Diathermy versus scalpel incisions in elective abdominal surgery: a comparative study

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1 International Surgery Journal Nandurkar VS et al. Int Surg J Se;5(9): htt:// ISSN eissn Original Research Article DOI: htt://dx.doi.org/ / isj Diathermy versus scalel incisions in elective abdominal surgery: a comarative study Vikranth S. Nandurkar*, Mohan Kumar K., Prakash M., Suma S. Deartment of Surgery, Sri Devaraj Urs Medical college, Kolar, Karnataka, India Received: 05 July 2018 Acceted: 02 August 2018 *Corresondence: Dr. Vikranth S. Nandurkar, dr.vikranth.sn@gmail.com Coyright: the author(s), ublisher and licensee Medi Academy. This is an oen-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which ermits unrestricted non-commercial use, distribution, and reroduction in any medium, rovided the original work is roerly cited. ABSTRACT Background: Scalel incisions roduce little damage to surrounding tissues. There has been a widesread use of diathermy for hemostasis but fear of roduction of large scars and imroer tissue healing has restricted their usage in making skin incisions. Use of diathermy in skin incisions reduces bleeding and makes the incision quicker, but there are no differences in wound burst strength. Objective of the study was to comare the use of diathermy and scalel incisions in elective abdominal surgery s to see the variations in incisional time, blood loss during incision, ostoerative ain and wound comlications Methods: This was a rosective randomized study, which included atients above 18 who underwent elective abdominal surgery. The atients were randomly included into A or B. In A incision was made with a scalel and in grou B with diathermy. Data was analyzed for incisional time, blood loss during incision, ostoerative ain and wound comlications. Results: There was a significant increase in mean time taken for incision in A when comared to B. Mean incision blood loss was found to be significantly higher in grou A comared to grou B atients. Postoerative ain was significantly higher in grou A ( value <0.05) on ostoerative day 1. Among wound comlications, no statistically significant differences were seen between the two grous. Conclusions: Electrocautery incisions were safe, less time consuming, reduced blood loss and had less ostoerative ain. We conclude that diathermy could be acceted as an alternative method for surgical skin incisions. Keywords: Diathermy, Electrocautery, Scalel, Skin incisions, Wound comlications INTRODUCTION Traditionally skin incisions have routinely been erformed with scalels. Now-a-days there is a shift in trend from this method to electrosurgical skin incisions. Currently most surgeons still make skin incisions with scalel and use coagulation diathermy to dissect deeer tissues. 1 Diathermy skin incisions are less oular among the surgeons, as it has been hyothesized that alication of extreme heat may result in significant ost-oerative ain and oor wound healing. 2 There has been a widesread use of diathermy for hemostasis, but fear of roduction of large scars and imroer tissue healing has restricted their use in making skin incisions. 3 Now-a-days electrodes used in making diathermy incision generate a ure sinusoidal current which roduces cleavage in tissue lanes without creating damage to the surrounding tissues, thus reducing damage inflicted to tissues leading to minimal scar formation. 4 This study was erformed to comare both methods of skin incisions to determine differences in incisional time, blood loss during incision, ostoerative ain and wound comlications. International Surgery Journal Setember 2018 Vol 5 Issue 9 Page 3124

2 METHODS Study design This was a rosective observational comarative study conducted in R. L. Jalaa Hosital and Research Center, Kolar, a tertiary teaching hosital in southern Karnataka, India over a eriod of 12 months (May 2017 to Aril 2018). Candidates enrolled in this study were of either sex above 18 of age, who scheduled for elective abdominal surgeries and willing to articiate in the study. dee fascia or aoneurosis was reached with comlete hemostasis. Incision length was measured using sterilized calibrated scales and blood loss during incision making was calculated by weighing the swabs re and ostoeratively (1 mg = 1 ml). Subcutaneous tissue was not aroximated with suture in either grou to maintain uniformity. Inclusion criteria All atients scheduled for elective abdominal surgeries for benign general surgical diseases, of either sex above 18 of age and willing to articiate in the study. Exclusion criteria Malignancy and chronic medical illness like diabetes mellitus, anaemia, asthma or tuberculosis. Method These candidates were randomly divided into two grous. In A, abdominal incision was made with a scalel and in B, abdominal incision was made with diathermy (at setting of 70 watt with monoolar current). The incisions included vertical, horizontal, inguinal hernia reair and aendicectomy incisions. Figure 2: Intraoerative images showing amount of blood loss in scalel incision (a) and electrocautery incision (b). These atients were evaluated clinically for ain daily during ostoerative eriod on day 0, day 1 and day 2 using Verbal Rating Score (VRS). VRS grading, 0: No ain, 1: mild ain, 2: moderate ain, 3: severe ain and 4: worst ain. Data was analyzed for indications, incisional blood loss, incision time, ostoerative ain and wound comlications like seroma, hematoma, fever, infection, dehiscence (searation of the subcutaneous tissues with skin). A wound culture was erformed if incision searation or urulent discharge occurred. The resence of a healing ridge with adequate tensile strength was used as an index of a healing wound while the Southamton grading system was used to denote the resence or absence of an infection. G0: normal wound healing, G1: normal healing with mild bruising or erythema, G2: erythema lus other signs of inflammation, G3: clear or serosanguinous discharge, and G4: urulent discharge. All atients were followed u in 2 nd, 4 th, 6 th week and 6 months after the discharge and any readmission after discharge from the hosital was evaluated to detect the occurrence of late wound comlications. Figure 1: Intraoerative images showing skin incision by scalel (a) and electrocautery (b). A medical history, a comlete hysical examination and routine laboratory tests were erformed. They were given a rohylactic dose of one gram of ceftriaxone one hour rior to the incision. The abdominal skin was reared with ovidone iodine in the oerating room after giving anesthesia. Incision time was calculated from the start of skin incision until Analysis and statistical methods All the data was recorded and analyzed for categorical and continuous variables such as age, sex, indications, incisional time, blood loss during incision making, ostoerative ain and wound comlications for both methods of skin incision. Data was entered into Microsoft excel data sheet and analyzed using SPSS 22 version software. Categorical data was reresented in the form of frequencies and roortions. Chi square test was used as test of significance for qualitative data. International Surgery Journal Setember 2018 Vol 5 Issue 9 Page 3125

3 Continuous data was reresented as mean and standard deviation. Indeendent t test was used as test of significance to identify the mean difference between two quantitative variables. A and B were in the age grou 51 to 60 i.e. 31% and 23.8% resectively. There was no significant difference in age distribution between two grous ( = 0.372). Table 2: Age distribution of subjects in both the grous. Figure 3: Postoerative scar in a atient with scalel incision (A) and electrocautery incision (B). Note there is no significant difference in terms of ostoerative scar. P value (robability that the result is true) of <0.05 was considered as statistically significant after assuming all the rules of statistical tests. Statistical software: MS Excel, SPSS version 22 (IBM SPSS Statistics, Somers NY, USA) was used to analyze data. RESULTS Total 84 atients were enrolled in this study, 42 were included in A and other 42 in B. They underwent various elective general surgical rocedures. Indications of surgeries are as shown in Table 1. Table 1: Indications of surgery. Indications Numbers Percentage Inguinal hernia Acute aendicitis Incisional hernia Eigastric hernia Umbilical hernia Pseudocyst of ancreas Total atients 84 In the resent study majority of the atients underwent mesh reair for inguinal hernia (n = 52; 61.9%), followed by oen aendicectomy for acute aendicitis (n = 16; 19.04%), reair of incisional hernia (n = 10; 11.9%), eigastric hernia (n = 3; 3.57%) and umbilical hernia (n = 2; 2.38%). One atient underwent cystogastrostomy for seudocyst of ancreas (n=1; 1.19%). In the study mean age of subjects in A was 46.7±18.3 (mean±sd) and in B was 50.4±16.0 (mean ± SD). Majority of subjects in A B < to to Age 41 to to to > Total Mean ± SD 46.7± ±16.0 χ 2 = 6.48; df = 6; = 0.372; SD = Standard Deviation Table 3: gender distribution of subjects in both the grous. A B Female Sex Male Total χ 2 = 0.283; df = 1; = Table 4: Outcome arameters comarison between two grous. A B value Mean SD Mean SD Time taken for incision (s) <0.001* Length of incision (cm) Blood loss (ml) * SD: standard deviation; <.05 considered statistically significant As seen in Table 3, majority of atients in both the grous were males (81% and 76.2% in A and B resectively). There was no significant difference in terms of gender distribution in both the grous There was statistically significant increase in the mean time taken for incision in A when comared with B (36.8±8.8 and 27.0±10.1 resectively; <.001). International Surgery Journal Setember 2018 Vol 5 Issue 9 Page 3126

4 Similarly, mean blood loss was statistically higher in A when comared with B (3.4±1.5 ml and 2.6±1.5 ml resectively; =.021). There was however no statistically significant difference between mean length of incision in A and B (7±2 cm and 6.9±2.9 cm resectively; =.811). Table 5: Pain score comarison between two grous at different ostoerative eriod. A B value Day Day * Day P<.05 considered statistically significant At Day 0, 100% of subjects in both the grous had grade 2 ain. On Day 1, in A, 100% of them had Grade 1 ain score, were as in B, 88.1% had Grade 1 and 11.9% had grade 0 ain score. This difference in ain score between two grous on day 1 was statistically significant. On Day 2, 100% of them had ain score of 0. Table 6: Wound characteristics comarison between two grous at different ostoerative eriod. A B valu e G0 Absent Present G1 Absent Present G2 Absent Present G3 Absent Present P<.05 considered statistically significant Table7: Comlications comarison between two grous at different ostoerative eriod. A B Primary Absent intension Present Delayed Absent healing Present value In the study there was no significant difference in wound characteristics between two grous at G0, G1, G2 and G3. In A, rimary intension was absent in 2.4% and delayed healing was resent in 2.4%. In B, rimary intension was absent in 4.8% and delayed healing was resent in 2.4%. There was no significant difference in comlications between two grous in rimary intension and delayed healing. DISCUSSION Several studies have shown that diathermy is increasingly being used for making skin incisions, and dissecting tissue lanes. It facilitates hemostasis, reduces overall intra-oerative time and shows similar wound healing as scalel incision. 4,5 In recent after introduction of advanced electrocautery units (ure sinusoidal current), there is an increasing trend in the use of cautery for making skin incision. Studies have shown that when comared with scalels, use of electrocautery results in reduced oerating time, minimum blood loss and early ain reduction and fewer analgesics in ostoerative eriod. In our study, use of electrocautery resulted in significantly reduced mean incision time (27±10.1 s vs 38.8±8.8 s; <.001) and significantly lower blood loss (2.6 ml versus 3.4 ml; =.021) when comared with scalel. Present findings are comarable to findings reorted by Talur et al, who in their study reorted statistically significant reduction in mean incision time and mean blood loss with electrocautery when comared with scalel (7.3057sec/cm 2 versus sec/cm 2 and ml/cm 2 versus ml/cm 2 resectively). 6 Similarly, Ly et al in their systemic review and metaanalysis of fourteen randomized trials comrising of 2541 atients (1267 undergoing abdominal wall incision by cutting diathermy and 1274 by scalel), found that diathermy may offer significant advantages in many variables including, oerative blood loss, incision time and ostoerative ain. 7 They noticed significantly reduced amounts of blood loss (mean difference of 0.72 ml/cm2 (P<0.001) and shorter incision time (mean difference of 36 seconds; P<0.001) with diathermy incisions as comared to scalel incisions. In resent study, it was concluded that ostoerative ain is significantly less ( value 0.021) in the electrocautery grou on day 1 and it is comarable with other study conducted by Ombolaji et al. 8 Kearns also found that ostoerative ain was significantly lower in the diathermy grou for first 48 hours after oeration which is consistent with resent study. 9 There was no significant difference in ain of both grous on ost-oerative day 0 and day 2 onwards. Aird et al noted that electrocautery significantly reduced ostoerative wound ain. 10 Results of resent study are consistent with other studies by Siraj International Surgery Journal Setember 2018 Vol 5 Issue 9 Page 3127

5 et al, Gilmore et al and Shivagouda et al, which showed that elective laarotomy incisions made with electrocautery had significant benefits comared to scalel incisions in terms of reduced early ostoerative ain. 11,12,13 There was no statistically significant differences in terms of wound comlications with use of electrocautery and scalel in our study. Talur et al have also shown no statistically significant difference in wound healing with electrocautery and scalel. 6 Eren et al comared wound comlications associated with scalel and electrocautery in atients oerated for gastrointestinal malignancies with different incision methods and showed no significant statistical difference in wound infection. 14 Not a single atient in both grous develoed wound infection or dehiscence as reorted by Gilmore and their colleagues, but wound discharge was noticed in the scalel grou in four atients that were treated conservatively with daily dressing for few days. 12 CONCLUSION The use of diathermy for abdominal skin incision was associated with reduced incisional blood loss, shorter incisional time and less ost-oerative ain as comared to scalel incision. There was no difference in the wound comlications rate between the scalel and diathermy incision. We conclude that diathermy could be acceted as an alternative method for surgical skin incisions. Funding: No funding sources Conflict of interest: None declared Ethical aroval: The study was aroved by the Institutional Ethics Committee REFERENCES 1. Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalel for skin incision. Br J Surg.2012;99: Chrysos E, Athanasakis E, Antonakakis S, Xynos E, Zoras OA. Prosective study comaring diathermy and scalel incisions in tension-free inguinal herniolasty. Am J Surg. 2005;71: Kearns SR, Connolly EM, McNally S, McNamara DA, Deasy J. Randomized clinical trial of diathermy versus scalel incision in elective midline laarotomy. Br J Surg. 2001;88: Ayandio OO, Afuwae OO, Irabor D, Oluwatosin OM, Odigie V. Diathermy versus scalel incision in a heterogeneous cohort of general surgery atients in a Nigerian teaching hosital. Niger J Surg. 2015;21: Siraj A, Gilani AAS, Dar MF, Raziq S. Elective midline laarotomy: comarison of diathermy and scalel incisions. Professional Med J. 2011;18: Talur AA, Khaskheli AB. Randomized, clinical trial on diathermy and scalel incisions in elective general surgery. Iran Red Crescent Med J. 2015;17:e Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalel for skin incision. Br J Surg. 2012;99: Ayandio OO, Afuwae OO. Diathermy versus scalel incision in a heterogeneous cohort of general surgery atients in a Nigerian teaching hosital, Niger J Surg. 2015;21: Kearns SR, Connolly EM, McNally S, McNamara DA, Deasy J. Randomized clinical trial of diathermy versus scalel incision in elective midline laarotomy. Br J Surg. 2001;88: Aird LN, Brown CJ. Systematic review and metaanalysis of electrocautery versus scalel for surgical skin incisions. Am J Surg. 2012;204: Siraj A, Gilani AAS, Dar MF, Raziq S. Elective midline laarotomy: Comarison of diathermy and scalel incisions. Professional Med J. 2011;18: Gilmore M, McCabe JP, Kaar K, Curtin W. Diathermy versus scalel incisions for hemiarthrolasty: A randomized rosective trial. Bone Joint Surg Br. 2004;86: Shivagouda P, Gogeri BV, Godhi AS, Metgud SC. Comaring the efficacy of diathermy incision versus scalel incision over skin in atients undergoing inguinal hernia reair: Prosective randomized control trial. Recent Research Sci Tech. 2010;2: Eren T, Balik E, Ziyade S, Yamaner S, Akyuz A, Bugra D. Do different abdominal incision techniques lay a role in wound comlications in atients oerated on for gastrointestinal malignancies? Scalel versus electrocautery. Acta Chir Belg. 2010;110: Cite this article as: Nandurkar VS, Kumar MK, Prakash M, Suma S. Diathermy versus scalel incisions in elective abdominal surgery: a comarative study. Int Surg J 2018;5: International Surgery Journal Setember 2018 Vol 5 Issue 9 Page 3128