Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 5  |  Page : 558-563  

A prospective study comparing diathermy and steel scalpel in abdominal incisions


1 Department of General Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, D. Y. Patil Vidyapeeth, Pimpri, Pune, India
2 Department of Obstetrics and Gynecology, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, D. Y. Patil Vidyapeeth, Pimpri, Pune, India

Date of Web Publication10-Sep-2014

Correspondence Address:
Bhupender Kadyan
Department of Surgery, Padmashree Dr. D Y Patil Medical College, Pune - 411 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.140382

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  Abstract 

Background: Diathermy is increasingly used for underlying tissue dissection, cutting, and hemostasis although fears of excessive scarring and poor wound healing have curtailed its widespread use for skin incision. Only few surgeons employ diathermy in making a skin incision with fear of producing deep burns and resultant scarring. Aims and Objectives: This prospective study was done to compare the outcome of diathermy incisions versus steel scalpel incisions in general surgery with regard to incision time, early postoperative pain, postoperative wound infection rate, and scar assessment. Materials and Methods: This study was conducted at Department of General Surgery. A total of 76 patients who underwent steel scalpel incision (group A: 38 patients) or diathermy incision (group B: 38 patients) were analyzed. Variables analyzed were incision time, early postoperative pain, post operative wound infection rate, and scar assessment. All patients aged from 15 years to 60 years who underwent elective surgery (appendectomy and cholecystectomy) were included in the study. The exclusion criteria were (1) emergency surgery, (2) surgically scarred tissues, (3) immune compromised patients, (4) pregnant patients, (5) patients with pacemaker device, (6) lost to follow up. Standard antiseptic protocol was followed for both the groups. Results: The results showed significantly less incision time as well as less pain scores associated with diathermy incisions over scalpel incisions. Incision time was significantly lower for patients in the diathermy group (P < 0.001). Early postoperative pain (VAS) was found to be markedly reduced during first 48 hours in group A (P < 0.0001). Postoperative wound infection rate (P > 0.05) was almost the same for both groups and was statistically insignificant. Conclusion: Diathermy skin incision in elective surgery has significant advantages over scalpel use as it results in less incision time, less early postoperative pain, and analgesia requirement.

Keywords: Diathermy, incision, scalpel


How to cite this article:
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

How to cite this URL:
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 [serial online] 2014 [cited 2019 Jun 20];7:558-63. Available from: http://www.mjdrdypu.org/text.asp?2014/7/5/558/140382


  Introduction Top


The high-frequency electric surgical knife is one of the common instruments in surgical operations since its inception in 1929. [1] While electrosurgical instruments are used increasingly for tissue dissection, cutting, and hemostasis, concerns about excessive scarring and poor wound healing have curtailed the widespread use of diathermy for skin incision. [2] Fear of deep burns with diathermy and resultant scarring continues compared with the scalpel, which produces a clean, incised wound with minimal tissue destruction. [3] The use of an electrode delivering a pure sinusoidal current, however, allows tissue cleavage without damage to surrounding area, thus explains the absence of tissue scarring and subsequent healing with minimal scarring. [4] Previous studies have compared diathermy and scalpel incisions in terms of incision time, blood loss, early post operative pain and post operative wound infection rates. [2],[3],[4] No single study to date has focused on diathermy incisions in elective surgical cases exclusively so as to figure out the post operative wound infection rate. This study compared diathermy and steel scalpel incision in terms of incision time, early post operative pain and post operative wound infection rate and scar character.


  Aims and Objectives Top


This prospective study was done to compare the outcome of diathermy incisions versus steel scalpel incisions in general surgery with regard to

  1. Incision time,
  2. Early post operative pain,
  3. Post operative wound infection rate,
  4. Scar character.



  Material and Methods Top


This was a prospective, comparative study carried out in Department of Surgery. First case was allocated a group on the basis of draw and thereafter patients were divided into two groups alternatively.

A total of 76 patients were included in the study. Group I patients, n = 38, underwent operation via scalpel incision. Group II patients, n = 38, underwent operation via diathermy incision. Group I and Group II were further subdivided as A1,A2, B1 & B2 as -



The inclusion criteria were patients of both sexes, aged between 15 and 60 years who were admitted for elective surgery like appendectomy and cholecystectomy.

The exclusion criteria were:

  1. Emergency surgery,
  2. Surgically scarred tissues,
  3. Immunocompromised patients,
  4. Pregnant patients,
  5. Patients with pacemaker device,
  6. Lost to follow up.


Equal numbers of cases from both the groups were operated under the same surgical unit. Study was approved by Institutional Ethical Committee. Patients were counselled about the merits and demerits of both the incisions, and informed consent was taken from all patients for the procedure to be undertaken. All the patients were operated under general or spinal anesthesia. All patients were given intravenous antibiotic prophylactically in the form of Ceftriaxone 1 gram intravenous at the time of induction of anesthesia. Dose was repeated 12 hourly for a period of 3 days. Diclofenac 75 mg intramuscular injection was given 12-hourly for 24 hours, followed by diclofenac oral 50 mg 8-hourly for next 24 hours. The drains (if placed) were removed after discharge decreased to <10 ml per day. Subcutaneous tissue was sutured using vicryl (polyglactin 910 Suture) 2/0 and skin closure was done using ethilon 2/0. Skin sutures were removed between the sixth and tenth postoperative days, after checking the tensile strength of wound (by gradual lateral traction).

Assessment of wound infection was done by sending wound discharge for culture. Wound infection was graded according to Southampton wound scoring system: Grade I, normal healing with mild bruising or erythema; Grade II, erythema plus other signs of inflammation; Grade III, clear or serosanguinous discharge; and Grade IV, purulent discharge and Grade V, deep or serious wound infection with or without tissue breakdown. [5] Time was recorded using a second's stopwatch. The incision time was considered as the time taken from initial skin incision to complete opening of the peritoneum with total hemostasis. Pain was assessed using visual analog scale. Visual analog scale is represented by a straight line measuring 10 cm, the extremes of which corresponds to no pain at one end and worst pain at the other end.

The XCEL LANCE 350 (Mumbai, India) electrosurgical unit was used providing a maximum power of 120 watts. Current intensity in pure cutting mode for skin incision was set at reading 30. For coagulation the current intensity was set at 35. Hemostasis was performed with coagulation diathermy, and large blood vessels were suture ligated in both groups. The follow-up schedule included initially weekly follow up during the first month and then monthly follow up for 3 months and a quarterly follow up for 6 months. Scars of all the patients were assessed and documented as per POSAS (Patient and Observer Scar Assessment Scale at 6 months).

The hypothesis tested in this study was that the diathermy incisions would be better than steel scalpel incisions in terms of incision time, postoperative pain, and wound complications.

Statistical Analysis

Statistical analysis was performed by using SPSS 18. A value of P < 0.05 was considered statistically significant.


  Results Top


In our study the mean age of patients was 37 years [Table 1]. In both groups, female predominance was seen; wherein the cholecystectomy group, female predominance was almost double [Table 2]. In our study the mean body mass index of subject undergone surgery was 23.2 kg/m 2 [Table 3].

Our study shows that the majority of patients had normal hemoglobin. Mean hemoglobin was 12.0gm% [Table 4] and it was comparable in both the groups. None of the patients had haemoglobin less than 10gm%. Various risk factors were identified that attributes to delayed wound healing [Table 5]. The level of wound contamination was comparable between the two study groups in all the surgical cases [Table 6].
Table 1: Age distribution (Years)

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Table 2: Gender distribution

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Table 3: Body mass index

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Table 4: Hemoglobin [Hb% (gm/dl)]

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Table 5: Risk factors for delayed wound healing

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Table 6: Nature of cases

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The mean incision length was 10.6 cm & 10 cm in Group I and Group II respectively in cholecystectomy cases whereas it was 5.3 cm and 5.75 cm in appendectomy cases in Group I & II respectively [Table 7]. The mean length of incision was comparable in both the groups. The results showed significantly less incision time (P < 0.001), as well as less pain scores associated with diathermy incisions over scalpel incisions [Table 8].
Table 7: Length of incision (cm)

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Table 8: Incision time (minutes)

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The early postoperative pain assessment was done by VAS and the mean were taken on postoperative days 1, 2 and 3. It was found that the mean postoperative pain score was higher in the Group I [Table 9] and [Table 10] (P < 0.05). Post-operative wound infection rate (P > 0.05) was almost same for both the groups and was not statistically significant [Table 11]. It was found that the mean Manchester scar score was higher in the Group II (7.94) than in group I (8.10), and the difference was statistically insignificant [Table 11].
Table 9: Early postoperative pain (appendectomy cases)

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Table 10: Early postoperative pain (cholecystectomy cases)

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Table 11: Immediate wound assessment (ASEPSIS score)

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The diagnosis of surgical site infection was based on the ASEPSIS score. [6] The number of surgical site infection in all the surgeries was lesser in group I (13.1%) than in the group II (15.7%) with overall wound infection 14.4% [Table 12].
Table 12: Surgical site infection (SSI) based on ASEPSIS score

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Wound assessment was done using Manchester Scar Score at the time of discharge [Table 13]. The score ranges from 5 to 18, with higher the score, poorer the scar and it was found that the mean Manchester scar score was higher in the group I (8.10) than in group I (7.94).
Table 13: Assessment of scar at the time of discharge [Manchester Scar Score (Mean Score)]

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The scar assessment at 6 months was done by POSAS which has a patient assessment and observer assessment [Table 14]a and b. The POSAS (Patient Observer and Scar Assessment Scale) Patients Score was higher in Group I (higher the score poorer the scar).{Table 14}


  Discussion Top


Electrosurgery has been used extensively since its introduction in 1929, and has now become an indispensable tool in every operating room. [1] Before the advent of nonexplosive anesthetic agents, electrosurgical units had limited application other than in underwater transurethral work, minor skin procedures and neurosurgery where regional or nitrous anesthesia was appropriate. [2]

Following the introduction of halothane, electrosurgery was used to achieve hemostasis and, to a lesser extent, for cutting. Despite this, few surgeons use diathermy to incise skin. This reluctance to incise skin with diathermy is partly attributable to the belief that electrosurgical instruments increase devitalized tissue within the wound, which consequently lead to wound infection, increased scar formation and delayed wound healing. However, the development of oscillator units capable of delivering pure sinusoidal current has generated renewed interest in electrosurgery. [2]

Early studies with primitive diathermy machines suggested that electrosurgical incisions were associated with just such charring and poor wound healing. [7] Subsequent animal studies suggested increased wound infection rates but no difference in wound bursting strengths. [8],[9] It has been suggested that local tissue heating increases subcutaneous oxygen tension, thus enhancing the resistance of the surgical wounds to infection. The lower visual analogue pain scores during the first 48 hours can be explained by the fact that cell vaporization caused by the application of pure sinusoidal current leads to immediate tissue and nerve necrosis without significantly affecting nearby structures.

Other studies have demonstrated significant advantages to the use of electrosurgical incision, including shorter incision time, reduced post-operative pain and sealing of lymphatics during excision of malignant tumors. [7] Furthermore, the recent increase in blood borne diseases such as hepatitis C and human deficiency virus infection makes exclusion of the scalpel from the operating field an attractive option. [2]

Dixon et al., has shown that diathermy incision is more rapid than scalpel incision. [4] In another study by Hussain and Hussain, it was concluded that postoperative pain is significantly less following the diathermy group. [10] Kearns also found that postoperative pain was significantly lower in the diathermy group for first 48 hours after operation which is consistent with our study.

In this study, a total of 76 patients were enrolled who were allotted to either group in a randomized manner. The incisions were evaluated in terms of incision time, postoperative pain and postoperative wound infection and scar assessment. This study demonstrates that diathermy incisions were faster and were associated with significantly lower postoperative pain scores in the first 72 hrs and results are consistent with the study conducted by Shamim. [11] There was no significant difference in wound or postoperative complications between the two groups as noted by Kearns et al. [2]

Many studies have been conducted to know the impact of body mass index (BMI) on peri-operative outcomes in patients undergoing major abdominal surgery. Obesity is associated with several medical co-morbidities, including diabetes, hypertension, and coronary artery disease. In addition, increased BMI (obesity) have a reduced overall life expectancy, with a two- to threefold increased risk of death from all causes during middle age. It has been observed that the incidence of surgical wound infection increases steadily with increasing BMI. The presence of excessive subcutaneous fat, with its relatively low blood perfusion and oxygen tension, in obese patients may predispose them to impaired wound healing, thus leading to wound infections. In addition, obese patients have a higher incidence of insulin resistance and poor glycemic control, which is known to increase the risk of postoperative wound infections. [12]

Many studies have reported that anemia leads to defective and delayed healing. Parmar et al. in their published study showed that the majority of patients had anemia as a preoperative predisposing factor. [13]

William et al. have studied the outcomes of patients undergoing major abdominal and neck surgeries and documented a morbidity rate ranging from 5% to 57% and a mortality rate ranging from 1.6% to 14%. Smoking, diabetes mellitus and hypertension were independent predictors of wound infections and mean increased length of hospital stay was 4 days in all the groups. [14]

However, in a study conducted by Mclean et al., it was shown that organisms can be cultured from most of the wounds in both of their study groups at the end of the operation. [15] The incidence of wound infection depends on the type of surgery. [16]

Kearns et al concluded that the use of diathermy for skin incision is associated with lesser early postoperative pain and less analgesia requirement. [2] Ahmad et al. also noted similar findings that postoperative pain was significantly less with diathermy incisions in first 24 hours. [17] Similar findings were noted by Siraj et al., in 2011, and reported that incision time in the diathermy group is significantly less than in the steel scalpel group. [18]

The assessment of the wound in the immediate postoperative period was assessed by the ASEPSIS wound score. The criteria used for assessment were nature of exudates, erythema and separation of deep tissues. The categories into which it is divided are satisfactory wound healing, disturbance of wound healing, minimal SSI, moderate SSI and severe SSI. [6] In our study the ASEPSIS score was suggestive of poorer outcome in the group II than in group I.

These findings are consistent with the study conducted by Siraj et al., and it was noted that the overall frequency of wound infection in his study was 5%, of which, three cases were seen in the group I and two in group II (P = 0.17). [18]

Similarly, Galal AN in 2007 noted the similar findings in 50 patients and stated that post operative complications were insignifi cant in either group. [19]

The diagnosis of surgical site infection was based on the ASEPSIS score. The number of surgical site infection in all the surgeries was lesser in the steel scalpel group (13.1%) than in the diathermy group (15.7%) with overall wound infection 14.4% [Table 12]. Groot et al. studied wound infection rate in cases of abdominal or thoracic wounds and compared the electrocautery and steel scalpel. They found that electrocautery does not increase the wound infection rate. [20] Ahmad et al. also revealed the similar findings and stated that post operative infections are comparable in diathermy and scalpel groups. [17]

Ali et al., in 2009, concluded that diathermy can safely be used to make skin incision and noted that SSI is 12.5% cases in the diathermy group whereas in the scalpel group it was 17.5% but this difference was not found to be statistically significant (P = 0.378). [21] Patil Shivagouda in his study in 2005 concluded that electrocautery can be safely used in making skin incisions as results are comparable in both groups. [22]

The assessment of wound at the time of discharge was done by Manchester Scar Score. The criteria assessed were color, nature, texture, contour and distortion. The system is applicable to a wider range of scars and well suited for postoperative scars assessment. The score ranges from 5 to 18, with higher the score, poorer the scar. [23] In the present study, it was found that the mean Manchester scar score was higher in the group II than group I, and the difference was statistically insignificant (P > 0.01).


  Conclusion Top


Diathermy incisions are equally prone to get wound infection, as do the incisions made with scalpel. Furthermore, lower incidence of early postoperative pain and a less incision time are the encouraging facts supporting routine use of diathermy for abdominal skin incisions after taking adequate precautions. Wound infection rate and scar character were insignificant among both incision techniques.

 
  References Top

1.Lawrenson KB, Stephens FO. The use of electrocuting and electrocoagulation in surgery. Aust NZ J Surg 1970;39:417-21.  Back to cited text no. 1
    
2.Kearns SR, Connoly 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.  Back to cited text no. 2
    
3.Johnson CD, Serpell JW. Wound infection after abdominal incision with scalpel or diathermy. Br J Surg 1990;77:626-7.  Back to cited text no. 3
    
4.Dixon AR, Watkin DF. Electrosurgical skin incision versus conventional scalpel: A prospective trial. J R Coll Surg Edinb 1990;35:299-301.  Back to cited text no. 4
    
5.Petrica A, Brinzeu C, Brinzeu A, Petrica R, Ionac M. Accuracy of surgical wound infection definitions- the first step towards surveillance of surgical site infections. TMJ 2009;59:362-5.  Back to cited text no. 5
    
6.Wilson AP, Gibbons C, Reeves BC, Hodgson B, Liu M, Plummer D, et al. Surgical wound infection as a performance indicator: Agreement of common definitions of wound infection in 4773 patients. BMJ 2004;25:720-4.  Back to cited text no. 6
    
7.Glover JL, Bendick PJ, Link WJ. The use of thermal knives in surgery: Electrosurgery, lasers, plasma scalpel. Curr Probl Surg 1978;15:1-78.  Back to cited text no. 7
    
8.Arnaud JP, Adloff M. Electrosurgery and wound healing: An experimental study in rats. Eur Surg Res 1980;12:439-43.  Back to cited text no. 8
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9.Hall RR. The healing of tissues incised by a carbon- dioxide laser. Br J Surg 1971;58:222-5.  Back to cited text no. 9
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10.Hussain SA, Hussain S. Incision with knife or diathermy and postoperative pain. Br J Surg 1988;75:1179-80.  Back to cited text no. 10
    
11.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. 11
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12.Adams KF, Schatzkin A, Harris TB, Kipnis V, Mouw T, Ballard-Barbash R, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 2006;355:763-78.  Back to cited text no. 12
    
13.Parmar G, Gohil A, Hathila VP. Burst abdomen - A grave postoperative complication. The Internet Journal of Surgery 2009;20(1).  Back to cited text no. 13
    
14.Henderson WG, Khuri SF, Mosca C, Fink AS, Hutter MM, Neumayer LA. Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: General surgical operations in men. J Am Coll Surg 2007;204:1103-14.  Back to cited text no. 14
    
15.McLean N, Mackinlay J. Op-site as a postoperative dressing in general surgery. Br J Clin Pract 1981;35:356-8.  Back to cited text no. 15
    
16.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.  Back to cited text no. 16
    
17.Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011;253:8-13.  Back to cited text no. 17
    
18.Siraj A, Dar MF, Gilani AAS, Raziq S. Elective midline laparotomy: Comparison of diathermy and scalpel incision. Prof Med J 2011;18:106-11.  Back to cited text no. 18
    
19.Abul Nagah G, Tarek EF, Lotfy H, Shehab W, Tarek A. Comparative study between using harmonic scalpel and electrocautery in modified radical mastectomy. Egyptian Journal of Surgery 2007;26:176-80.  Back to cited text no. 19
    
20.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. 20
    
21.Ali Q, Siddique K, Mirza S, Malik AZ. Comparison of superficial surgical site infection following use of diathermy and scalpel for making skin incision in inguinal hernioplasty. Niger J Clin Pract 2009;12:371-4.  Back to cited text no. 21
[PUBMED]    
22.Patil S, Gogeri BV, Goudhi AS, Metgud SC. Prospective randomized controlled trial comparing the efficacy of diathermy incision versus scalpel incision over skin in patients undergoing inguinal hernia repair. Rec Res Sci Tech 2010;2:44-7.  Back to cited text no. 22
    
23.Fearmonti R, Bond J, Erdmann D, Levinson H. A review of scar scales and scar measuring devices. Open Access J Plast Surg 2010;10:354-63.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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  In this article
Abstract
Introduction
Aims and Objectives
Material and Methods
Results
Discussion
Conclusion
References
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