OBJECTIVES: The Harmonic® scalpel has demonstrated clinical and surgical benefits as an effective and efficient alternative to traditional electrosurgery. However, ultrasonic devices incur higher device cost than electrosurgery. The aim of this study is to review the economic evidence comparing total procedural costs performed with ultrasonic devices to conventional techniques. METHODS: A comprehensive literature review was conducted to identify publications where ultrasonic energy devices were used in comparison with conventional surgical techniques for the period 2004-2014. No restriction on the surgical specialty was applied. Primary inclusion criteria were: 1) randomized-controlled studies; 2) human studies; 3) total procedure cost was evaluated for economic impact.  Articles were reviewed to collect direct and indirect cost information such as OR time, blood loss, hospital length of stay, resource and surgical consumables, as well as quality of life data. RESULTS: For 39 articles identified for full-text screening, 9 articles were evaluated based on the inclusion criteria. Therapeutic areas included breast, colon, and thyroid surgery. All economic studies considered total medical direct costs.  Except for one article that showed ultrasonic devices to be more expensive and one that showed no economic difference, all other articles demonstrated that the higher cost of the Harmonic® device is offset by improved clinical outcomes and efficiency without an increase in surgical complications, especially in complicated procedures entailing considerable loss of blood or longer operative time. The average overall cost savings ranged from $85 to $400 USD per patient. Two studies estimated the incremental cost-effective ratio and both indicated the Harmonic® device to be superior compared to conventional technique.   CONCLUSIONS: Ultrasonic devices shorten OR time and improve clinical outcomes in a variety of procedures investigated without an increase in complications, and thus can be considered as a cost effective alternative to conventional surgical techniques.