Clinical Usefulness of the Valsalva Maneuver to Improve Hemostasis During Thyroidectomy
Conditions: The Role of Valsalva Manoeuvre, in Thyroidectomy to Reduce Postoperative Bleeding
Sponsor: University of Foggia

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Clinical usefulness of the Valsalva maneuver to improve 
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hemostasis during thyroidectomy 
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Keywords: Valsalva manoeuvre, hemostasis, Surgical Drains, 
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thyroidectomy 
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Short title: Valsalva maneuver in thyroidectomy 
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Date 15/07/2022 
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Abstract 
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Introduction Bleeding after total thyroidectomy remains a rare event which affects early 
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postoperative morbidity, occurring in 0.3% up to 4.2% of cases. Intraoperative bleeding is an 
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unpleasant complication, and it is often easily manageable though postoperative bleeding may 
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represent a life-threatening condition for the patient. The purpose of our study is to clarify the 
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role of Valsalva manoeuvre, in order to reduce postoperative bleeding.  
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Methods Between January 2019 to February  2022 , 250 consecutive patients were listed for 
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thyroid surgery at our surgical department. We selected 178 patients and divided them in two 
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groups based on the execution of the Valsalva Manoeuvre. 
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Results The cohort is made up of one hundred and seventy-eight patients, divided into two groups 
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based on the use of the VM. There is no difference in the duration of surgery between the two 
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groups.  In Group B there is a lower number reintervention for bleeding. In Group A there is a 
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significant greater volume of drainage output than in Group B. The Correlation test used, confirms 
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these results. 
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Conclusion Cervical hematoma can compromise the patient's life, so bleeding control is crucial. 
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The use of a simple, and safe Valsalva Manoeuvre can improve postoperative course, giving a 
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significant reduction of drainage output but  does not prevent the risk of reoperation for 
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haemorrhage. 
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Introduction 
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Total Thyroidectomy (TT) is one of the most performed operations in the world. In neck surgery, it 
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is among the most important interventions, considering its complexity and diffusion1. 
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Despite innovative approaches in surgery and innovations in surgical instruments, bleeding after 
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TT remains a rare event which affects early postoperative morbidity, occurring in 0.3% up to 4.2% 
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of cases 2. The causes are not to be found only in the complex anatomy of the anterolateral region 
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of the neck, which is richly vascularized, but also in the strategies adopted to achieve perfect 
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haemostasis in an operative field where the nearby anatomical structures must be preserved 3.  
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Intraoperative bleeding is an unpleasant complication, that most of the time it is easily 
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manageable and resolvable though it engages the surgeon and it might lengthen the operating 
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times; in the other hand postoperative bleeding can instead represent a life-threatening condition 
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for the patient. For this reason, the need to adopt all known methods and strategies to minimize 
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postoperative bleeding. Over time, the use of new instruments, the use of Collagen-Fibrinogen-
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Thrombin Patch (CFTP), cellulose gauze and other Haemostatic agents have made it possible to 
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reduce the incidence of postoperative bleeding and reintervention but not to cancel it4. 
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The purpose of our study is to clarify whether the routine intraoperative execution of a Valsalva 
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manoeuvre (VM) may affect the detection of bleeding that would otherwise remain occult and 
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therefore may manifest in the postoperative period. 
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Methods  
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Between January 2019 to February  2022 , 250 consecutive patients were listed for thyroid surgery 
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at our surgical department. In order to evaluate the role of VM, all patients treated with minimally 
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invasive approaches (Mini Invasive Video Assisted Thyroidectomy MIVAT) or with robot-assisted 
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transaxillary thyroid surgery (RATS) were excluded in the cohort. Loboistmectomies were also 
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excluded. Other exclusion criteria were the need for lymph node dissections, patient coagulation 
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disorders and an high anaesthesiologic risk (ASA 3). We chronologically divided our cohort of 178 
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patients into 2 non-randomized groups: Group A (n = 96 patients) in which no MV was performed, 
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and Group B (n = 82 patients) who had VM performed at the end of the TT.  
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VM was performed after thyroid excision and after a first revision of haemostasis in the operative 
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field. Thanks to the anaesthesiologist VM was achieved by applying an incremental PEEP (positive 
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end expiratory pressure) up to 30cm H2O, and subsequently a new VM by setting the mechanical 
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ventilator in manual mode through the APL (adjustable pressure-limiting) valve. 
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All patients were treated by a team with the same surgical approach with extensive experience in 
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neck surgery, therefore all procedures were standardized. 
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The two groups are comparable in demographics data (Table 1). 
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Group A (n=96) 
Group B (n=82) 
Overall (n=178) 
p value 
Age (Range) 
Mean 
Median (±DS) 
20-74 
47.82 
49.5 (±14.49) 
18-74 
45.51 
45.5 (±14.28) 
18-74 
46,75 
48 (±14,36) 
 
0.143 
M F 
37/59 
28/54 
65/113 
0.543 
BMI(Range) 
Mean 
Median (±DS) 
23-40 
31.47 
30.5(±4.80) 
24-41 
32.28 
33(±4.77) 
23-41 
31.84 
32(±4.79) 
 
0.130 
ASA score 
I 
II 
 
38/96 
58/96 
 
35/82 
47/82 
 
63/178 
115/178 
 
0.675 

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Table 1 Demographic data. BMI (Body Mass Index), ASA score (American Society of 
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Anesthesiologists).  Significance test used are T test in numerical variable, and chi-square tests for 
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categorical variables. A 𝑝 value of less than 0.05 was considered statistically significant. 
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Haemostasis is reached with monopolar or bipolar coagulators, and LigaSure ™ (LSJ Medtronic, 
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Covidien product, Minneapolis, MN, USA) was also used to achieve better sealing of the vessels. In 
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dangerous areas, vessel’s ligation and application of small surgical clips is preferred to avoid 
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recurrent laryngeal nerve injury. 
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At the end of the operation (after the execution of the VM in Group B), a human fibrinogen and 
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human thrombin (CFTP) patch is always applied and 2 suction surgical drains are placed in the 
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thyroid lodges. 
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After the surgery, and the anaesthesiologic awakening, the patient waits about 2 hours in the 
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recovery room, with personnel assigned to check the patient and the drainage output. Sometimes 
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a longer observation time is required. If there is a rapid filling of the drains, or symptoms such as 
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dyspnoea, difficulty breathing, suffocation and smoothing of the jugule appear, then the patient 
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quickly undergoes new surgery for revision of the haemostasis. 
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Primary outcomes considered include drainage volume, reoperation rate in the first 6 hours, and 
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reoperation in the first 24 hours. The duration of the operation and the occurrence of other 
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complications other than bleeding were also evaluated. 
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Statistic analysis 
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T test in numerical variable, and chi-square tests for categorical variables was performed for 
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statistical comparison of the groups. Phi Coefficient was calculated for association between 
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dichotomous variables. Point-Biserial Correlation was calculated for correlation between variables 
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dichotomous and continuous. A 𝑝 value of less than 0.05 was considered statistically significant. 
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Results  
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The cohort is made up of one hundred and seventy-eight patients, divided into two groups based 
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on the use of the VM. There are no statistically significant differences in age, sex, BMI (Body Mass 
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Index), and ASA score (American Society of Anesthesiologists) between the two groups (p value> 
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0.05 for all; Table 1). 
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In table 2, surgical and postoperative data are shown and analyzed. There is no difference in the 
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duration of surgery between the two groups. On the other hand, it should be emphasized that in 
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Group B there is a lower number of cases of both early (<6h) and late re-intervention within 24h. 
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These results were not statistically significant. The average period of stay under observation in the 
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recovery room was also slightly shorter in Group B, albeit not in a statistically significant manner. 
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The results show that in Group A there is a significant greater volume of drainage output than in 
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Group B, and that more frequently they are kept in place even on the second postoperative day. 
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All patients included in this study underwent double suction drains placement in the right and left 
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thyroid lodges, respectively. 
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GROUP A (N=96) 
GROUP B (N=82) 
P VALUE 
OPERATION 
LENGTH (MIN) 
126.11 
126.78 
0.416 
RECOVERY 
ROOM STAY 
(MIN) 
126.93 
123.96 
0.083 
REOPERATION 
(<6H) 
6/96 
1/82 
0.085 
REOPERATION 
(<24H) 
4/96 
0/82 
0.125 
DRAINAGE 
VOLUME (ML) 
79.38 
56.67 
< 0.001 
PERMANENCE 
OF THE 
DRAINAGES 
BEYOND THE 
FIRST 
16/96 
5/82 
0.029 

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POSTOPERATIVE 
DAY 
HOSPITAL STAY 
(DAYS) 
2.22 
2.15 
0.175 
Table 2 Surgical and Post surgical data. Significance Test used is Chi-Square. A 𝑝 value of less than 
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0.05 was considered statistically significant. 
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In table 3, we used Correlation tests (Phi Coefficient between dichotomous variables and Point-
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Biserial was between variables dichotomous and continuous), to evaluate the real contribution of 
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the VM during TT. The results obtained showing there is no significant correlation for early or late 
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reoperation, not even for the length of the drainage beyond the first postoperative day. On the 
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other hand, the correlation with the overall volume of drainage output was statistically significant. 
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Table 3 Tests of Correlation. Phi Coefficient was calculated for association between dichotomous 
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variables. Point-Biserial Correlation was calculated for correlation between variables dichotomous 
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and continuous. A 𝑝 value of less than 0.05 was considered statistically significant. 
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Φ VALUE 
P VALUE 
REOPERATION (<6H) 
-0.129 
0.914 
REOPERATION (<24H) 
-0.140 
0.938 
PERMANENCE OF THE 
DRAINAGES ON THE 
SECOND DAY 
-0.163 
0.970 
 
r VALUE 
P VALUE 
DRAINAGE VOLUME 
(ML) 
-0.851 
< 0.001 
 
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Finally, in Table 4, we analyse the incidence of main complications during TT ( Postoperative 
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Hypoparathyroidism, recurrent laryngeal nerve palsy, Wound Infection ).  The two groups were 
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homogeneous, so there are no significant differences between the groups and these complications 
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are not related to the application of VM.  All patients included in this study had a 30-day follow-up 
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after surgery. All cases of hypoparathyroidism and cases of recurrent laryngeal nerve palsy 
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resolved during follow-up and were therefore deemed transient. 
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Table 4 Most important complications during TT. 
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GROUP A 
(N=96) 
GROUP B 
(N=82) 
P VALUE 
WOUND INFECTION  
2/96 
1/82 
0.655 

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TRANSIENT 
POSTOPERATIVE 
HYPOPARATHYROIDISM, 
𝑛 (%) 
14/96 
9/82 
0.474 
TRANSIENT RECURRENT 
LARYNGEAL NERVE 
PALSY, 𝑛 (%) 
2/96 
2/82 
0.873 
 
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Discussion  
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Total thyroidectomy and lymph node dissections of the neck are among the most common surgery 
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performed at the cervical level and had low rates of morbidity and mortality. Bleeding after 
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thyroidectomy is well known complication, but with improved surgical technique e meticulous 
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hemostasis has become a rare occurrence. However, although it is a rare occurrence if it is not 
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diagnosed early and managed correctly, it becomes potentially life-threatening. 
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Indeed, patients with postoperative cervical hematoma they required a new surgery and longer 
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hospital monitoring 5. Symptoms that arise are: respiratory distress, choking, difficulty swallowing 
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and a feeling of constriction in the neck. In 72% of cases, postoperative hematoma occurs within 6 
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hours after surgery and 89% of the time within 12 hours 6 7. The risk of bleeding is affected not 
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only by the patient's factors, but also by the underlying thyroid disease and the haemostatic 
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techniques used. 
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The use of drains in thyroid surgery is still widespread. In our unit, all patients undergoing TT are 
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routinely subjected to placement of a drain for the right thyroid lodge, and one for the left thyroid 
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lodge and placed on suction. They are then removed in the first postoperative day or remain 
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longer in case of too high an output. 
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Traditionally, the main purpose for the use of drains is to prevent postoperative complications 
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evacuating postoperative hematoma or lymphatic fluid and to notify the surgeon as soon as 
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possible. However, the use of drains may be omitted in uncomplicated cases because often the 
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drained volume is very low and it may not be necessary, or why haemostasis was remarkably 
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adequate during surgery 8 9. In light of improvements in hemostasis techniques and increasing 
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surgical skills, the value of drainage in thyroid surgery may again be questioned, but to date, 
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numerous randomized trials have failed to solve this question 10 11. However we believe that life-
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threatening complications, such as postoperative bleeding, hematoma, compression of air 
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passages or suffocation, can be more promptly signaled by the presence of drains, and guarantee 
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the surgeon a more timely diagnosis and the patient a less rapid onset of symptoms associated 
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with hematoma. 
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The VM is a fairly common procedure for detecting bleeding points during thyroidectomy 
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procedures 12. During VM, increased intrathoracic and intraabdominal pressures causing internal 
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jugular vein distension and increasing internal jugular venous pressure. The venous hipertension 
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that involves the large veins causes a involves also the vessels of the thyroid lodge, increasing 
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blood flow and forcing any bleeding, which can be detected. 
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Tokaç et al suggest that intraoperative application of VM has no positive effects on postoperative 
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hemorrhagic complication13, Beyoglu in 2020 recommends to keep airway pressure at 50 cm H2O 
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for 22.5 s in order to a more efficacious intraoperative detection of bleeding points in patients 
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undergoing total thyroidectomies 14. Ozdemir affirms that The Valsalva maneuver helps to detect 
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any bleeding point after Trendelenburg positioning15. 
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In our study, we considered how VM can help surgeons practicing TT. In order to reduce 
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postoperative bleeding at the end of haemostasis phase we perform a double VM by applying an 
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incremental PEEP up to 30cm H2O, and afterwards a new VM setting the mechanical ventilator in 
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manual mode. The second shot, often show a new bleeding point so the surgeons can reach a 
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clean and dry surgical field. 
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This procedure allowed us to have fewer re-operations both in the first 6 postoperative hours and 
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in the following 24 hours. These data were not statistically significant in our study, while a 
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significant difference was in the reduction of the total volume of drains and in a lower incidence of 
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permanence of the drains beyond the first postoperative day. VM did not affect any of the other 
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complications examined. 
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Conclusion 
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The manifestation of a hematoma can be life-threatening causing a compression of the airway 
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therefore severe bleeding control is crucial. Technological progress and the use of new hemostatic 
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agents have contributed to reducing the incidence of this phenomenon. However, the use of a 
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simple, economical and safe maneuver such as the VM can improve postoperative course, giving a 
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significant reduction of drainage output but  does not prevent the risk of reoperation for 
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haemorrhage. 
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