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  Table of Contents  
ORIGINAL ARTICLE
Year : 2011  |  Volume : 48  |  Issue : 2  |  Page : 216-219
 

A comparative study of scalpel and surgical diathermy incision in elective operations of head and neck cancer


Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, India

Date of Web Publication11-Jul-2011

Correspondence Address:
H S Shukla
Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.82904

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 » Abstract 

Objective: The aim of the study was to assess the outcome of patients following use of scalpel or surgical diathermy in elective skin incision of head and neck cancer. Materials and Methods: 80 patients undergoing surgery for various head and neck cancers were analyzed retrospectively from Jan 2002 to May 2005 and divided into two groups, matched for age, sex, stage and histopathology according to the method used to perform incision, i.e., scalpel or surgical diathermy. Blood loss, total operative time, blood transfusions, wound related complications and cosmetic assessments of the scar were compared. Results: The two groups did not differ significantly in relation to patients or wound characteristics in terms of total operative time and quantity of blood transfusions. There was significantly less blood loss in the diathermy group compared with the scalpel group. There was no difference between the groups in wound complications and cosmetic results before discharge and at 1-month follow-up. Conclusions: There is no change in wound complication rate and scar formation even after application of heat during use of surgical diathermy. Therefore, surgical diathermy is safe and as effective as scalpel during elective skin incision of head and neck cancer.


Keywords: Scalpel and diathermy, wound healing


How to cite this article:
Kumar V, Tewari M, Shukla H S. A comparative study of scalpel and surgical diathermy incision in elective operations of head and neck cancer. Indian J Cancer 2011;48:216-9

How to cite this URL:
Kumar V, Tewari M, Shukla H S. A comparative study of scalpel and surgical diathermy incision in elective operations of head and neck cancer. Indian J Cancer [serial online] 2011 [cited 2019 Oct 19];48:216-9. Available from: http://www.indianjcancer.com/text.asp?2011/48/2/216/82904



 » Introduction Top


Although electrosurgical instruments are used increasingly for making incisions and tissue dissection, concerns about excessive scarring, higher wound infection rate and poor wound healing have curtailed the widespread use of surgical diathermy for skin incisions. [1],[2],[3]

Studies conducted in humans provided conflicting results. Soballe et al, [4] reported that electric coagulation increases the incidence of indurated margins, infections, and weakness of the wound cut in comparison with the knife. Conversely, Groot et al, [5] reported that use of surgical diathermy to create surgical wounds in patients undergoing abdominal or thoracic operations carries a wound infection rate similar to that of scalpel.

The purpose of the present study was to explore in our clinical setting the efficacy of surgical diathermy incisions versus conventional scalpel incisions, particularly to see if they take a longer time to perform, affecting the overall operating time, blood loss, wound complication and cosmetic result, by assessing scar tissue in head and neck cancer patients.


 » Materials and Methods Top


A total of 80 consecutive patients were included in the study and divided into two groups of 40 each, in which skin incisions were given with scalpel (group A) or surgical diathermy (group B). Both the groups were matched for age, sex, stage and histopathology of the tumor. Patients who had diabetes and previous head and neck operations or prior radiotherapy or neoadjuvant chemotherapy were excluded from the study. All the patients were informed about the nature of skin incision and written informed consent was taken. Skin incision was marked and skin as well as all layers of tissues including raising of subplatysmal skin flap was carried out with either scalpel (group A) or surgical diathermy (group B). In addition, diathermy was used for hemostasis during the dissection process in both the groups. The surgical diathermy machine used was from Alan Electronics, Mumbai, India, providing pure cutting current with minimum charring, having nominal frequency of 660 kHz, with non-modulated sinuous current form: HF voltage max: 690 Vrms/

480 Vrms, Crest factor 1.41 and max hp: 300 W/500 W. Diathermy incision was made using a standard diathermy pen electrode, set on cutting mode and delivering a 500 kHz sinusoidal current.

All patients received antibiotic prophylaxis: Amoxicillin and Clavulanic acid 1.2 g and Metronidazole 500 mg at induction and for two postoperative doses. Patients allergic to penicillin were given 1 g Ceftriaxone with Metronidazole. At the conclusion of operation, wound closure was achieved by closure of platysma with 3/0 vicryl and of skin with interrupted silk sutures. Blood loss during skin incision was measured by weighing swabs (1 g = 1 ml). No suction evacuation of blood was done while making the skin incision. Other parameters recorded were total operative blood loss, total operating time and blood transfusion.

The observations were entered on SPSS database. Student's " t" test and c2 test were used to express the significance of difference in the observations in the two groups. Wound complications occurring at any stage after the operation and at 1-month follow-up were recorded for all patients by independent observers blinded to the method of incision used. Wound infection was defined as the discharge of pus or fluid containing pathogenic organisms. [6] The cosmetic appearance of the scar was assessed as good, poor, contracted and formation of keloids by the operating surgeon [Figure 1].


 » Results Top


There were no significant demographic differences between the groups. The mean age in the diathermy groups was 55.83 ΁ 9.15 years compared with 55.63 ΁ 10.30 years in the scalpel group. The indication for surgery in terms of underlying diagnosis did not differ significantly between the groups and malignancy was diagnosed in majority of patients in each group: diathermy 33/40 (82.5%) and scalpel 32/40 (80%).



Outcomes measured

  • Mean blood loss while making skin incision
  • Total time taken in performing operative procedure
  • Peroperative and postoperative blood requirement
  • Wound related complication
  • Cosmetic assessment of scar


Blood loss, total operative time and postop and perop blood transfusion

The method of surgical diathermy incision was observed to be easy, safe and highly effective. With this technique, less bleeding was noticed at the initial skin incision. The field of dissection was drier and further dissection was considerably facilitated. Wound related mean blood loss (in milliliters) in various head and neck operations is shown in [Table 1].
Table 1: Mean blood loss while making skin incision in ml (±SD) during various head and neck operations


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Although of little clinical importance, the total time taken to perform operative procedure in both the groups was similar [Table 2]. Similarly, perop and postop blood requirement in both the groups did not differ significantly. However, it was found to be slightly more in patients in whom dissection was performed by scalpel [Table 3].
Table 2: Total time taken in performing operative procedure (minutes)


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Table 3: Perop and postop transfusion required (in units)


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Wound complications

The overall incidence of wound related complications was few and there was no significant difference in wound complication rate between the two groups before discharge and at 1-month follow-up [Table 4]. All infected wounds responded to conservative treatment with parenteral antibiotics. Similarly, wound dehiscence was taken care of and was resutured later.
Table 4: Wound related complications


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Cosmetic assessment of scar tissue

At the outpatient department, we reviewed the respective cosmetic grading of wounds between the two groups [Table 5]. Comparable trends were seen in both the groups and the difference between these groups was not statistically significant.
Table 5: Cosmetic assessment of scar tissue


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 » Discussion Top


Surgical diathermy was introduced at the beginning of the 20 th century [7],[8],[9],[10] to obviate the inherent disadvantages of steel scalpel, i.e. (1) lack of hemostasis leading to undesired blood loss; (2) indistinct tissue planes; (3) increased operative time; (4) use of foreign material (ligature) in the wound, leading to infection risk; (5) possibility of accidental injury in the operations theater; and (6) potential for tumor metastasis through lymphatic channels. [11],[12],[13] With the advent of modern electrosurgical units capable of delivering pure sinusoidal current, this technique is now becoming extremely popular because of rapid hemostasis, faster dissection and reduced overall operative blood loss. [14],[15],[16],[17],[18] However, electrosurgery may cause complications, with electrical burns being the most common hazard in operating room. [19] Inadvertent burns may occur at the surgical site or at the site of placement of the dispersive electrode (grounding pad). [20],[21],[22] Electrosurgery related fire hazards have also been reported in the literature before the advent of non-explosive anesthetic agents. Following the introduction of halothane, electrosurgery has been widely used as has been described in thyroidectomy by head and neck surgeons [23] and blepharoplasty by plastic surgeons. [24] Excellent cosmetic results with minimal scaring have also been reported in reconstructive and cosmetic faciomaxillary surgery. [25] Electrosurgical incision is not a true cutting incise. [26] It acts by heating the cells within the tissue so rapidly that they explode into steams, leaving a cavity. When the electrode is moved forward, fresh tissue is contacted, new cells are exploded and an incision is made. This phenomenon may explain minimal blood loss and healing with minimal amounts of scar tissue.

On the basis of this study, it is suggested that the skin may be safely incised using electrosurgery. Complications like contracted wounds, hypertrophic scar formations and increased infections rates were not found and the technique has been shown to be particularly useful in making head and neck incisions. It may be the ideal method of skin incision in these patients as the conservation of blood and operating time is very important in onco-surgery. These data demonstrate a significant advantage for the exclusive use of surgical diathermy in head and neck incision in cancer patients. Furthermore, the recent increase in blood borne diseases such as hepatitis C and human immunodeficiency virus infections makes exclusion of the scalpel from the operative field an attractive option and the role of scalpel in making incision may be completely taken over by the electrocautery. [27]

A Pubmed survey of 2009 shows few publications which have also included incision time and postoperative pain during diathermy incision. [28] In our study, no differentiation was made for the individual step including the operating time. It is the total time of operation that is important. Researchers have also investigated the hypothesis that application of extreme heat may result in significant postoperative pain and poor wound strength because of excessive tissue damage and scarring, respectively, and have observed that there was no difference between the two groups in terms of wound strength. Infectious complications were totally absent. The use of diathermy for skin incision during inguinal hernioplasty [29],[30] was found as safe as the use of scalpel in terms of wound healing and reduces the analgesic requirements in the postoperative period. Postoperative pain and analgesic dose were not measured in the outcome in our study.

Surgical diathermy is a safe and effective method to make skin incision. The electrocautery skin incision helps in the conservation of blood at the beginning of operative procedure and fear of increased infection rates is unfounded.

 
 » References Top

1.Kim H, Brunner E, Ritter E. Relevance of methods of skin incision technique on development of wound infection. Am Surg 1990;56:129-30  Back to cited text no. 1
    
2.Rappaport WD, Hunter GC, Allen R, Lick S, Halldorsson A Chvapil T. Effect of electrocautery on wound healing in midline laparotomy incisions. Am J Surg 1990;160:618-20.  Back to cited text no. 2
    
3.Gallup DG. Opening and closing of the abdomen and wound healing. In: Gershenson DM, DeCherney AH, Curry SL, editors. Operative gynecology. 1st ed. Philadelphia: Saunders; 1993. p. 127-46.   Back to cited text no. 3
    
4.Soballe PW, Nimbkar NV, Hayward I. Electric cautery lowers the contamination threshold for infection of laparotomies. Am J Surg 1998;175:263-6.  Back to cited text no. 4
    
5.Groot G, Chappell EW. Electrocautery used to create incisions does not increase wound infection rates. Am J Surg 1994;167:601-3.  Back to cited text no. 5
[PUBMED]    
6.Ljungqvist U. Wound sepsis after clean operations. Lancet 1964;1:1095-7.  Back to cited text no. 6
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7.Cushing H. Electrosurgery as an aid to the removal of intracranial tumors with a preliminary note on a new surgical current generator. Surg Gynecol Obstet 1989;64:47:751-84.  Back to cited text no. 7
    
8.Kramolowsky EV, Tucker RD. The urological application of electrosurgery. J Urol 1991;146:669-74.  Back to cited text no. 8
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9.O'Connor JL, Bloom DA, William T. Bovie and electrosurgery. Surgery 1996;119:390-6.  Back to cited text no. 9
    
10.Hill FT. Harris peyton mosher: historical vignette. Arch Otolaryngol 1996;84:143-50.  Back to cited text no. 10
    
11.Arsonval A. Action physiologique des courants alternatifs. In: Glover JL, Bendick PJ, Link WJ, editors. The use of thermal knives in surgery: Electrosurgery, lasers and plasma scalpel. Curr Probl Surg 1978;1:1.  Back to cited text no. 11
    
12.Glover JL, Bendick PJ, Link WJ. The use of thermal knives in surgery: Electrosurgery, lasers and plasma scalpel. Curr Probl Surg 1978;1:1.  Back to cited text no. 12
    
13.Murthy SM, Goldschmidt RA, Rao LN, Ammitati M, Buchmann T, Scanlon EF. The influence of surgical trauma on experimental metastasis. Cancer 1989;64:2035-44.  Back to cited text no. 13
    
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15.Laughlin SA, Dudley DK. Electrosurgery. Clin Dermatol 1992;10:285- 90.  Back to cited text no. 15
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16.Pearce JA. Electrosurgery. New York; John Wiley and Sons; 1986. p. 32-7.  Back to cited text no. 16
    
17.Odell RC. Electrosurgery: Principles and safety issues. Clin Obstet Gynecol 1995;38:610-21.  Back to cited text no. 17
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18.Sigel B, Dunn MR. The mechanism of blood vessel closure by high-frequency electrocoagulation. Surg Gynecol Obstet 1965;121:823- 31.  Back to cited text no. 18
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19.Parker EO 3rd. Electrosurgical burn at the site of an esophageal temperature probe. Anesthesiology 1984;61:93-5.  Back to cited text no. 19
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20.Watson AB, Loughman J. The surgical diathermy: principles of operation and safe use. Anaesth Intensive Care 1978;6:310-21.  Back to cited text no. 20
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21.Lawson BN. A nurse's guide to electrosurgery. AORN J 1977;25:315- 29.  Back to cited text no. 21
    
22.Bloch EC, Burton LW. Electrosurgical burn while using a battery-operated Doppler monitor. Anesth Analg 1979;58:339-42.  Back to cited text no. 22
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23.Kamer FM, Cohen A. High frequency needle dissection rhytidectomy. Laryngoscope 1985;95:1118-20.  Back to cited text no. 23
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24.Tobin HA. Electrosurgical blepharoplasty: A technique that questions conventional concepts of fat compartmentisation. Ann Plast Surg 1985;14:59-63.  Back to cited text no. 24
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25.Peterson A. The use of electrosurgery in reconstructive and cosmetic maxillo-facial surgery. Dent Clin North Am 1982;26:799-823.  Back to cited text no. 25
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26.Dixon AR, Watkin DFL. Electrosurgical skin incision versus conventional scalpel: A prospective trial. J R Coll Surg Edinb 1990;35:299-301.  Back to cited text no. 26
    
27.Kearns SR, Connolly EM, McNally S, McNamara DA, Deasy J. Randomized clinical trial of diathermy versus scalpel incision in elective medline laparotomy. Br J Surg 2001;88:41-4.  Back to cited text no. 27
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28.Shamim M. Diathermy vs. scalpel skin incisions in general surgery: Double-blind, randomized, clinical trial. World J Surg 2009;33:1594-9  Back to cited text no. 28
    
29.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.  Back to cited text no. 29
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30.Sheikh B. Safety and efficacy of electrocautery scalpel utilization for skin opening in neurosurgery. Br J Neurosurg 2004;18:268-72.  Back to cited text no. 30
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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