A Systematic Review and Meta-analysis of Harmonic Technology Compared With Conventional Techniques in Mastectomy and Breast-conserving Surgery With Lymphadenectomy for Breast Cancer

Breast cancer is the leading cause of cancer-related deaths among females worldwide, with an incidence rate of close to 90 cases per 100,000 females. The occurrence of breast cancer, especially in low- to middle-income countries, continues to increase with time.¹ The surgical treatment of breast cancer has undergone substantial changes over the last few decades. Mastectomy remains an important surgical option for breast cancer patients; however, for patients with earlier stages of breast cancer, breast-conserving surgery (BCS) followed by radiation therapy is a safe alternative to radical mastectomy, with acceptable local recurrence rates, similar survival, and improved cosmetic outcomes.² Both mastectomy and BCS often involve axillary lymph node dissection as the axillary lymph nodes are a common site of metastasis in breast carcinoma, and axillary node status provides an important prognostic indicator through histological examination.^3–8

Surgical complications can be common with breast cancer surgeries, particularly with modified radical mastectomies. Apart from the long-term risk of lymphedema in postoperative breast surgery patients, several acute surgical complications may occur such as hemorrhage,⁹ tissue necrosis,¹⁰ wound infection,¹¹ and seroma.¹² Seromas represent the most frequent complication of mastectomy, developing in close to 30% of patients.¹² Sealing the lymphatic ducts is thought to be particularly important in reducing the risk of postoperative seromas.⁷ Breast surgery complications may be reduced through the use of meticulous techniques, hemostasis, and wound closure.^13,14

Monopolar or bipolar electrosurgery is a common conventional method used to dissect tissue and control blood loss in breast cancer surgery, along with other conventional methods such as ligation, scalpel, and scissors often being used in BCS.¹⁵ Despite the benefits of electrosurgery in controlling blood loss, studies have indicated that risk of complications, such as seroma, may be increased with this technique.¹⁶ In particular, electrosurgery can cause thermal injury and incomplete sealing of the vessels and lymphatic channels, leading to surgical complications.¹⁷

Harmonic devices (Harmonic^®; Ethicon Inc., Cincinnati, OH, USA) perform simultaneous ultrasonic cutting and coagulation through the use of mechanical vibration, producing hemostasis at a lower temperature than electrosurgical devices while providing excellent dissecting capability.^18,19 Several systematic reviews and meta-analyses have reported favorable outcomes with the Harmonic technology compared to conventional methods across several types of surgeries.^20–23 A recent meta-analysis by Huang et al,²³ in modified radical mastectomy for breast cancer, reported that Harmonic technology was associated with a significant reduction in postoperative drainage, seroma development, intraoperative blood loss, and wound complications compared with electrosurgery dissection. However, it is noted that studies of BCS patients were not included in the meta-analysis, and only a subset of surgical complications was evaluated.

The purpose of this systematic review and meta-analysis was to evaluate both efficacy and complications associated with Harmonic technology versus conventional techniques in both mastectomy and BCS patients, typically involving lymph node dissection, using all the latest randomized controlled trials (RCTs) available.