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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 26  |  Issue : 2  |  Page : 100-105

Surgical outcome of cutting diathermy versus scalpel skin incisions in uncomplicated appendectomy: A comparative study


1 Department of Surgery, Federal Medical Center, Owo, Ondo State, Nigeria
2 Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. Olusegun Isaac Alatise
Department of Surgery, PMB 5538, OAUTHC, Ile-Ife, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_25_19

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  Abstract 

Background: It is traditionally believed that diathermy skin incisions produce a comparatively poorer surgical outcome despite recent evidences to the contrary. This study set out to compare diathermy and scalpel skin incisions with respect to immediate post-operative pain, surgical-site infection and surgical scar cosmesis. Methodology: This was a randomised, double-blinded study comparing cutting diathermy and scalpel skin incisions in patients undergoing open appendectomies for uncomplicated appendicitis. The post-operative pain was rated with the Visual Analogue Pain Scale 6, 12 and 24 h postoperatively, and 30 day wound infection was rated with the Southampton score. Scar cosmesis was assessed at 3 months, by a plastic surgery trainee, using the Patient and Observer Scar Assessment Scale (POSAS). The patients also self-evaluated their scars using POSAS. Results: A total of 64 patients were randomised to cutting diathermy (32) and scalpel (32) skin incision groups. The mean pain score was higher in the diathermy incised wounds, but this was not statistically significant (P = 0.094). There was one wound infection recorded in the scalpel incision group and none in the diathermy incision group (P = 0.524). At 3 months post-surgery, there was no difference between the diathermy and scalpel incised wounds in mean (±SD) objective POSAS scores (15.64 [±5.98] vs. 17.79 [±6.37], P = 0.228) or subjective POSAS scores (22.44 [±13.13] vs. 22.21 [±13.17], P = 0.951), respectively. The mean scar satisfaction score, as assessed by the patients, was better for the diathermy incised wounds, but this was not statistically significant (P = 0.406). Conclusion: In patients undergoing open appendectomy for uncomplicated acute appendicitis, skin incision with a cutting diathermy is not inferior to the scalpel in surgical outcome, with respect to post-operative pain, wound infection and surgical scar cosmesis.

Keywords: Appendectomy, diathermy, scalpel


How to cite this article:
Okereke CE, Katung AI, Adesunkanmi AK, Alatise OI. Surgical outcome of cutting diathermy versus scalpel skin incisions in uncomplicated appendectomy: A comparative study. Niger Postgrad Med J 2019;26:100-5

How to cite this URL:
Okereke CE, Katung AI, Adesunkanmi AK, Alatise OI. Surgical outcome of cutting diathermy versus scalpel skin incisions in uncomplicated appendectomy: A comparative study. Niger Postgrad Med J [serial online] 2019 [cited 2019 Jun 18];26:100-5. Available from: http://www.npmj.org/text.asp?2019/26/2/100/259914


  Introduction Top


Historically, the cold steel scalpel (CSS) has been the instrument of choice for surgical incisions because of ease of use, accuracy and predictable tissue damage.[1] However, the use of the CSS is associated with bleeding which slows the surgery, obscures the surgical field and, in some instances, leads to increased swelling, bruising and pain.[2]

To reduce blood loss following surgical incision with CSS, other methods have been investigated, and these include the use of cutting electrosurgery, laser incision technology and radiowave surgery.[3] Of these, cutting diathermy is the most readily available in most operating theatres in both high- and low-income countries.[4] The cutting diathermy has been shown to significantly reduce incisional blood loss when compared to CSS,[4],[5],[6] eliminate concerns regarding sharps safety[7] and lead to improved cutaneous wound healing and scar formation.[8] Despite these, its adoption for making surgical skin incisions has been rather slow. This has been attributed to a number of factors which include the fear of deep burns, with increased tissue devitalisation leading to increased wound infection rate, prolonged healing time and cosmetically inferior scar.[9],[10],[11],[12] Recent meta-analyses and systematic reviews have, however, reported no difference in wound infection rate and cosmetic outcome, but rather a possible benefit with respect to early post-operative wound pain.[13],[14]

In abdominal surgery, only few studies had compared the surgical outcome of CSS and cutting electrosurgery.[4],[5] The few studies available included a heterogeneous group of abdominal operations,[4],[5],[15] making it difficult to acceptably make comparisons of outcome measures such as post-operative pain and wound infection rates across a spectrum of different surgical operations. This is due to the effect of confounders, such as the differences in anatomic sites, extent of the underlying tissue dissection and inherent class of surgical wound, which may affect the assessment of pain and wound infection rates. Furthermore, it may not be appropriate to compare the cosmetic outcomes of various abdominal incisions made at different orientations to the natural skin tension lines.

Among the various abdominal operations, appendectomy is one of the most commonly performed in most parts of Africa.[16],[17],[18] Most patients requiring this procedure are young, in whom the outcome measures are of particular importance.[19] Furthermore, the similarity in wound characteristics also makes open appendectomy for acute appendicitis a suitable choice for comparing the two skin incision modalities.

This study was thus conceptualised with the aim to compare the surgical outcome of diathermy skin incisions and scalpel incisions in open appendectomy for uncomplicated appendicitis, with respect to the immediate post-operative pain, surgical-site infection (SSI) and cosmesis of the resulting scars.


  Methodology Top


This was a prospective comparative study, carried out in the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Osun state, between June 2016 and May 2017. Ethical approval was obtained from the OAUTHC Ethical and Research Committee with the protocol number ERC/2015/12/04, approved on 2 June 2016, and an informed consent was obtained from each of the patients to be recruited into the study.

Study population

Consented eligible adults (aged at least 18 years) with uncomplicated acute appendicitis requiring emergency open appendectomy and those scheduled for elective interval appendectomy were included in the study. Diagnosis was made clinically after detailed history taking and physical examination. Abdominal ultrasonography, as a useful adjunct, was done as indicated, especially in female patients.

Patients who had a planned lower midline or laparotomy incision and those with an existing scar at the planned surgical incision site in the right iliac fossa region were excluded from the study. Also excluded were patients who had a known predilection for keloid scars, those with a diagnosed connective tissue disorders (such as Ehlers–Danlos syndrome, Marfan syndrome and scleroderma) and those with known medical conditions that predisposed to SSIs, for example, diabetes, AIDS and prolonged systemic steroid use. Patients with appendicitis in pregnancy and those with any form of cognitive impairment were also excluded from the study.

Sample size and sampling method

The minimum sample size was calculated using the following formula to compare two proportions:[20]

Zα/2 is 1.96 (from Z table), at type 1 error of 5%

Zβ is 0.842 (from Z table), at 80% power.

p1 and p2 are the proportions of abdominal surgical incisions made with the scalpel and diathermy, shown from an initial pilot study to be 70% and 30%, respectively.

This gave the minimum sample size to be 24 in each treatment arm, with a total number of 48.

Adding an expected attrition rate of 30%[21] (to account for the anticipated loss to follow-up), the calculated sample size came to 64, randomised to 32 participants in each arm [Figure 1].
Figure 1: Patient allocation and follow-up

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Simple random sampling method was used, which entailed an equal number of ballot papers pre-labelled with either scalpel skin incision (A) or diathermy skin incision (B), sealed in similarly opaque envelopes and picked by each recruited patient shortly before the surgical procedure. The patients were thus assigned to either the CSS or 40 W pure cutting-mode diathermy using TEKNO TOM 201 Diathermy Machine (Tekno-Medical OptikChirugie GmbH and Co, Tuttlingen/Germany), with a blade electrode tip. The length of the incisions varied from 4 to 8 cm, depending on the surgeon and the body habitus of the patient.

The procedure

Each patient had open appendectomy under general anaesthesia, through a 4–8 cm transverse skin crease incision, centred on the McBurney's point,[22] made using either skin incision modality [Figure 2]. Deep to this skin incision, the diathermy was employed for haemostasis in both treatment arms. The peri-operative antibiotics were standardised in both treatment arms. All skin incisions were closed with staples.
Figure 2: Diathermy and scalpel skin incisions

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Postoperatively, the patients were placed on intravenous pentazocine and paracetamol, both administered 8 hourly for 48 h, with the first dose given after the reversal of anaesthesia. Skin staples were removed in the outpatient clinic between the 8th and 10th post-operative days, or earlier, if a patient had SSI.

Assessment of outcome measures

Outcome measures comprised the post-operative incision pain measured with the Visual Analogue Pain Scale, 30-day wound infection rate measured with the Southampton wound scoring system and scar cosmesis at 3 months [Figure 3], measured with the Patient and Observer Scar Assessment Scale (POSAS). The follow-up schedule included a review of the wound at the 1st, 4th and 12-week post-operation.
Figure 3: Surgical scars from diathermy and scalpel skin incisions

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Statistical analysis

Statistical data were summarised, and statistical testing was conducted using the IBM SPSS software, version 22 (Chicago IL, USA). Continuous variables were summarised and presented as mean. The categorical variables were presented as absolute numbers and percentages. The comparison of the mean age, body mass index (BMI) and post-operative pain scores between the groups was performed using the Student's t-test, whereas the analysis of variance test was used to compare the subjective and objective scar assessment scores. Comparison of the gender distribution, occupation, time of surgery and co-morbidities between the groups was done using the Chi-squared test. P < 0.05 was considered statistically significant.


  Results Top


Sixty-four patients were recruited into the study, with ages ranging from 18 to 53 years, and a mean age of 27 years (standard deviation ± 9.1). There was a male predominance with 41 males and 23 females. The sociodemographic data of the patients are summarised in [Table 1]. There was no significant difference in the age distribution (P = 0.349) between the two interventional groups; however, the gender distribution was of significant statistical difference (P = 0.017) [Table 1]. Four patients had controlled high blood pressure (3 of 32 in the scalpel group and 1 of 32 in the diathermy skin incision group) (P = 0.343). At 3 months postoperatively, four patients in the diathermy incision group and six patients in the scalpel group were lost to follow-up, for the surgical scar assessment [Figure 1].
Table 1: Sociodemographic data of the study cohort

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The mean duration of surgery in the diathermy and scalpel groups was 63 and 66 min, respectively (P = 0.622). All the patients, on an average, commenced graduated oral intake on the 1st post-operative day and were discharged on the 2nd post-operative day. The mean number of days to staple removal in the diathermy and scalpel incision groups was also found to be comparable (P = 0.732). The distribution of BMI in the two study groups was comparable (P = 0.625).

Patients in the diathermy skin incision group had comparatively higher mean pain scores than those in the scalpel incision group at the 6th, 12th and 24th post-operative hours [Figure 4]. The difference was, however, not statistically significant (P = 0.094). The pain scores were not influenced by the gender, age, occupation or the BMI of the respondents [Table 2].
Figure 4: Visual Analogue Pain Scores (maximum score of 10)

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Table 2: Relationship between the mean pain scores and sociodemographic characteristics

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There was no significant difference in wound infection rates between the diathermy (0 of 32) and scalpel (1 of 32) skin incision groups (P = 0.524). The single patient who had a wound infection had wound care, and a therapeutic course of culture-sensitive antibiotic and did not require secondary wound closure.

As regard the scar performance, patients in both treatment arms showed comparable mean total Patient Scar Assessment Scores (PSAS) (22.44 in the diathermy vs. 22.21 in the scalpel groups, P = 0.95), but better mean scar opinion (or satisfaction) scores as judged by both the patients (3.76 vs. 4.46, P = 0.41) and an independent observer (2.80 vs. 3.21, P = 0.21). Overall, objective and subjective scar assessment at 3 months showed no significant statistical difference between both intervention groups for both total scar scores (P = 0.228 vs. 0.951, respectively) and overall scar opinion (or satisfaction) scores (P = 0.212 vs. 0.406, respectively) [Table 3].
Table 3: Patient and Observer Scar Assessment Scores (lower scores imply better surgical scars)

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To test for interrater variability, Pearson's correlation between the PSAS and Observer Scar Assessment Score (OSAS) total scores was r = 0.350 (P = 0.014), while that between the PSAS overall opinion and OSAS overall opinion scores was r = 0.385 (P = 0.006), indicating a positive correlation between the scar scores given by the patients and the independent assessor. The relationship between PSAS total scores and patients' sociodemographic characteristics such as age, gender and occupation was assessed using bivariate analysis, and none of these had any statistically significant relationship with PSAS score, with P = 0.206, 0.230 and 0.192, respectively. There was no significant difference between the patients' BMIs and both the PSAS (P = 0.245) and OSAS (P = 0.755) scores obtained [Table 4].
Table 4: Relationship between body mass index and mean Patient Scar Assessment Score and Observer Scar Assessment Score

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  Discussion Top


The advantages derivable from the use of diathermy in terms of haemostasis, and the concerns regarding its effect on wound outcomes, when used for skin incisions, provided the clinical equipoise for its comparison with the traditional scalpel technique in this study. In comparing the surgical outcome between these two surgical techniques, this study found no difference in the diathermy and scalpel incised surgical wounds for open appendectomy, with respect to post-operative pain, SSI and surgical scar cosmesis.

The intention for selecting appendectomy wounds was to study relatively young patients in whom the surgical outcomes of interest will be of importance, and this aim was achieved as reflected by the mean ages of 28 and 25 years in the diathermy and scalpel skin incision groups, respectively. Although patients were not randomised based on age, the mean age of patients in the two treatment arms which was statistically similar provided a rational basis for comparison. The other sociodemographic characteristics of the patients in the two treatment arms were found to be comparable except the sex distribution which was found to be significantly different. When this was tested statistically, however, no significant relationship was found between gender and pain score, wound infection rate, as well as assessment of scar cosmesis, suggesting that observations made in this study were not influenced by the unequal gender distribution. This is further supported by studies on the role of gender in the assessment of post-operative pain and surgical scar cosmesis, which have also not shown any convincing association.[23],[24],[25]

The post-operative pain in the diathermy incision group, at the different times assessed, was found not to be statistically different from the scalpel incision group. This is similar to the findings by Gupta et al.[26] who studied eighty patients undergoing inguinal herniorrhaphies and found comparable pain scores. Another study by Ali et al.[6] on patients undergoing elective open cholecystectomies under general anaesthesia also revealed no significant difference in immediate post-operative pain in the diathermy and scalpel incision groups.

Aird et al.,[13] while evaluating the post-operative pain between the two skin incision techniques in 66 patients undergoing different forms of bowel resection surgery (both open and laparoscopic), found lower pain scores with the diathermy skin incision group. This difference could have resulted because the surgical cases were heterogeneous and there were variations in the orientation and length and number of abdominal incision employed. Furthermore, there was variability among patients in their study groups, with respect to route (such as patient-controlled vs. epidural analgesia), type and amount of post-operative analgesia. As most of the patients in their study had bowel resections for malignant causes, the pain scores could also have been affected by the patients' use of pre-operative analgesics and extent of surgery (curative vs. palliative). All these factors which were not controlled for in their study could potentially affect the interpretations of post-operative pain and comparison of the scores. Differences in findings may also be accounted for by the differences in the electrosurgical generators, as well as the types of electrode tips used.

In this study, wound infection rates in the two treatment arms were also found not to be different. All the diathermy incised wounds healed normally, while one (3%) of the scalpel incised wounds was infected. This is similar to the findings by Ali et al.[27] who compared the rate of wound infections in eighty patients who had inguinal herniorrhaphies and randomised into equal numbers for diathermy and scalpel skin incisions. The wound infection rate was higher in the scalpel incised wounds (17.5%), compared to diathermy incised wounds (12.5%). This was, however, not significant. Kadyan et al.,[28] in 2004, compared the rate of SSI for clean contaminated surgical procedures (appendectomies and cholecystectomies) and recorded lesser number of cases of SSIs in the scalpel skin incision group (13.1%) compared to the diathermy group (15.7%). This difference was also not significant. Groot and Chappell,[29] while comparing wound infections between diathermy and the scalpel for abdominal and thoracic wounds, found that electrocautery did not increase the wound infection rate. Ahmad et al.[30] also revealed similar findings and stated that post-operative infections were comparable in the diathermy and scalpel incision groups.

Regardless of the modality of assessing wound infection, two meta-analyses have shown that diathermy incised wounds are not more prone to infection.[8],[31] This may be because the heating effect of the diathermy produces local tissue heating, which in turn increases subcutaneous oxygen tension and enhances the resistance of the surgical wound to infections.[32]

Few studies have compared diathermy and scalpel skin incisions, using the cosmetic outcome of the scar as a primary outcome measure. Because the assessment of scar cosmesis is by its nature subjective, this study evaluated the surgical scars with the POSAS, to allow a subjective perspective to the resulting scars and to determine patients' satisfaction. A positive correlation between the subjective and objective scar scores (P = 0.014) highlights the improbability of inter-patient variability that might have influenced the subjective scores. Findings from this study revealed that there were no differences in scars between the two treatment groups based on either objective or subjective measures.

Dixon and Watkin[33] compared diathermy and scalpel incisions in 84 patients undergoing inguinal herniorrhaphy or open cholecystectomy and found no difference in the patients' assessment of their wound cosmesis, but noted a significant preference for the diathermy incisions when they were assessed by a surgeon or nurse. In our study, the mean scar scores were better (i.e., lower OSAS) for the diathermy incised wounds. This difference was however not statistically significant (P = 0.23).

Douglas et al.,[34] in their prospective, randomised, double-blinded cross-over study, evaluated 31 patients with abdominal incisions, in which one-half of the skin incision was made using a diathermy and the other half using a scalpel blade, and found no difference in the wound cosmesis between the scalpel and diathermy skin incisions. A third of the patients in their study were actually unable to make any distinction between the two halves of the wound. Chau et al.[35] studied 19 patients undergoing bilateral neck dissection and randomly assigned each side's skin incision to diathermy or scalpel. They found no difference in cosmesis at 6 months postoperatively.

These findings are probably because, in the cutting mode, the electrode rapidly heats cells to the point of vaporisation. The excess heat disperses quickly so that the heat is not passed to the tissues adjacent to the incision site. This may explain the lack of tissue char and minimal scarring on wound healing.[33],[36]

This study shows that, in patients undergoing open appendectomy for uncomplicated appendicitis, surgical outcome, with respect to post-operative pain, wound infection and scar cosmesis, is not affected by the modality of skin incision. The mean post-operative pain, though higher in the diathermy incised wounds, was not significant. The wound infection rate between the two surgical modalities was not different. Surgical scar cosmesis had a better mean score for the diathermy incised wounds, but this, again, was not significant.

Limitations

The study was not without some limitations. A follow-up period of 3 months was employed for assessing the surgical scar cosmesis, to keep within the allotted period for the study. A longer period of follow-up could possibly be more informative.


  Conclusion Top


Based on the finding of this study, we recommend that the diathermy device may be accepted as an alternative modality used for abdominal surgical skin incisions; we, however, require a larger, multicentric study, to further validate this result.

A larger multicentric study, with a longer duration of follow-up, may also be required to detect subtle cosmetic differences between diathermy and scalpel incised skin that may be significant in more cosmetically critical areas of the body.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Lee BJ, Marks M, Smith DP, Hodges-Savola CA, Mischke JM, Lewis RD, et al. Advanced cutting effect system versus cold steel scalpel: Comparative wound healing and scar formation in targeted surgical applications. Plast Reconstr Surg Glob Open 2014;2:e234.  Back to cited text no. 1
    
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Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. Br J Surg 2012;99:613-20.  Back to cited text no. 8
    
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Aird LN, Bristol SG, Phang PT, Raval MJ, Brown CJ. Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions. Br J Surg 2015;102:489-94.  Back to cited text no. 13
    
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