Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 2, 2011, pp. 216-219

Indian Journal of Cancer, Vol. 48, No. 2, April-June, 2011, pp. 216-219

Original Article

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

V Kumar, M Tewari, HS Shukla

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

Correspondence Address: H S Shukla Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005 India harishukla@usa.net

Code Number: cn11052

DOI: 10.4103/0019-509X.82904

Abstract

Keywords: Scalpel and diathermy, wound healing

Introduction

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

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 χ² 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

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].

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].

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.

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.

Discussion

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

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