Cutting Diathermy and Scalpel for Skin Incisions - Term Paper Example

Introduction

In the early 1900s, eccentric inventor known as Dr William Bovie developed Electrosurgery and applied by Harvey Cushing in 1961for the first time in clinical surgery. Since then, it has become an evolving and integral branch of surgical practice1.A practice that is common to the majority of surgeons is making skin incisions using a scalpel and dividing the deeper tissues using coagulation diathermy. Cutting diathermy incises skin with little charring and necrosis contrasted with coagulation diathermy, which its rate of generating heat is slower through an interrupted current output.

Using thermal energy, of whichever type is greating a lot of concern regarding impaired wound healing, collateral heat damage and a probable increased risk of wound infection secondary to necrosis at the wound edges. In rats, early experimental studies presented some evidence that prop up these matters 2–5. Clinical data are however insufficient that validates this belief. An earlier meta-analysis did not find any difference in the rate complications of wound between scalpel and cutting diathermy, and the former also leading to improved postoperative pain scores 6, less blood loss and shorter incision times. This study however incorporated non-randomized data and was only limited to incisions of abdomen. Furthermore, since its publication, four further randomized clinical trials have been in print on this subject7–10.

The rationale behind the present meta-analysis was to evaluate cutting diathermy and scalpel for skin incisions from the entire operations with the use of randomized data completely, with the primary endpoints below: postoperative pain, incision time, wound complication rate and incision-related blood loss.

Methods

A systematic and comprehensive search in accordance with the PRISMA, which stands for Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was carried out for pertinent randomized clinical trials circulated from January 1980 until June 2011. The following were the sources: the Cochrane Library, MEDLINE and PubMed. The search was not limited to language and mingled the following terms: incision, electrocautery diathermy and scalpel. Reference lists of articles that were published were also investigated to make sure that all possible studies are included.

Inclusion criteria

In this meta-analysis, randomized clinical studies that contrsted scalpel for skin incisions with cutting diathermy were fitting for inclusion. These were not restricted to any specific surgical subspecialty and consequently integrated all operation types. Studies that did not account for the primary results were not included. There was evaluation of studies for quality with the use of the Jadad scoring system for restricted experiments that were random. The extraction of data was by two independent investigators from a predefined pro forma. The main outcomes were incision time, postoperative pain wound complication rate and incision-related blood loss.

Definitions

The description of a scalpel incision against a cut-ting diathermy incision was taken as illustrated by the individual studies. Generally, a scalpel incision was defined as an incision that is via the fascia, skin and subcutaneous tissue using a scalpel. A cut-ting diathermy incision entailed either an inci-sion made with the use of cutting diathermy only to cut into the skin via the fascia or scoring the skin (epidermis not distinguished) using a scalpel prior to going on via the succeeding layers and the fascia using cutting diathermy. For scalpel and cutting diathermy incisions, coagulation diathermy was only applied for haemostasis, apart from two studies whereby coagulation diathermy was aplied in incising fascia and the subcutaneous tissue in the diathermy group.

Postoperative wound complications entailed all reported wound complications, no matter how major or minor; these entailed dehiscence, seroma, haematoma and infection. Incision time entailed achieve haemostasis and the time taken in making the skin incision. Blood loss was determined by weighing the swabs applied during the incision time until the achievement of haemostasis. Scores of pain were gauged with the use of verbal or visual analogue pain scales with rankings out of 10, derived from the first 24 h subsequent to surgery.

Statistical analysis

Review Manager Version 5.0.23 (Revman; Copenhagen, Cochrane Collaboration and Denmark) were applied in production of all forest plots and statistical computations. Where studies reported median and range rather than variance and mean, their variance and mean was computed basing on the techniques illustrated in Hozo and colleagues.

Odds ratios having 95% confidence intervals (c.i.) were computed for dichotomous variables with the use of a replica that is fixed-effects and the Mantel – Haenszel techniue. Differences of weighted mean that have 95% c.i. were computed for continuous variables, with the use of an inverse variance technique and a random-effects replica. P < 0·050 was taken to be statistically pertinent for heterogeneity measures and result.

Results

From the initial search, 61 studies were discovered, whereby 14 randomized clinical trials qualified the inclusion standard in the meta-analysis7 – 10, 13 – 15, 17 – 23. 47 studies were not included for reasons illustrated in Fig. 1.

In Table 1, the characteristics of all incorporated studies are summa-rized as well as a quality assessment with the use of the Jadad score12. 11 studies entailed a permutation of universal surgical operations7,9,10,13 – 15,17 – 20,22. a study compared results after hysterectomy21. Another one examined the results subsequent to hemiarthroplasty for hip fracture23, and another study accounted for results subsequent to neck incision8. Outcome data for 2541 patients were incorporated and 1274 patients going through skin incision by scalpel and 1267 by cutting diathermy. The median length of follow-up across all studies was 6 weeks varying from 4 days to 19 months.

Wound complications

Postoperative wound complications were described in 11 studies whereby (1105 patients in the scalpel group and 1097 in the cutting diathermy group) 7, 9, 10, 13 – 15,18,19,21 – 23. The pace of postoperative wound impediments was no dissimilar cutting diathermy against scapel for skin opening.

Fig. 1 PRISMA diagram that illustrate selection of articles for inclusion in review

Table 1 Included studies

No. of

Jadad

Reference

Year

patients

Diathermy

Scalpel

Type of incision/procedure

score

Hussain and Hussain17

1988

200

100

100

Abdominal

2

Dixon and Watkin18

1990

84

42

42

Abdominal

1

Johnson and Serpell19

1990

240

110

130

Abdominal

1

Pearlman et al.13

1991

59

28

31

Abdominal

3

Telfer et al.20

1993

101

51

50

Abdominal

2

Hemsell et al.21

1993

380

189

191

Abdominal gynaecological

2

Groot and Chapell15

1994

492

242

250

Abdominal/thoracic

3

Kearns et al.22

2001

100

50

50

Abdominal

3

Byrne et al.23

2007

100

50

50

Hemiarthroplasty

2

Shamim14

2009

369

185

184

Abdominal

5

Chau et al.8

2009

38

19

19

Neck

5

Eren et al.7

2010

218

121

97

Abdominal

2

Shivagouda et al.9

2010

60

30

30

Abdominal

3

Siraj et al.10

2011

100

50

50

Abdominal

2

Total

2541

1267

1274

Incision time

Incision times were described in 8 studies, whereby seven reported incision times notwithstanding the wound’s size (506 in the scalpel group and 485 in the cutting diathermy group) 8,13,14,18 – 20,22. Cutting diathermy in this analysis led to a statistically significant shorter incision time as compared to scalpel: mean difference 36·19 (95% c.i. 22·77 to 49·61) s (P < 0·001) (Fig. 3a). 3 studies described incision times proportional the wound’s size, and again diathermy was shown to lead to considerably faster incision times: mean difference 1·73 (0·19 to 3·27) s/cm2 (P = 0·03)10,14,22 (Fig. 3b). Significant heterogeneity was eminent for the data that relates to incision times (I2 = 92 – 99 per cent).

Wound complications

ReferenceDiathermyScalpelWeight ()Odds ratioOdds ratio

Byrne et al.23

2 of 50

4 of 50

3·4

0·48 (0·08, 2·74)

Dixon and Watkin18 (hernia repair)

0 of 30

2 of 30

2·2

0·19 (0·01, 4·06)

Dixon and Watkin18 (cholecystectomy)

1 of 12

2 of 12

1·6

0·45 (0·04, 5·81)

Eren et al.7

15 of 121

5 of 97

4·3

2·60 (0·91, 7·44)

Groot and Chappell15

30 of 242

38 of 250

28·8

0·79 (0·47, 1·32)

Hemsell et al.21

9 of 189

6 of 191

5·0

1·54 (0·54, 4·42)

Johnson and Serpell19

18 of 110

26 of 130

17·5

0·78 (0·40, 1·52)

Kearns et al.22

3 of 50

3 of 50

2·5

1·00 (0·19, 5·21)

Pearlman et al.13

2 of 28

0 of 31

0·4

5·94 (0·27, 129·32)

Shamim14

25 of 185

29 of 184

22·1

0·84 (0·47, 1·49)

Shivagouda et al.9

14 of 30

21 of 30

9·8

0·38 (0·13, 1·08)

Siraj et al.10

2 of 50

3 of 50

2·5

0·65 (0·10, 4·09)

Total

121 of 1097

139 of 1105

100·0

0·87 (0·66, 1·13)

Heterogeneity: χ2  11·26, 11 d.f., P  0·42, I 2  2

Test for overall effect: Z  1·05, P  0·29

0·01

0·1

1

10

100

Favours diathermy

Favours scalpel

Fig. 2 Forest plot that compares postoperative wound complication rates after procedures having scalpel incisions against cutting diathermy. A Mantel – Haenszel fixed-effects model was applied. Odds ratios are revealed with 95% intervals of confidence

Diathermy

Scalpel

Incision time

Incision time

Weight

Reference

(s)∗

n

(s)∗

n

()

Mean difference

Mean difference

Chau et al.8

210·33(68·62)

19

239·06(82·99)

19

5·5

−28·73 (−77·15, 19·69)

Dixon and Watkin18

90(22)

30

126(25)

30

16·7

−36·00 (−47·92, −24·08)

(hernia repair)

Dixon and Watkin18

260(43)

12

412(51)

12

7·6

−152·00 (−189·74, −114·26)

(cholecystectomy)

Johnson and Serpell19

196·5(26)

110

214·5(29·6)

130

18·3

−18·00 (−25·04, −10·96)

Kearns et al.22

469(21)

50

509(25)

50

17·7

−40·00 (−49·05, −30·95)

Pearlman et al.13

420(180)

28

540(300)

31

1·1

−120·00 (−244·89, 4·89)

Shamim14

87·5(3·9)

185

104·3(3·4)

184

19·2

−16·80 (−17·55, −16·05)

Telfer et al.20

330(38·7)

51

345(57·6)

50

13·8

−15·00 (−34·18, 4·18)

Total

485

506

100·0

−36·19 (−49·61, −22·77)

Heterogeneity: τ2  243·60; χ2  86·89, 7 d.f., P  0·001, I 2  92

−200

−100

0

100

200

Test for overall effect: Z  5·28, P  0·001

Favours diathermy

Favours scalpel

a Incision time

Diathermy

Scalpel

Incision time

Incision time

Weight

Reference

(s/cm2)∗

n

(s/cm2)∗

n

()

Mean difference

Mean difference

Kearns et al.22

6·1(0·4)

50

7·5(0·5)

50

33·5

−1·40 (−1·58, −1·22)

Shamim14

6·25(0·51)

185

9·47(0·84)

184

33·5

−3·22 (−3·37, −3·08)

Siraj et al.10

6·2(0·97)

50

6·76(0·84)

50

33·0

−0·56 (−0·92, −0·20)

Total

285

284

100·0

−1·73 (−3·27, −0·19)

Heterogeneity: τ2  1·84; χ2  352·32, 2 d.f., P  0·001, I 2  99

−4

−2

0

2

4

Test for overall effect: Z  2·21, P  0·03

Favours diathermy

Favours scalpel

b Incision time relative to wound size

Fig. 3 Forest plot that compares a incision times and b incision times proportional to the size of the wound for procedures that have scalpel incisions against cutting diathermy. An inverse variance random-effects model was applied. *Values are mean (s.d.). Mean differences are revealed with

95% confidence intervals

Cutting diathermy versus scalpel for skin incision

617

Diathermy

Scalpel

Blood loss

Blood loss

Weight

Reference

(ml/cm)∗

n

(ml/cm)∗

n

()

Mean difference

Mean difference

Byrne et al.23

0·64(0·01)

50

1·75(0·1)

50

25·2

−1·11 (−1·14, −1·08)

Kearns et al.22

0·8(0·1)

50

1·7(0·3)

50

24·7

−0·90 (−0·99, −0·81)

Shamim14

0·99(0·078)

185

1·75(0·067)

184

25·3

−0·76 (−0·77, −0·75)

Siraj et al.10

1·43(0·201)

50

1·53(0·201)

50

24·8

−0·10 (−0·18, −0·02)

Total

335

334

100·0

−0·72 (−1·01, −0·43)

Heterogeneity: τ2  0·08; χ2  803·15, 3 d.f., P  0·001, I 2  100

−1

−0·5

0

0.5

1

Test for overall effect: Z  4·93, P  0·001

Favours diathermy

Favours scalpel

Fig. 4 Forest plot that compares blood loss for procedures having scalpel incisions against cutting diathermy. An inverse variance random-effects model was applied. *Values are mean (s.d.). Mean differences are shown with 95% confidence intervals

Diathermy

Scalpel

Reference

Pain score∗

n

Pain score∗

n

Weight ()

Mean difference

Mean difference

Hussain and Hussain17

4·35(2·02)

100

6·75(2·29)

100

18·8

−2·40 (−3·00, −1·80)

Kearns et al.22

2·3(0·1)

50

2·7(0·1)

50

20·6

−0·40 (−0·44, −0·36)

Shamim14

3·2(0·1)

185

5(0·1)

184

20·6

−1·80 (−1·82, −1·78)

Shivagouda et al.9

2·5(0·86)

30

2·4(0·51)

30

20·0

0·10 (−0·26, 0·46)

Telfer et al.20

6(0·57)

51

6(1·15)

50

20·0

0·00 (−0·36, 0·36)

Total

416

414

100·0

−0·89 (−1·77, −0·00)

Heterogeneity: τ2  0·99; χ2  4010·02, 4 d.f., P  0·001, I 2  100

−2

−1

0

1

2

Test for overall effect: Z  1·96, P  0·05

Favours diathermy

Favours scalpel

Fig. 5 Forest plot that compares pain scores at 24 h after procedures that have scalpel incisions against cutting diathermy. An inverse variance random-effects model was applied. *Values are mean (s.d.). Mean differences are shown with 95% confidence intervals.

Blood loss

Blood loss was described in 6 studies, whereby 4 reported blood loss proportional to the wound’s size (334 in the scalpel group and 335 in the cutting diathermy group) 10,14,22,23. Blood loss was considerably less subsequenting incisions made through the cutting of diathermy instead of a scalpel. The mean difference is 0·72 (0·43 to 1 ·01) ml/cm2 (P < 0·001) (Fig. 4). Among studies, there was considerable heterogeneity (I2 = 100 per cent). In addition, the other two studies accounted for considerable differences in absolute blood loss favouring the incisions made using cutting diathermy: 10 versus 25 ml (P < 0·001)20 and 13 versus 31 ml (P < 0·050)13.

Pain

Pain scores were described in 8 studies but five only could be integrated in the analysis, due to the differences in the way these scores were described (414 in the scalpel group and 416 in the diathermy group)9,14,17,20,22. There was no considerable difference in postoperative pain scores at 24 h between incisions made using scalpel and cutting diathermy. The mean difference 0·89 (0·00 to 1·77) (P = 0·05) (Fig. 5). There was considerable heterogeneity between studies (I2 = 100%). There was no evidence of a significant difference in pain scores10,13,18 in the rest of the three studies that studied postoperative pain.

Discussion

This meta-analysis of 14 randomized clinical trials showed that it is possible to make a skin incision more quickly through cutting of diathermy than using scalpel, without increase in the rate of postoperative pain scores or wound impediments and less blood loss. The lower blood loss and shorter incision time are most likely explicated by the fact that accomplishing haemostasis with a scalpel incision neccesssitates a number of instrument interactions with coagulation diathermy, a drawback that can be tackled with the use of cutting diathermy. Despite the fact that the reduction in blood loss may appear to be irrelevant clinically, regular instrument interactions that call for handing off the scalpel may lead to an increase in the risk of ‘sharps’ injuries to the surgeon, assistant, patient and nurse. The threat of soft tissue and skin damage, and the prospective for noteworthy expo-sure to bloodborne infections and bleeding, is well renowned. Sharps injuries have been estimated to crop up at a tempo of approximately 6·4 per 1000 surgical procedures, which likens to potentially more than a dozen times amongst the number of processes in the current meta-analysis24. Injuries due to the scalpel itself are estimated to make up 18% of all sharps injuries in the operating room, second to injuries from stitch needles which crop up at a rate of approximately 41 %. The most possibly convincing rationale behind the routine use of cutting diathermy for skin incisions is thus removing the scalpel from elimination of an essential injury source and the operating theatre.

Matters that deal with the outcome of cutting diathermy on wound healing are derived from the preceding experimental studies. These advocated that wounds that are created with diathermy have condensed tensile strength, an increased rate of infection and a greater zone of wound necrosis histologically than the ones made using a scalpel2 – 5, 25, 26. However, not all of these experimental studies differentiated between the use of coagulation diathermy and cut-ting, and the described effects seemed to be associated more to the application of coagulation diathermy4,5. Studies that particularly examined the use of cutting diathermy attained conclusions that are not consistent 5,26. Clinical studies have been carried out to examine these concerns – 29, the biggest is a potential non-randomized multicentre collaborative trial of 964 patients, in print in the year 2001; this study did not find any variation in the tempo of wound impediments between scalpel and cutting diathermy 28, as validated in the current meta-analysis. It may be that cutting diathermy produces heat so quickly that tissue vaporization takes place, against the necrosis and charring related with coagulation diathermy that may perhaps incline to wound impediments1, 3, 4.

Injuries to the in service patient and surgeon as a result of the use of diathermy have been described in about 2 for every 1000 surgical techniques1. A burn injury may crop up if the truthfulness of the gloves of the surgeon is conciliated. In addition, the patient may be burnt involuntarily through conduction with the use of the length of the diathermy tip, improper grounding and other surgical instruments. Increasing concern has also been raised about diathermy smoke plumes and the potential long-term outcomes of inhalation for a long time to patients and theatre staff. Diathermy smoke plume has been shown to contain a number of chemicals that have the prospective for carcinogenesis, and organisms have been depicted to have the ability of being recovered from the plume, increasing the likelihood of transmission of disease 30. There should be suitable preventative measures when addressing this issue, as well as using smoke extraction systems.

On the contrary, the outcomes of a preceding meta-analysis6, postoperative pain scores at 24 h were not considerably dissimilar between scalpel groups and cutting diathermy in the currrent study. One rodent study described that the thermal injury from bipolar electrocautery led to interruption of nerve fibre and as a result abridged pain31. Other experimental studies on the other hand challenged these conclusions32 – 34. Animal studies have recommended an raise in lateral thermal spread due to diathermy, leading to a broader zone of tissue damage than the one that ensue from the use of scalpel. This result in buildup of acute-phase reactants and more harm to ischaemic tissue, both of which might result in increased pain32 – 34. Some clinical studies have described abridged pain at 48 h in a case where cutting diathermy is applied for slitting of the skin14,22. Current studies on the other hand studies did not find any diversity in postoperative pain perception10. The correlation between scalpel versus cutting diathermy and pain has not been clarified clearly, and calls for more examination.

In this review particularly, the effect of cutting diathermy on long-term cosmesis could not be scrutinized due to deficiency of data. Previously, a prospective controlled study has examined the outcome of the cosmetic on the skin incisions made using scapel versus diathermy 18. After transcribing for 6 weeks subsequent to inguinal hernia repair, a considerable difference in rating of cosmetic was discovered, that favour diathermy. Skin diathermy burns were only spotted after conventional scalpel incision, and fearing poorer cosmetic results and keloid formation were groundless. In another study of 19 patients who undergo neck incisions, there is no difference in objective or subjective cosmetic effect, or in patient satisfaction scores was renowned between scalpel and cutting diathermy groups after 6 months8. An additional new retrospective study examined the cosmetic effect of scalpel versus diathermy skin incisions in neck and head surgery35; no difference in cosmetic upshot between the two groups was discovered after one month. Supplementary research is needed to clarify the long-term outcome of diathermy on cosmesis, despite the fact that there is no evidence to recommend that diathermy leads to a worse result at present.

Despite the fact that a number of surgeons still persist on their liberty to choose patient benefits of incising the skin with cutting diathermy, the efficiency, using a similar apparatus in dividing fascia and muscle and safety is capable of swaying some of them to retire the scalpel.