthews BD, Sing RF, Backus C, Pratt B,
Greene FL. Initial results with an electrothermal bipolar
vessel sealer. Surg Endosc 2001;15:799801.
[7] Hope WW, Burns JM, Newcomb WL, Heniford BT,
Sing RF. Safety and efcacy of the electrothermal bipolar
vessel sealer in trauma. Injury 2009;40:5646.
[8] Attner P, Haraldsson PO, Hemlin C, Hessen Soderman AC.
A 4-year consecutive study of post-tonsillectomy haemorrhage. ORL J Otorhinolaryngol Relat Spec 2009;71:2738.
[9] Windfuhr JP, Wienke A, Chen YS. Electrosurgery as a risk
factor for secondary post-tonsillectomy hemorrhage. Eur
Arch Otorhinolaryngol 2009;266:11116.
[10] Macassey EA, Baguley C, Dawes P, Gray A. 5-year audit of
post-tonsillectomy haemorrhage at Dunedin Hospital.
Aust N Z J Surg 2007;77:57982.
[11] Hesham A. Bipolar diathermy versus cold dissection in
paediatric tonsillectomy. Int J Pediatric Otorhinolaryngol
2009;73:7935.
[12] Kamal SA, Basu S, Kapoor L, Kulandaivelu G, Talpalikar S,
Papasthatis D. Harmonic scalpel tonsillectomy: a prospective
study. Eur Arch Otorhinolaryngol 2006;263:44954.

Copyright of Acta Oto-Laryngologica is the property of Taylor & Francis Ltd and its content may not be copied
or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.