|Year : 2017 | Volume
| Issue : 1 | Page : 21-25
A comparative study of scalpel versus surgical diathermy skin incisions in clean and clean-contaminated effective abdominal surgeries in AVBRH, Wardha, Maharashtra, India
Noopur Priya, YR Lamture, Luv Luthra
Department of General Surgery, Jawaharlal Nehru Medical College, DMIMSDU, Wardha, Maharashtra, India
|Date of Web Publication||25-Jul-2017|
Y R Lamture
Department of General Surgery, Jawaharlal Nehru Medical College, DMIMSDU, Sawangi (M), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: To study the safety and efficacy of diathermy as a modality to give skin incisions. Study Design: Observational study conducted in department of surgery at AVBRH, over 2 years from 2013 to 2015. Material and Methods: 100 cases were studied. In 50 cases incision was given by scalpel and in 50 incisions was given by diathermy. Primary outcome variable was the incisional blood loss, calculated by measuring the weight of swabs used exclusively during incision until complete hemostasis was achieved. Secondary outcome variables were incision time, operative time, pain verbal rating scale (VRS), wound healing, and wound complications. Incision time was defined as the time from the beginning of skin incision until subcutaneous fat arrived, with complete haemostasis; it was expressed in s/cm2. Severity of pain was defined using VRS. Results: we reported shorter time for skin incision, lesser blood loss during surgery and lesser wound complication in cases of diathermy incision, and has more significant pain reduction as compared to scalpel group. Conclusion: The findings of the present study shows that diathermy seems to provide some benefit with respect to postoperative wound pain and has obvious safety advantages to the surgical team compared with scalpel.
Keywords: Blood loss, electrocautery incision, incision time
|How to cite this article:|
Priya N, Lamture Y R, Luthra L. A comparative study of scalpel versus surgical diathermy skin incisions in clean and clean-contaminated effective abdominal surgeries in AVBRH, Wardha, Maharashtra, India. J Datta Meghe Inst Med Sci Univ 2017;12:21-5
|How to cite this URL:|
Priya N, Lamture Y R, Luthra L. A comparative study of scalpel versus surgical diathermy skin incisions in clean and clean-contaminated effective abdominal surgeries in AVBRH, Wardha, Maharashtra, India. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Jun 16];12:21-5. Available from: http://www.journaldmims.com/text.asp?2017/12/1/21/211575
| Introduction|| |
Incision is a “cut or slit” to gain access to the underlying structures. Traditionally, incisions are made with stainless steel scalpel. These incisions are supposed to be more bloody and painful. Electrosurgical devices stand out as some of the most useful and most used instruments in surgeon's armamentarium. Cauterization is a medical term describing burning of body to remove or close a part of it. Electrocauterization or electrocautery is routinely used in surgery to remove unwanted or harmful tissue, i.e., tissue dissection, burn and seal blood vessels, and to create a surgical incision. It is also used increasingly to reduce or stop bleeding. It is achieved through a small probe with an electric current running through it, that is used to burn or destroy the tissue. However, electrocautery, which is available in all surgical theaters, is less frequently used for skin incisions due to fear of tissue damage, poor wound healing, postoperative pain, and excessive scarring.
This study is undertaken to alleviate the fear of using electrocautery for skin incisions in surgical community, particularly to observe whether they take a longer time to perform, affecting overall operating time, wound complications, cosmetic results, and by assessing skin edge for necrosis from incision site.
In 1926, Cushing, a neurosurgeon, used Bovie's, a physicist, side-by-side electrosurgical units, a vacuum tube-based design for cutting, and a spark gap version for coagulation to perform neurosurgery on a patient with an otherwise inoperable vascular myeloma. Both are often credited for the invention of electrosurgery. The results of this and other procedures were published in 1928.
Electrosurgical technology offers two types of devices for energy delivery: monopolar and bipolar.
The monopolar instrument
In monopolar modality, the patient lies on top of the return electrode, a relatively large metal plate or a relatively large flexible metalized plastic pad, which is connected to the other electrode of alternating current (AC) source. The surgeon uses a single-pointed probe to make contact with the tissue. The electrical current flows from the probe tip through the body and then returns to electrode, from which it flows back to the electrosurgical generator. This results from the fact that the current rapidly spreads out laterally, as it enters the body causing a dramatic decrease in the current density.,
Bipolar instruments resemble surgical forceps with both the active electrode and the return electrode. Voltage is applied to the patient using a special forceps, with one tine connected to one pole of the AC voltage source and the other tine connected to the other pole of the voltage source. The electrosurgical energy does not travel through the patient but is confined to the tissue between the forceps. When a piece of tissue is held by the forceps, a high-frequency electrical current flows from one to the other forceps tine, through the intervening tissue.,
| Materials and Methods|| |
Enrollment of patients
All patients who required abdomen surgery were admitted at a tertiary-level center from July 2013 to September 2015.
The patients were divided into two groups. Patients were allocated to Group A and to Group B. Group A was scalpel, they received conventional scalpel skin incision and. Group B (diathermy) received diathermy skin incision made with force two-valley laboratory diathermy machine in cutting mode, power of 5W and 515 kHz sinusoidal waveform at surgery.
- Patients of both sexes
- Patients in the age group of 8–80 years with clean and clean-contaminated wounds were included in the study.
- Patients with the presence of untreated coagulopathy
- Diabetes mellitus and immunocompromised status
- Dirty and contaminated wounds were excluded from the study.
The surgical incision in each case was made through skin and subcutaneous tissue according to the proposed operation site.
Blood loss measurement
Blood loss was calculated by measuring the weight of swabs used exclusively during incision until complete hemostasis was achieved.
Incision time measurement
Incision time was defined as the time from the beginning of skin incision until subcutaneous tissue was reached with complete hemostasis; it was expressed in seconds.
Skin edge was taken from the incision site and was sent for histopathological analysis to assess necrosis.
Wound complication measurement
All the sterile dressings were opened on postoperative day 5 or when required to check any complication.
Pain intensity measurement
The pain assessment was done by surgical residents at fixed times on postoperative days 1, 3, and 5 using the verbal, numerical rating scale to assess the level of pain.
The follow-up schedule included a review at 1st month and 6th month for cosmetic assessment of scar.
| Observation and Results|| |
An interventional study involving 100 cases were randomized prospectively to either electrocautery group or scalpel group for skin incision in the Department of Surgery at AVBRH, Wardha, Maharashtra, India. The patients were enrolled from July 2013 to September 2015, with a 6-month follow-up period.
Time taken for skin incision
The incision time was significantly higher in patients in scalpel group compared to diathermy group (P < 0.0001). [Table 1] shows that the mean incision time in scalpel group is 55.54 ± 22.24 s and in diathermy group is 28.58 ± 18.90 s.
Blood loss during skin incision
We recorded the blood loss (ml) in both groups. We noticed that the blood loss was comparatively very less in diathermy group as compared to scalpel group as shown in [Table 2].
A pain score measures a patient's pain tolerance. We found significantly higher pain score in scalpel group on days 1, 3, and 5 compared to diathermy group. Severity of pain score was significantly higher in scalpel group on days 1, 3, and 5 compared to diathermy group. Considering this statement, we recommend diathermy for incision which is extremely less painful [Table 3].
We have recorded the wound complication in both groups of patients. Wound complications such as purulent collection, hematoma, and seroma were less in diathermy group as compared to scalpel group [Table 4].
Patients' follow-up for scar
We followed up patients for 6 months and noted the scar health on 1st month and 6th month [Table 5].
Necrosis from the skin edge
In the histopathological analysis of skin edge from both the groups, there was no evidence of necrosis in either of the groups.
| Discussion|| |
In this study, diathermy incision for all types of abdominal general surgery was associated with a shorter incision time and reduced incisional blood loss largely due to the intrinsic hemostatic effect of diathermy.
The shorter incision time is most likely explained by the fact that achieving hemostasis with a scalpel incision requires several instrument exchanges with coagulation diathermy, especially the subcutaneous tissue. In agreement to other studies, cutting diathermy resulted in a statistically significant shorter incision time than use of the scalpel [Table 6].
|Table 6: Comparing incision time for procedures with cutting diathermy versus scalpel incisions|
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Blood loss was significantly less following incisions made by cutting diathermy rather than scalpel. It has been reported by many studies that blood loss during skin opening was significantly less using diathermy compared to scalpel group [Table 7]].
|Table 7: Comparing blood loss for procedures with cutting diathermy versus scalpel incisions|
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There was a significant difference in postoperative pain scores at 1 day (24 h), 3 days, and 5 days between incisions made with cutting diathermy and scalpel. This finding is consistent with the results of two meta-analyses. Our results suggested a significantly reduced postoperative pain in the diathermy group. This may be explained by the localized sensory nerve destruction with the subsequent disruption of transmission of nerve impulses resulting from diathermy ablation. Cell vaporization caused by the application of pure sinusoidal current leads to immediate tissue and nerve necrosis without significantly affecting the nearby structures. Consequently, there is total or partial injury to the cutaneous nerves in the area of the surgical wound with a reduced postoperative pain profile in patients who had diathermy skin incisions. [Table 8].
|Table 8: Comparing pain scores at 24 h after procedures with cutting diathermy versus scalpel incisions|
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The most frequent complications seen during the wound healing process are hematoma, seroma, purulent collection, and wound dehiscence. Yilmaz et al. compared scalpel and electrocautery and reported that seroma incidence was higher in the electrocautery group than the other groups and there was no difference between groups with respect to hematoma. Similarly, we found that the incidence of seroma was higher in the scalpel group than the diathermy group.
Assessment of necrosis on skin edge
Farnworth et al. studied comparison of skin necrosis in rats using a new microneedle electrocautery, standard size needle electrocautery, and the Shaw hemostatic scalpel. The microneedle caused less necrosis than the standard size needle electrocautery (0.18 vs. 0.27 mm, P< 0.01) and less necrosis than the Shaw hemostatic scalpel set at 220°F (0.18 vs. 0.25 mm, P< 0.05).
In our study, skin edges of both the groups were sent for histopathological analysis and there was no evidence of necrosis in the skin edge, suggesting that electrosurgical incision does not cause skin charring and damage to adjacent tissues and is as safe as the conventional scalpel incision.
In this study, both the groups were comparable in terms of age, sex, body mass index, nature of operation, mode of anesthesia, mode of analgesia, clean and clean-contaminated wound, and length of incision. Based on observations made in this study, it has been concluded that skin incisions made by cutting diathermy are quicker and associated with less blood loss than those made by scalpel. Cutting diathermy is a cosmetically acceptable technique for abdominal skin incisions. There is no increased risk of wound infection, and diathermy may convey benefit in terms of less postoperative wound pain. The findings of the present study show that diathermy seems to provide some benefits with respect to postoperative wound pain and has obvious safety advantages to the surgical team compared with scalpel.
Based on the present findings and recent data from meta-analyses, we support the efficacy of diathermy for skin incisions, and hence recommend the use of diathermy for abdominal skin incisions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zinner MJ, Schwartz SI, Ellis H. Incisions, closures and management of the wound. In: Maingot EH, editor. Maingot's Abdominal Operations. 10th
ed. New Jersey: Prentice Hall International Inc.; 1997. p. 395-426.
Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: History, principles, and current and future uses. J Am Coll Surg 2006;202:520-30.
Kadyan B, Chavan S, Mann M, Punia P, Tekade S. A prospective study comparing diathermy and steel scalpel in abdominal incisions. Med J DY Patil Univ 2014;7:558-63. [Full text]
Kumar V, Tewari M, Shukla HS. A comparative study of scalpel and surgical diathermy incision in elective operations of head and neck cancer. Indian J Cancer 2011;48:216-9.
] [Full text]
Cushing H. Electro-surgery as an aid to the removal of intracranial tumors. Surg Gynecol Obstet 1928;47:751-84.
Shamim M. Diathermy vs. scalpel skin incisions in general surgery: Double-blind, randomized, clinical trial. World J Surg 2009;33:1594-9.
Chau JK, Dzigielewski P, Mlynarek A, Cote DW, Allen H, Harris JR, et al.
Steel scalpel versus electrocautery blade: Comparison of cosmetic and patient satisfaction outcomes of different incision methods. J Otolaryngol Head Neck Surg 2009;38:427-33.
Dixon AR, Watkin DF. Electrosurgical skin incision versus conventional scalpel: A prospective trial. J R Coll Surg Edinb 1990;35:299-301.
Johnson CD, Serpell JW. Wound infection after abdominal incision with scalpel or diathermy. Br J Surg 1990;77:626-7.
Kearns SR, Connolly EM, McNally S, McNamara DA, Deasy J. Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy. Br J Surg 2001;88:41-4.
Pearlman NW, Stiegmann GV, Vance V, Norton LW, Bell RC, Staerkel R, et al.
A prospective study of incisional time, blood loss, pain, and healing with carbon dioxide laser, scalpel, and electrosurgery. Arch Surg 1991;126:1018-20.
Telfer JR, Canning G, Galloway DJ. Comparative study of abdominal incision techniques. Br J Surg 1993;80:233-5.
Ayandipo OO, Afuwape OO, Irabor D, Oluwatosin OM, Odigie V. Diathermy versus scalpel incision in a heterogeneous cohort of general surgery patients in a Nigerian teaching hospital. Niger J Surg 2015;21:43-7.
] [Full text]
Byrne FJ, Kearns SR, Mulhall KJ, McCabe JP, Kaar K, Gilmore M, et al.
Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: A randomised prospective trial. Eur J Orthop Surg Traumatol 2007;17:445-8.
Siraj A, Gilani AA, Dar MF, Raziq S. Elective midline laparotomy: Comparison of diathermy and scalpel incisions. Prof Med J 2011;18:106-11.
Aird LN, Brown CJ. Systematic review and meta-analysis of electrocautery versus scalpel for surgical skin incisions. Am J Surg 2012;204:216-21.
Chrysos E, Athanasakis E, Antonakakis S, Xynos E, Zoras O. A prospective study comparing diathermy and scalpel incisions in tension-free inguinal hernioplasty. Am Surg 2005;71:326-9.
Hussain SA, Hussain S. Incisions with knife or diathermy and postoperative pain. Br J Surg 1988;75:1179-80.
Yilmaz KB, Dogan L, Nalbant H, Akinci M, Karaman N, Ozaslan C, et al.
Comparing scalpel, electrocautery and ultrasonic dissector effects: The impact on wound complications and pro-inflammatory cytokine levels in wound fluid from mastectomy patients. J Breast Cancer 2011;14:58-63.
Farnworth TK, Beals SP, Manwaring KH, Trepeta RW. Comparison of skin necrosis in rats by using a new microneedle electrocautery, standard-size needle electrocautery, and the Shaw hemostatic scalpel. Ann Plast Surg 1993;31:164-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]