|Year : 2018 | Volume
| Issue : 2 | Page : 55-59
Electrosurgery versus steel scalpel for elective surgery: A prospective study
Sangameshwar Annarao Patil1, Ravindra Devani2, Veerabhadra Radhakrishna3, Madhu Patil4
1 Department of General Surgery, Basaveshwar Hospital, Gulbarga, Karnataka, India
2 Department of General Surgery, KBN Hospital, Gulbarga, Karnatak, India
3 Department of Paediatric Surgery, Manipal Hospital, Bengaluru, Karnataka, India
4 Department of Obstetrics and Gynaecology, Azeezia Medical College, Kollam, Kerala, India
|Date of Web Publication||29-May-2018|
Dr. Veerabhadra Radhakrishna
Department of Paediatric Surgery, Manipal Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: The use of electrocautery in incising the skin was hypothesized to be questionable. It is believed to cause deep burns, excessive scarring and poor wound healing. However, many of the recent studies show that the electrosurgery has advantages of faster dissection, quicker hemostasis, reduced blood loss, and reduced operative time. Most of these studies included a homogeneous group of surgeries. Hence, a study was conducted to assess whether the electrosurgery can be used to incise skin.
Materials and Methods: A prospective nonrandomized study was conducted in a tertiary center from December 2009 to May 2011. Patients were divided into electrosurgery and skin scalpel groups. Moreover, these were compared regard to duration of the incision, blood loss, operative and postoperative complications, and postoperative pain using visual analog scale.
Results: A total of 60 patients were studied. Electrosurgery group and steel scalpel group both had 30 patients (50%) each in their group. The electrosurgery group had a significantly low blood loss (18.1 g ± 16.1 g vs. 35.8 g ± 16.9 g; t = 4.1; P = 0.0001) and lesser incision time (4.7 min ± 1.9 min vs. 6.6 min ± 3.1 min; t = 2.8; P = 0.006; Student's t-test) compared to steel scalpel group. Electrosurgery group also had a significantly lesser postoperative pain score at 6 h, 12 h, and 24 h. There was no statistical significance found between the groups regard to wound infection (P = 1; Fischer's exact test).
Conclusion: Electrosurgery was superior to steel scalpel for incising skin, hence, can be used a primary choice to incise the skin.
Keywords: Electrocautery, electrosurgery, postoperative pain, skin incision, steel scalpel, surgical blood loss
|How to cite this article:|
Patil SA, Devani R, Radhakrishna V, Patil M. Electrosurgery versus steel scalpel for elective surgery: A prospective study. Saudi Surg J 2018;6:55-9
|How to cite this URL:|
Patil SA, Devani R, Radhakrishna V, Patil M. Electrosurgery versus steel scalpel for elective surgery: A prospective study. Saudi Surg J [serial online] 2018 [cited 2018 Oct 15];6:55-9. Available from: http://www.saudisurgj.org/text.asp?2018/6/2/55/233494
| Introduction|| |
It has been a century since the electrosurgery was introduced, but it is used mostly for hemostasis and dissection. The use of electrocautery to incise the skin has been avoided as it is believed to cause deep burns, excessive scarring, and poor wound healing. Although the modern electrosurgical units have evolved to prove this wrong, a few recent studies have found increased scarring and impaired healing with diathermy use. On the other hand, many studies show that the electrosurgery has advantages of faster dissection, quicker hemostasis, reduced blood loss, and reduced operative time., The studies that have been published to date have included a homogeneous group of surgeries. Hence, a study was undertaken to compare the electrosurgery and steel scalpel with regards to incision time, blood loss, postoperative pain, and wound infection rate in a heterogeneous group of surgeries.
| Materials and Methods|| |
A prospective study was conducted in the Department of General Surgery in a tertiary center for 18 months, from December 2009 to May 2011.
Inclusion and exclusion criteria
A total of 60 patients were studied. Patients requiring a flank, midline, or a Kocher's incision were included in the study. Patients on anticoagulant therapy, requiring incisions over previous scars, pregnant women and requiring emergency surgeries were excluded from the study.
The study was started after approval from “Institute Ethics Committee (Human studies).” The trial was registered in Clinical Trials Registry - India with registration number CTRI/2017/08/009446. The patients presenting to the department of general surgery were recruited based on the selection criteria. A written informed consent was obtained from the patient for the study. After preliminary investigations, confirmation of diagnosis and preanesthetic check-up, patients were taken up for the required surgery.
Two techniques, incision by steel scalpel and incision by electrosurgery were performed in all the types of surgeries. Patients were allocated to either steel scalpel or electrosurgery group by consecutive, nonrandomized technique. The study participants were blinded during the study. All surgeries were done in a single surgical unit under controlled conditions. All patients received 1g intravenous ceftriaxone as prophylaxis at the time of anesthetic induction.
No suction was used during the incision. Blood loss was calculated by weighing the sterile surgical mops used exclusively for the incision pre- and post-operatively in a sterile weighing scale with 2 g of precision. Time was recorded using a stopwatch. Incision time was defined as the time taken from the beginning of skin incision till the complete opening of peritoneum with thorough hemostasis. A sterile metallic scale was used to measure the depth of the wound. Incision length was recorded at the end of the skin closure using a sterile metallic scale.
Surgical site infection (SSI) was defined as per center for disease control guidelines. Infection occurring in an operative site within 90 days after the surgery having one of the following criteria was considered as SSI:
- A purulent drainage from the incision
- Aseptically obtained a culture from the incision showed growth of a microorganism
- The incision was dehisced or deliberately opened by the surgeon or attending physician or other designee and was culture positive or not cultured and the patient had at least one of the following symptoms or signs: erythema; localized swelling; pain or tenderness; or heat.
The pain was assessed using visual analog scale. The continuum of pain was represented by a straight line, with no pain at one end and intolerable pain at the other end. The length of the line was 10 cm. All patients received intramuscular diclofenac as analgesic every 8 h.
The Martin ME 400 electrosurgical unit was used providing a maximum power of 120 watts. The current intensity for cutting was in the range of 3–5, and for coagulation, it was 3–5. Diathermy incisions were feted with a small flat blade pen electrode at cutting mode by delivering 120-watt sinusoidal current. Hemostasis was controlled by coagulation current applied to a hemostat accurately placed on the vessel to avoid skin necrosis and blistering. Scalpel incisions were made by a steel scalpel with hemostasis by means of forceps coagulation using Martin ME 400 electrosurgical generator with a maximum power of 120 watts in pulsed sine waves.
Descriptive statistics were expressed as mean ± standard deviation and percentage. The difference between the two groups, electrocautery and steel scalpel, were assessed using Mann–Whitney U-test (Postoperative pain score), Student's t-test (blood loss and incision time) and Chi-square test (age and gender distribution) or Fischer's exact test (Wound infection). P < 0.05 was considered statistically significant.
| Results|| |
A total of 60 patients were studied. Electrosurgery group and steel scalpel group both had thirty patients (50%) each in their group [Figure 1]. The youngest patient in the study group was a 15 years boy while the oldest patient was a 70-year-old man. Of 60 patients enrolled in the study, 24 patients (40%) were males while the remaining 36 patients (60%) were females.
There was no statistical significance in the mean age (electrosurgery [40.3 years ± 14.3 years] versus steel scalpel [41.2 years ± 15.4 years]; t = 0.3; P = 0.8) and gender distribution between the electrosurgery and steel scalpel group (electrosurgery [males = 9 and females = 21]; steel scalpel [males = 15 and females = 15]; χ2 = 2.5; df = 1; P = 0.1).
All surgeries (n = 60)
A total of 60 patients were included in the study with 30 patients in each group. The electrosurgery group had a significantly low blood loss (18.1 g ± 16.1 g vs. 35.8 g ± 16.9 g; t = 4.1; P = 0.0001) and lesser incision time (4.7 min ± 1.9 min vs. 6.6 min ± 3.1 min; t = 2.8; P = 0.006) compared to steel scalpel group. Electrosurgery group also had a significantly lesser postoperative pain score at 6 h, 12 h, and 24 h [Table 1]. There were two cases of wound infection noted in electrosurgery group while steel scalpel group had three cases of wound infection, but there was no statistical significance found between the groups (P = 1; Fischer's exact test) [Table 1].
|Table 1: Electrosurgery versus steel scalpel for all types of incisions (n=60)|
Click here to view
Flank incision (n = 16)
A total of 16 patients underwent flank incision with eight patients in each group. The electrosurgery group had a significantly lesser blood loss (32.8 g ± 14.6 g vs. 50.8 g ± 6.7 g; t = 3; P = 0.01) and lesser incision time (7 min ± 0.9 min vs. 9.6 min ± 2.3 min; t = 2.7; P = 0.02) compared to steel scalpel group. Electrosurgery group also had a significantly lesser postoperative pain score at 6 h, 12 h, and 24 h [Table 2]. There was no wound infection in either of the groups [Table 2].
Kocher's incision (n = 30)
A total of 30 patients underwent Kocher's incision with fifteen patients in each group. The electrosurgery group had a significantly lesser blood loss (14.9 g ± 14.7 g vs. 33.4 g ± 13.6 g; t = 3.5; P = 0.002) and lesser incision time (4.2 min ± 1.3 min vs. 6.2 min ± 2.5 min; t = 2.6; P = 0.02) compared to steel scalpel group. Electrosurgery group also had a significantly lesser postoperative pain score at 6 h, 12 h, and 24 h [Table 3]. There was one wound infection noted in electrosurgery group while the steel scalpel group had two wound infections, but there was no statistical significance found between the groups (P = 1; Fischer's exact test).
|Table 3: Electrosurgery versus steel scalpel in Kocher's incision (n=30)|
Click here to view
Midline laparotomy incision (n = 14)
A total of 14 patients underwent midline laparotomy incision with seven patients in each group. The electrosurgery group had a significantly lesser blood loss (8.3 g ± 6.7 g vs. 23.7 g ± 18.8 g; t = 1.9; P = 0.08) and a lesser postoperative pain score at 6 h, 12 h, and 24 h [Table 4]. However, there was no statistically significant difference was found between the electrosurgery group and steel scalpel group in terms of incision time (2.9 min ± 1.2 min vs. 4 min ± 1.9 min; t = 1.2; P = 0.3). There was one case of wound infection in either of the groups with no statistical significance between them (P = 1; Fischer's exact test) [Table 4].
|Table 4: Electrosurgery versus steel scalpel in midline laparotomy incision (n=14)|
Click here to view
| Discussion|| |
The scalpel is used for surgical incision since ancient Egyptian empire. However, these incisions are bloody and painful. To overcome such problems, electrosurgical instruments were introduced in the field of surgery in 1920s.
In electrosurgery, an electric current is applied to the tissues via an electrode which dehydrates, coagulates, and cuts the tissue. During the process of dehydration (white coagulation), the superficial cells dry out and shrink, small blood vessels, and capillaries get sealed, thus provides hemostasis. During the process of electrocoagulation (black coagulation), the cells burn leaving behind a homogeneous granular debris. The coagulation is achieved by intermittent short bursts of current at lower temperatures which desiccates cells. A rapid destruction of a thin line of tissue leads to cutting effect. During cutting, heat is dissipated into steam and not conducted through the adjacent tissues.,
Many surgeons do not use electrosurgery to incise the skin for the fear of excessive scarring, deep burns, and poor wound healing. Early studies with electrosurgery supported this belief. However, the newer electrosurgery with oscillator units which deliver pure sinusoidal currents has renewed the interest in their use. A few animal studies documented increased wound infection rates with diathermy use. However, Johnson and Serpell concluded that there was no difference between electrosurgery and scalpel in terms of wound infection. However, the electrosurgery was not used for all the layers of the incision. Recent studies found that the electrosurgery is known to have better and quicker hemostasis, good tissue dissection, prevention of accidental injury to the operating surgeon or assistants and prevention of tumor metastasis through lymphatic channels.
Our study included 60 patients with 30 patients in each group. Both groups did not differ in terms of age and gender distribution. Our study found that the blood loss was low in electrosurgery group compared to steel scalpel group which was statistically highly significant (18.1 g ± 16.1 g vs. 35.8 g ± 16.9 g; t = 4.1; P = 0.0001). This finding was consistent with Kearns et al. The electrosurgery units coagulate all the cut edges and seals bleeding capillaries. Hence, prevents blood loss.
Dixon et al. found incision by electrosurgery was quicker than steel scalpel  and our study demonstrated the same (4.7 min ± 1.9 min vs. 6.6 min ± 3.1 min; t = 2.8; P = 0.006). We found that the postoperative pain score was significantly less in electrosurgery group at 6 h, 12 h as well as 24 h which was consistent with Kearns et al., Ayandipo et al., Kumar et al., and Hussain et al. There was no significant difference between electrosurgery and steel scalpel groups in terms of wound infection. This finding was consistent with Kearns et al., Ayandipo et al., and Kumar et al. In steel scalpel incisions, there was an extra time needed to coagulate bleeders, which was avoided in electrosurgery incisions. Hence, the incision by electrosurgery was quicker.
Electrosurgery group had a significantly lesser postoperative pain score at 6 h, 12 h, and 24 h [Table 3]. The nerve endings get exposed through steel scalpel incisions. But, in electrosurgery, the thermal effect of diathermy disrupts the transmission of nerve impulses. The cell vaporization effect of pure sinusoidal current causes immediate tissue and nerve necrosis without any effect on the adjoining structures. These were the reasons why electrosurgery incisions were less painful compared to steel scalpel incisions.
We found no difference in the wound infection rates. Moreover, similar findings were found in most of the other studies such as Ozgün et al. and Ayandipo et al. The wound infection is directly proportional to the amount of contamination and does not depend on the method of skin incision.
Our study is unique compared to other studies as we have included a heterogeneous group of surgeries.
| Conclusion|| |
The incision by electrosurgery is superior in terms of blood loss, incision time, and postoperative pain than incision by steel scalpel. The wound infection rate in incision by electrosurgery is comparable to the incision by steel scalpel. Hence, the electrosurgery can be used as a primary choice for skin incision.
We would like to acknowledge the help of residents and teachers in the Department of General Surgery in conducting the study and managing the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Memon MA. Surgical diathermy. Br J Hosp Med 1994;52:403-8.
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.
Ozgün H, Tuncyurek P, Boylu S, Erpek H, Yenisey C, Köse H, et al.
The right method for midline laparotomy: What is the best choice for wound healing? Acta Chir Belg 2007;107:682-6.
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]
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for disease control and prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control 1999;27:97-132.
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S240-52.
Conolly WB, Hunt TK, Dunphy JE. The place of electrosurgery in abdominal operations. Am J Surg 1969;118:422-6.
Rappaport WD, Hunter GC, Allen R, Lick S, Halldorsson A, Chvapil T, et al.
Effect of electrocautery on wound healing in midline laparotomy incisions. Am J Surg 1990;160:618-20.
Glover JL, Bendick PJ, Link WJ. The use of thermal knives in surgery: Electrosurgery, lasers, plasma scalpel. Curr Probl Surg 1978;15:1-78.
Johnson CD, Serpell JW. Wound infection after abdominal incision with scalpel or diathermy. Br J Surg 1990;77:626-7.
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]
Dixon AR, Watkin DF. Electrosurgical skin incision versus conventional scalpel: A prospective trial. J R Coll Surg Edinb 1990;35:299-301.
Hussain SA, Hussain S. Incisions with knife or diathermy and postoperative pain. Br J Surg 1988;75:1179-80.
[Table 1], [Table 2], [Table 3], [Table 4]