Effect of Intraoperative Valsalva Maneuver Application on Bleeding Point Detection and Postoperative Drainage After Thyroidectomy Surgeries

Thyroidectomy is one of the most commonly performed operations worldwide.¹ Though a series of improvements were introduced to the operation process, still several postoperative complications remain to be faced such as seroma, wound infection, skin flap complications, and hematoma.^2,3

Despite the richness of the blood vessels in the thyroid area,⁴ the rate of postoperational bleedings thus hematoma events are low (1–5% of the cases).⁵ However, once not controlled, hematoma can result in airway compression and create a life-threatening situation for the patient.⁶ Hence, preventive measures have been emphasized and employed to avoid postoperational bleedings after thyroidectomy. These approaches range from exercises to avoid Valsalva maneuver kind of forces such as coughing or straining at opening bowel⁷ to the use of drains after the operation. However, recent literature indicates that the drain usage does not have a significant effect on the recovery period or on the duration of the hospital stay.^3,5,8,9 Furthermore, it may cause wound infection and contribute to the discomfort of the patients.^5,8,10,11 Thus a proper hemostasis and an early detection of potential bleeding sites are crucial steps for a successful operation and a steady recovery period.⁴ Several techniques have been used to detect and treat bleeding points immediately after the operation to prevent postoperational hematoma. These techniques involve the use of hydrogen peroxide, water in the wound, Valsalva maneuver, and Trendelenburg tilt.^4,7 Recently, the success of Valsalva maneuver and Trendelenburg tilt application on bleeding point detection was demonstrated by Moumoulidis et al.⁴ However, no further information is provided until now regarding the postoperational evaluation of the patients.

In this paper, we aim to analyze the effect of the Valsalva maneuver application on the identification of bleeding points before finalizing the surgery and its influence on the postoperative drainage, complications, and recovery process.

Methods

Results

One hundred patients, 77 females and 23 males, were included in this study (mean age: thyroidectomy group, 49.30 ± 12.06 years; thyroidectomy + Valsalva group, 45.82 ± 11.98 years; Table 1). Two groups of 50 patients were formed to test the effect of Valsalva maneuver on the identification of bleeding points after the bilateral thyroidectomy operation. There was no significant difference between the groups regarding the disease diagnosis, thyroid function test, ASA, and the type of operation applied (P > 0.05 for all; Table 1).

Table 1 Demographic and clinical characteristics of patients in study groups

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Operative and postoperative evaluation of patients

The average size of the left and right lobes, as well as the total volume of the thyroid gland, was not significantly different between the 2 study groups (P > 0.05 for all; Table 2). Similarly, the average duration of the operation and the postoperative hospital stay were not significantly different between the groups with and without the application of Valsalva maneuver (P > 0.05 for all; Table 2).

Table 2 Thyroid lobe size, operative and postoperative parameters of patients in study groups

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Upon Valsalva maneuver, 68% of the patients showed no bleeding, whereas 26% of the patients had 1 and 6% of the patients had 2 minor bleeding points identified.

Application of the Valsalva maneuver did not have any significant effect on the duration of the drain usage (P > 0.05; Table 2). There was only a slight but nonsignificant decrease in the total amount of drainage in the study group receiving Valsalva maneuver application (Table 2). There was no significant difference regarding the postoperative complications between the 2 study groups (P > 0.05; Table 3). Only 1 patient in the group without the Valsalva maneuver application experienced postoperative hematoma and was operated on again under emergency circumstances, whereas none of the patients had hematoma or reoperation incident in the Valsalva maneuver group. Nonetheless, these parameters were not significantly different between the study groups (Table 3).

Table 3 Postoperative complications in the study groups

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Discussion

This is the first study evaluating the effect of intraoperative Valsalva maneuver on bleeding point detection and postoperative drainage after thyroidectomy surgeries. We found that although intraoperative Valsalva maneuver provides identification of bleeding points in 32% of the cases, it had no effect on the duration of postoperative drain usage, the amount of drainage and risk of hematoma.

When performed correctly and followed by a proper hemostasis, thyroidectomy surgeries are routinely performed and result in successful operations with a fast recovery. However, any uncontrolled postoperative bleeding resulting in hematoma represents a severe danger to patient's health causing respiratory problem and cardiac arrest.^12,13 Thus, the precise detection of bleeding points following the operation is highly critical. Few trivial methods have been used to identify the bleeding points before finalizing thyroidectomy surgeries, such as the use of water or hydrogen peroxide in the operation area.⁷

Recently, the application of another intraoperative technique, Valsalva maneuver, was emphasized as an alternative to these methods.⁴ Valsalva maneuver is widely used to test cardiac and baroreflex functions in addition to adrenergic system responses.^14–16 Besides being used for these purposes, Moumuolidis et al recently demonstrated that the application of Valsalva maneuver helps to identify potential bleeding sites after head and neck surgeries.⁴ Additionally, a precise control over potential bleeding points was unceasingly brought into attention as a crucial step to the recovery process by preventing hematoma and excessive drainage.^4,6,11,12 Therefore, in this study we aimed to evaluate the effect of Valsalva maneuver application on the detection of bleeding sites and more importantly on postoperative parameters, such as the drainage and complications particularly after thyroidectomy operations.

We observed that the application of Valsalva maneuver did not prolong the operation time between the groups, but allowed the operation team to detect potential bleeding points in 32% of the cases (26% with one bleeding point and 6% with 2 minor bleeding points). The percentages of patients identified with 1 or 2 bleeding points were consistent with the data presented by Moumoulidis et al.⁴

However, identification of bleeding points did not have a favorable effect on the duration of postoperative drain usage, the amount of drainage and risk of hematoma. The values for these parameters were similar to the previously described data.¹⁷ The amount of drainage in both groups was also comparable with the rates defined in former studies.^9,17 Only a slight but nonsignificant decrease was observed in the amount of total drainage with the study group receiving the Valsalva maneuver application. The lack of clinical effect of Valsalva maneuver can be explained by 2 possibilities. First, Valsalva maneuver application may trigger minor bleedings due to the excessive pressure applied, which under normal conditions do not take place. Secondly, even if minor bleedings occur in patients for whom Valsalva maneuver was not applied, these bleedings can be overcome by the natural hemostasis mechanisms of the body before reaching a critical state.

It should also be noted that the Valsalva maneuver is temporally limited to 1 minute to avoid the consequences of barotrauma.⁴ To overcome this limitation, Trendelenburg tilt was suggested as a supplementary approach to be used during head and neck operations following Valsalva maneuver.^4,18 This approach showed an increased sensitivity for the detection of bleeding points.⁴

Lastly, the use of drains after thyroidectomy operations has been highly debated in the literature. It was shown that there is no beneficial effect of drain use with respect to recovery time and hospital stay.^3,5,8,9 Furthermore, it may trigger infection and prolong hospital stay if not changed frequently.^5,19 Only in certain cases where the patients use anticoagulants or undergo lymphatic dissection, the use of drains is recommended.¹⁷ Optional tools are also suggested to replace drains for hematoma treatment, such as needle aspiration.²⁰ Thus, a future step would be to test the application of Valsalva maneuver and the Trendelenburg tilt on the recovery and postoperative complications of patients without the use of drains.

In clinical practice, surgeons generally believe that intraoperative approaches such as Valsalva maneuver can detect bleeding points and potentially prevent the occurrence of postoperational bleedings. However, our finding showed that although intraoperative Valsalva maneuver provides identification of minor bleeding points in some patients, it had no beneficial effect on postoperative parameters. On the other hand, it should also be noted that there were no hematoma or reoperation cases observed for the group with Valsalva maneuver application and the percentage of patients experiencing postoperative complications was similar for both groups. But since the rates of hematoma, postoperative complications, and reoperation were very low, further large-scale studies are needed to accurately conclude whether intraoperative Valsalva maneuver has clinical advantages in terms of these parameters or not.

In conclusion, we suggest that intraoperative application of Valsalva maneuver has no beneficial effect on postoperative hemorrhagic complication after thyroidectomy operations. Surgeons should consider giving up intraoperative Valsalva maneuver in thyroid operations without causing any postoperative disadvantage.