Effect of electrocautery on wound healing in midline laparotomy incisions

Coagulant Protein-Free Blood Coagulation Using Catechol-Conjugated Adhesive Chitosan/Gelatin Double Layer

Since the discovery of polyphenolic underwater adhesion in marine mussels, researchers strive to emulate this natural phenomenon in the development of adhesive hemostatic materials. In this study, bio-inspired hemostatic materials that lead to pseudo-active blood coagulation, utilizing traditionally passive polymer matrices of chitosan and gelatin are developed. The two-layer configuration, consisting of a thin, blood-clotting catechol-conjugated chitosan (CHI-C) layer and a thick, barrier-functioning gelatin (Geln) ad-layer, maximizes hemostatic capability and usability. The unique combination of coagulant protein-free condition with CHI-C showcases not only coagulopathy-independent blood clotting properties (efficacy) but also exceptional clinical potential, meeting all necessary biocompatibility evaluation (safety) without inclusion of conventional coagulation triggering proteins such as thrombin or fibrinogen. As a result, the CHI-C/Geln is approved by the Ministry of Food and Drug Safety (MFDS, Republic of Korea) as a class II medical device. Hemostatic efficacy observed in multiple animal models further demonstrates the superiority of CHI-C/Geln sponges in achieving quick hemostasis compared to standard treatments. This study not only enriches the growing body of research on mussel-inspired materials but also emphasizes the potential of biomimicry in developing advanced medical materials, contributing a promising avenue toward development of readily accessible and affordable hemostatic materials.

Efficacy of local infiltration of tranexamic acid in subcutaneous surgery: A protocol from a single medical center

BACKGROUND

The purpose of this study was to explore efficacy of locally injected tranexamic acid (TXA) at a concentration of 1 mg/mL for reduction perioperative bleeding and postoperative complications in subcutaneous tumor excisions. We present the protocol and also compare results between the group of use antithrombotic group and not used.

METHODS

This is a retrospective study. Fifty-three patients were divided into 3 groups. Group 1 (n = 14): using antithrombotic drugs (antiplatelet or anticoagulants) with locally injected TXA. Group 2 (n = 17): using antithrombotic drugs without locally injected TXA. Group 3 (n = 22): not using antithrombotic drugs but with locally injected TXA. TXA was diluted to 1 mg/mL for use based on our experience. All patients were operated by 1 surgeon in 1 single medical center in Taipei from March 1st, 2020, to March 31st 2022. Outcomes such as the quality of perioperative surgical field and postoperative surgical complications were evaluated and compared. The quality of field was intraoperatively recorded by an assessment and photos from the surgeon. The statistical relationships between the complication rates were analyzed using χ2 test and a 1-way ANOVA by SPSS 25.

RESULTS

From Groups 1 and 3, a total of 36 patients, 29 patients had a clear surgical field during procedure. When comparing Groups 1 and 2, use of locally injected TXA had greater positive advantage in terms of a clearer vision whilst surgery (P = .031). Group 2 had more minor complications such as hematoma, severe ecchymosis, wound dehiscence, wound infection. By postoperatively reducing hematomas for 24 hours, it significantly reduce the incidence of abovementioned minor complications (P = .036). With the help of locally injected TXA, shorter time was required to remove drain, hence reducing duration of in-hospital stay.

CONCLUSION

The use of locally injected TXA whilst performing subcutaneous surgery on patients taking antithrombotic drugs is cost-effective. It could reduce bleeding and provide a more effective surgical field. In our study, favorable results were obtained from the use of diluted tranexamic acid (1 mg/mL) mixed with lidocaine, namely in clearing the surgical field as well as reducing postoperative surgical complications.

Is Iatrogenic Implant Contamination Preventable Using a 16-Step No-Touch Protocol?

BACKGROUND

Intraoperative contamination of the surgical field during aesthetic breast augmentation may lead to implant infection with devastating consequences. This study covers a period of 30 years and is divided into 2 phases: a retrospective phase from 1992-2004 when a standard approach was used and a prospective phase from 2004-2022 when a no-touch approach was implemented to avoid contamination.

METHODS

Patients in the standard and no-touch groups underwent aesthetic breast augmentation by the same senior surgeon (FDP) in the same outpatient surgical facility during the 30-year period of the study. Patients are divided into 2 groups: from 1992-2004 and from the implementation of the no-touch protocol in 2004-2022.

RESULTS

Patients who underwent breast augmentation using the no-touch approach developed no infections, whereas the standard group had an infection rate of 3.54% (P = .017). The validity of this finding is discussed.

CONCLUSIONS

The no-touch approach as described in this article was effective in reducing implant infection rate when performing aesthetic breast augmentation by 1 surgeon at 1 surgical center during an 18-year observation period. Multicenter prospective cooperative studies are necessary to validate perioperative iatrogenic contamination as the cause of implant infection and to explore optimal approaches that could eliminate implant contamination.

Quantifying the magnitude of local tendon injury from electrosurgical transection

BACKGROUND

Electrocautery is a common surgical technique and is often used during shoulder arthroplasty to elevate or transect the subscapularis tendon. The relative amount of tissue damage caused by cautery as opposed to sharp transection is not currently known. The purpose of this study was to examine local tissue damage resulting from electrocautery vs. sharp transection with a scalpel. We hypothesized that the electrosurgical unit would cause higher collateral tissue damage and cell death compared with sharp transection.

METHODS

Twelve cadaveric ovine shoulders were randomized to either the electrosurgical or sharp transection group. The infraspinatus tendon was isolated, and a partial-thickness transection was made using either a monopolar electrosurgical device (Bovie) or No. 10 scalpel blade. Tendon explants were then visualized with confocal microscopy to evaluate tissue architecture. A live/dead assay was performed using microscopy imaging analysis software. Comparisons between Bovie and scalpel transection were made using the Mann-Whitney U test, and the cell death percentage at standardized distances from the transection site was compared between groups using a mixed-model analysis. Significance was defined at P < .05.

RESULTS

The cellular and tendon fibril architecture was well maintained beyond the scalpel transection site, whereas Bovie transection disrupted the architecture beyond its transection path. The percentage of dead cells in the Bovie group (74.9% ± 31.2%) was significantly higher than that in the scalpel group (27.6% ± 29.9%, P = .0004). Compared with the transection site, the cell death percentage after Bovie transection significantly declined at 2.5 mm whereas that after scalpel transection significantly declined at 1 mm from the transection site.

CONCLUSION

There was a significantly higher dead cell percentage in the Bovie transection group, indicating extensive damage beyond the local incision site, compared with sharp transection. Electrosurgical transection of the ovine infraspinatus tendon ex vivo caused higher cell death and greater tissue architecture disruption compared with sharp scalpel transection.

Do Gloves Provide Adequate Protection Against Infection?

In the early 1800s gloves were a foreign concept to surgeons, as a result, patient care suffered, and mortality was high due to poor sanitary conditions in the operating room. This all changed in 1889, where the introduction of the surgical glove completely revolutionized surgical aseptic ideals. Through the work of William Halsted and his desire to help his nurse, Caroline Hampton, who was from suffering contact dermatitis, the first pair of rubber gloves were created. Since this invention, there have been significant advancements in glove technology including the use of latex and non-latex gloves. However, significant problems remain including, perioperative contamination in longer procedures, a false sense of sterility, and no consensus in optimal glove donning procedures. Additional measures including patient preparation, limited handling of tissue specimens, minimal coagulation, and in particular a no-touch strategy need to be continued and optimized to minimize iatrogenic infection and sequelae. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

It is time for a more cautious approach to surgical diathermy, especially in COVID-19 outbreak: A schematic review

Background

Many surgeons are unaware of the risks posed by the surgical diathermy. Apart from the numerous chemicals, surgical smoke had been shown to harbour intact bacterial and virus particles especially COVID-19 in the current time.

Objective

To identify the inhalational, infectious, chemical, and mutagenic risks of surgical smoke and suggest evidence-based hazard reduction strategies. Also to cogitate on the very high risk of viral spread by the use of surgical diathermy in COVID-19 outbreak.

Methods

A review of articles indexed for MEDLINE on PubMed using the keywords surgical smoke, diathermy, electrocautery, surgical smoke hazards, smoke evacuator, and guidelines for surgical smoke safety was performed. The review included evidences from 50 articles from the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature.

Results

There are risks associated with surgical smoke. Although some surgeons were aware, majority were not keen in the hazard reduction strategies.

Conclusion

Many chemical and biological particles have been found in surgical smoke. It is highly recommended to follow the standardised guidelines for surgical smoke safety. Surgical smoke carries full virus particle(such as COVID-19 virus), it is strongly recommended to minimise or avoid electrocautery during the COVID-19 outbreak.

Diode laser surgery versus electrocautery in the treatment of inflammatory fibrous hyperplasia: a randomized double-blind clinical trial

OBJECTIVES

To compare the efficacy and safety of diode laser and electrocautery techniques for inflammatory fibrous hyperplasia (IFH) removal.

MATERIALS AND METHODS

In this randomized double-blind clinical trial, 40 individuals were randomly allocated to two groups: group 1 (G1) consisted of 20 individuals assigned to treatment with diode laser and group 2 (G2) consisted of 20 individuals assigned to treatment with electrocautery. The following transoperative parameters were evaluated: bleeding, temperature, and surgical technique parameters (energy deposited on tissue, flow rate, and time of incision). The postoperative parameters evaluated were as follows: pain, functional alterations (chewing, speaking), analgesic medication intake, swelling, healing of the wound area, and patient satisfaction.

RESULTS

Among the 40 individuals included in the study, four (two in G1 and two in G2) did not complete the entire follow-up. Therefore, 36 individuals (18 in G1 and 18 in G2) participated. Participants in G1 and in G2 had similar demographic characteristics. No difference regarding the trans- or postoperative parameters evaluated was observed between G1 and G2 (p > 0.05). Also, no difference regarding the time for healing was observed between groups.

CONCLUSIONS

Diode laser seems to be as effective and safe as electrocautery when applied under similar conditions for IFH removal.

CLINICAL RELEVANCE

IFH corresponds to 65% of the lesions observed in denture wearers. This study shows that under similar conditions diode laser is as effective and safe as electrocautery for removal of IFH.

Diathermy versus scalpel for skin incision in patients undergoing open inguinal hernia repair: A systematic review and meta-analysis

OBJECTIVES

To compare outcomes of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies comparing use of diathermy and scalpel for skin incision in patients undergoing inguinal hernia repair. Surgical site infection (SSI) was the primary outcome measure. Secondary outcome measures included haematoma, seroma, visual analogue scale (VAS) pain score at 6 h, 12 h, and 24 h, and incision time. We used Cochrane risk of bias tool and ROBINS-I tool to assess the risk of bias of randomised and non-randomised studies. Fixed-effect model was applied to calculate pooled outcome data.

RESULTS

We identified 9 studies, 4 randomised controlled trials and 5 prospective cohort studies, enrolling a total of 830 patients. Meta-analysis of RCTs showed no difference between the diathermy and scalpel groups in terms of surgical site infection (OR: 0.77, 95% CI 0.34, 1.75, P = 0.53), seroma (OR: 0.86, 95% CI 0.29, 2.55, P = 0.78), VAS pain score at 6 h (MD: -0.10, 95% CI -0.31, 0.11, P = 0.34), 12 h (MD: -0.10, 95% CI -0.13, 0.33, P = 0.40), and 24 h (MD: 0.03, 95% CI -0.16, 0.21, P = 0.79). Use of diathermy for skin incision was associated with shorter incision time (MD: -36.00, 95% CI -47.92, -24.08, P < 0.00001) and lower risk of haematoma (OR: 0.14, 95% CI 0.03, 0.65, P = 0.01). Meta-analysis of observational studies showed no difference between the diathermy and scalpel groups in terms of surgical site infection (OR: 0.87, 95% CI 0.54, 1.39, P = 0.55), haematoma (OR 0.14, 95% CI 0.02-1.23, P = 0.08), seroma (OR: 0.86, 95% CI 0.29, 2.55, P = 0.78), VAS pain score at 6 h (MD: -0.10, 95% CI -0.44, 0.24, P = 0.56), 12 h (MD: -0.10, 95% CI -0.26, 0.46, P = 0.58), and 24 h (MD: 0.10, 95% CI -0.27, 0.47, P = 0.59). Use of diathermy for skin incision was associated with shorter incision time (MD: -39.40, 95% CI -41.02, -37.78, P < 0.00001). The results remained consistent through sensitivity analyses. The between-study heterogeneity was low and the quality of the available evidence was moderate.

CONCLUSIONS

There is no difference between use of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair in terms of surgical site infection, seroma and postoperative pain. Use of diathermy for skin incision may be associated with shorter incision time and may reduce the risk of haematoma formation.

Subcutaneous Injection of Tranexamic Acid to Reduce Bleeding During Dermatologic Surgery: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial

BACKGROUND

Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding.

OBJECTIVE

To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery.

METHODS

In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test.

RESULTS

One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) (p < .001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; -0.83; -1.20 to -0.46 p < .001). The subjective hemostasis assessment was significantly better in the TXA group overall (p = .043) and anticoagulant subgroup (p = .001) compared with the placebo group.

CONCLUSION

Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.

Prevention of pharyngocutaneous fistula in salvage total laryngectomy: role of the pectoralis major flap and peri-operative management

OBJECTIVE

This study aimed to evaluate the impact of an onlay pectoralis major flap in reducing the incidence of pharyngocutaneous fistula after salvage total laryngectomy and determine the complications of pectoralis major flap reconstruction.

METHODS

A retrospective study was conducted of consecutive patients who underwent salvage total laryngectomy between 1995 and 2016. The pharyngeal defects were primarily closed with or without the pectoralis major flap.

RESULTS

Of 64 patients, 34 had primary pharyngeal closure alone (control group) and 30 received an onlay pectoralis major flap (pectoralis major flap group). The overall fistula rate was 15.6 per cent, with 17.6 per cent occurring in the control group and 13.3 per cent in the pectoralis major flap group (p = 0.74). The incidence rates of voice failure (p = 0.02) and shoulder disability (p < 0.001) were significantly higher in the pectoralis major flap group.

CONCLUSION

The pectoralis major flap in salvage total laryngectomy did not decrease the pharyngocutaneous fistula rate, and the incidence of flap-related complications was high. Appropriate surgical technique and post-operative care may reduce the incidence of pharyngocutaneous fistula.

Scalpel Versus Diathermy in Wound Healing After Mucosal Incisions: A Split-Mouth Study

PURPOSE

The aim of this study was to analyze and compare the healing of scalpel and diathermy incision wounds in the oral mucosa.

MATERIALS AND METHODS

This is a prospective split-mouth study conducted from January 2015 to April 2017 among patients undergoing either Le Fort I or anterior maxillary osteotomy (or both). The study groups were classified based on the different techniques used to make the incision (group A, incision made by a scalpel; group B, incision made by diathermy). Wound healing was assessed on the first, third, seventh, and tenth postoperative days using the Southampton scoring system. Data were statistically analyzed using the Student t test for continuous variables and the χ² test for categorical variables, and P < .05 was considered significant.

RESULTS

Among the 113 participants included in the study, the age range was 16 to 35 years and male patients comprised 50.4%. The rates of postoperative complications of wound healing were 68.1% (n = 77) in group A and 77% (n = 87) in group B. Wound healing showed a statistically significant difference between the techniques (P < .001).

CONCLUSIONS

The findings of this study suggest that wounds caused by scalpel incisions healed better than those caused by diathermy incisions in the oral mucosa.

Healing comparison of porcine cutaneous incisions made with cold steel scalpel, standard electrosurgical blade, and a novel tissue dissector

Background:

Standard electrosurgery provides superior hemostasis compared to a cold steel scalpel, but inferior tissue healing. A novel electrosurgical blade with an advanced waveform, the MEGADYNE ACE BLADE™ 700 Soft Tissue Dissector (ACE), was designed to provide both excellent hemostasis and wound healing. This study compared ACE to scalpel and standard electrosurgery in a porcine model of wound healing.

Methods:

Skin incisions from six pigs were evaluated at time points of 0, 1, 2, 3 and 6 weeks after application of the three devices. Histopathology was performed on samples from each time point. For each non-initial time point, the healing incisions were photographed for later evaluation by expert graders, and excised for wound strength testing.

Results:

Time 0 photomicrographs showed a gradient of thermal tissue damage by initial incision, ranging from no damage made by the scalpel, minimal damage made by ACE, and twice the ACE damage made by a nonstick PTFE-coated electrosurgical blade. Histopathologic analysis at 6 weeks showed comparable dermal scar width measurements for scalpel and ACE incisions. Scars were wider for incisions made by standard electrosurgical blade. Wound strength was greater for scalpel and ACE than for standard electrosurgery. Cosmetic results at 6 weeks were not significantly different between scalpel and ACE incisions, while standard electrosurgical blade incisions were significantly inferior to ACE (odds ratio: 53.4, p<0.001).

Conclusion:

The MEGADYNE ACE BLADE™ 700 Soft Tissue Dissector represents a significant improvement in electrosurgical technology for skin incisions and dispels the traditional concerns of delayed healing and poor cosmetic result that have been attributed to using conventional electrosurgical blades for skin incisions.

Alopecia Following Bicoronal Incisions

Importance

Multiple techniques may be used to perform bicoronal incisions, and alopecia is a known postoperative complication of this procedure. To date, no large studies exist comparing alopecia outcomes among bicoronal incision techniques with and without the use of Raney clips.

Objective

To determine (1) whether postoperative alopecia is more common when bicoronal incisions are performed with monopolar cautery, Colorado microdissection tip cautery, or traditional cold steel and (2) whether this outcome is affected by the use of Raney clips.

Design, Setting, and Participants

This retrospective study of postoperative alopecia included 505 patients undergoing bicoronal incisions in a single head and neck surgery practice from 1997 to 2015 with a minimum follow-up of 1 year. Patients with preexisting baldness as well as patients not following up for the minimum period were excluded. All data analysis took place between 1997 and 2015.

Main Outcomes and Measures

Maximum alopecia width was measured in the postoperative period and compared among the technique groups both with and without Raney clip use. Raney clip duration as a product of surgery length was also compared.

Results

A total of 505 patients (301 male, 204 female) ranging in age from 3 to 97 years were included in the study (median age, 53.9 years). Of these, 236 underwent bicoronal incisions to approach the skull base, 78 to treat chronic frontal sinusitis unresponsive to endoscopic management or frontal sinus mucocele, 143 for trauma, and 48 for craniofacial surgery. For 173 patients, the cold steel technique was used for both skin and subcutaneous incision, 102 of whom needed Raney clips. For 161 patients, cold steel technique was used for skin incisions and monopolar cautery for subcutaneous incision; 81 of these patients required Raney clips. For 171 patients, Colorado tip microdissection cautery was used for both skin and subcutaneous incision, with Raney clips used in 66 of these patients. Incisions made with cold steel for both skin and subcutaneous tissue, regardless of Raney clip use, had lower postoperative alopecia than those made with cautery: for scalpel use for both skin and subcutaneous tissue, average alopecia width was 2.8 mm without Raney clip and 3.5 mm with Raney clip. For scalpel use with skin and monopolar cautery for subcutaneous tissue, average alopecia width was 3.8 mm without Raney clip and 4.3 mm with Raney clip. Colorado tip microdissection cautery used for skin and subcutaneous tissue was associated with the greatest alopecia width: Colorado tip for skin and subcutaneous tissue, average alopecia width, 4.9 mm; with Raney clip, 5.9 mm. Duration of Raney clip use was significantly associated with increased alopecia width: less than 3 hours, 4.1 mm; 3 hours or more, 5.2 mm (P < .001).

Conclusions and Relevance

When performing bicoronal incisions, postoperative alopecia can be minimized by preferentially using a cold steel scalpel for skin and subcutaneous incisions. Raney clip use should be avoided when possible or used for only a short time during the procedure.

Level of Evidence

3.

Scalpel versus electrosurgery for major abdominal incisions

BACKGROUND

Scalpels or electrosurgery can be used to make abdominal incisions. The potential benefits of electrosurgery may include reduced blood loss, dry and rapid separation of tissue, and reduced risk of cutting injury to surgeons. Postsurgery risks possibly associated with electrosurgery may include poor wound healing and complications such as surgical site infection.

OBJECTIVES

To assess the effects of electrosurgery compared with scalpel for major abdominal incisions.

SEARCH METHODS

The first version of this review included studies published up to February 2012. In October 2016, for this first update, we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, EBSCO CINAHL Plus, and the registry for ongoing trials (www.clinicaltrials.gov). We did not apply date or language restrictions.

SELECTION CRITERIA

Studies considered in this analysis were randomised controlled trials (RCTs) that compared electrosurgery to scalpel for creating abdominal incisions during major open abdominal surgery. Incisions could be any orientation (vertical, oblique, or transverse) and surgical setting (elective or emergency). Electrosurgical incisions were made through major layers of the abdominal wall, including subcutaneous tissue and the musculoaponeurosis (a sheet of connective tissue that attaches muscles), regardless of the technique used to incise the skin and peritoneum. Scalpel incisions were made through major layers of abdominal wall including skin, subcutaneous tissue, and musculoaponeurosis, regardless of the technique used to incise the abdominal peritoneum. Primary outcomes analysed were wound infection, time to wound healing, and wound dehiscence. Secondary outcomes were postoperative pain, wound incision time, wound-related blood loss, and adhesion or scar formation.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out study selection, data extraction, and risk of bias assessment. When necessary, we contacted trial authors for missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data, and mean differences (MD) and 95% CI for continuous data.

MAIN RESULTS

The updated search found seven additional RCTs making a total of 16 included studies (2769 participants). All studies compared electrosurgery to scalpel and were considered in one comparison. Eleven studies, analysing 2178 participants, reported on wound infection. There was no clear difference in wound infections between electrosurgery and scalpel (7.7% for electrosurgery versus 7.4% for scalpel; RR 1.07, 95% CI 0.74 to 1.54; low-certainty evidence downgraded for risk of bias and serious imprecision). None of the included studies reported time to wound healing.It is uncertain whether electrosurgery decreases wound dehiscence compared to scalpel (2.7% for electrosurgery versus 2.4% for scalpel; RR 1.21, 95% CI 0.58 to 2.50; 1064 participants; 6 studies; very low-certainty evidence downgraded for risk of bias and very serious imprecision).There was no clinically important difference in incision time between electrosurgery and scalpel (MD -45.74 seconds, 95% CI -88.41 to -3.07; 325 participants; 4 studies; moderate-certainty evidence downgraded for serious imprecision). There was no clear difference in incision time per wound area between electrosurgery and scalpel (MD -0.58 seconds/cm2, 95% CI -1.26 to 0.09; 282 participants; 3 studies; low-certainty evidence downgraded for very serious imprecision).There was no clinically important difference in mean blood loss between electrosurgery and scalpel (MD -20.10 mL, 95% CI -28.16 to -12.05; 241 participants; 3 studies; moderate-certainty evidence downgraded for serious imprecision). Two studies reported on mean wound-related blood loss per wound area; however, we were unable to pool the studies due to considerable heterogeneity. It was uncertain whether electrosurgery decreased wound-related blood loss per wound area. We could not reach a conclusion on the effects of the two interventions on pain and appearance of scars for various reasons such as small number of studies, insufficient data, the presence of conflicting data, and different measurement methods.

AUTHORS' CONCLUSIONS

The certainty of evidence was moderate to very low due to risk of bias and imprecise results. Low-certainty evidence shows no clear difference in wound infection between the scalpel and electrosurgery. There is a need for more research to determine the relative effectiveness of scalpel compared with electrosurgery for major abdominal incisions.

Healing of canine skin incisions made with monopolar electrosurgery versus scalpel blade

OBJECTIVE

To determine the influence of monopolar electrosurgery in cutting mode set at 10, 20, or 30 W on surgery time, hemostasis, and healing of cutaneous wounds compared to scalpel incisions.

STUDY DESIGN

Randomized blinded control trial.

ANIMALS

Dogs (n = 15).

METHODS

Four skin incisions were created on either side of the dorsal midline with a scalpel, or monopolar electrosurgery at 10, 20, and 30 W. Surgical time and incisional bleeding were measured. Each incision was assessed daily for edema, erythema and discharge, and complications. Healing was evaluated via histology at 7 days. Results were analyzed for significance at P ≤ .05.

RESULTS

Surgical time and hemostasis were improved in all electrosurgery groups. Erythema was reduced in all electrosurgical incisions for days 1-4, but was greater in wounds created via electrosurgery at 20 W than those made with a scalpel blade by day 7. No difference was noted in the degree of edema or presence of wound discharge. All histologic variables of tissue healing were lower in electrosurgical incisions than scalpel incisions (P < .001). Ten incisional complications occurred, all associated with electrosurgery.

CONCLUSIONS

The use of monopolar electrosurgery at 10, 20, and 30 W in a cutting waveform improved hemostasis and surgical time when incising canine skin, but delayed healing and increased complications within the first 7 days compared to scalpel incisions.

The effects of scalpel, harmonic scalpel and monopolar electrocautery on the healing of colonic anastomosis after colonic resection

Purpose

In our study, the effects of harmonic scalpel, scalpel, and monopolar electrocautery usage on the health and healing of colon anastomosis after resection was investigated.

Methods

In this study, 120 female albino Wistar rats were divided into 3 groups each containing 40 rats. Group A, resection with scalpel; group B, resection with monopolar electrocautery; group C, resection with harmonic scalpel. The groups were divided into 4 subgroups consisting of 10 rats and analysed in the postoperative 1st, 3rd, 5th, and 7th days. Anastomotic bursting pressures, hydroxyproline levels and histopathological parameters were surrogate parameters for evaluating wound healing.

Results

The tissue hydroxyproline levels did not show any significant difference between the groups and subgroups. The mean bursting pressure of group A on the 5th day was significantly higher than groups B and C (P < 0.001). When the fibroblast and fibrosis scores were evaluated, scores of group C on the 5th day were significantly higher than the other groups, but the results of bursting pressures and biochemical parameters did not support the fibroblast and fibrosis scores. There were not any significant differences between the groups in other histopathologic parameters.

Conclusion

The use of monopolar electrocautery needs more attention since the device causes tissue destruction. The obliterating effect of harmonic scalpel on luminal organs is an important problem, especially if an anastomosis is planned. Despite the disadvantages of scalpel, its efficacy on early wound healing is better than the other devices.

Comparison of impact of four surgical methods on surgical outcomes in endoscopic dacryocystorhinostomy

PURPOSE

To evaluate differences in the surgical outcomes of endoscopic dacryocystorhinostomy (DCR) according to four different surgical methods.

MATERIAL AND METHODS

This retrospective study included 222 patients who underwent endoscopic DCR from 2011 to 2013. All patients were assigned to one of four groups according to instruments for incision of nasal mucosa and the formation of mucosal flap: group 1, a sickle knife with mucosal flap; group 2, a sickle knife without mucosal flap; group 3, electrocautery with mucosal flap; and group 4, electrocautery without mucosal flap. The follow up period was at least 6 months.

RESULTS

There were 33 eyes in group 1, 44 eyes in group 2, 49 eyes in group 3, and 97 eyes in group 4. There were no significant differences in success rate between groups (P = 0.878). Wound healing time was significantly different between groups (P < 0.001). In post hoc analysis, wound healing time was significantly shorter in group 1 and group 2 than in group 3 and group 4. The vertical ostium size and postsurgical complication were not significantly different between groups.

CONCLUSIONS

The use of cold instruments such as sickle knife may be more helpful and effective for shortening wound healing time rather than making mucosal flaps in endoscopic DCR.

Advanced Cutting Effect System versus Cold Steel Scalpel: Comparative Wound Healing and Scar Formation in Targeted Surgical Applications

Background:

Use of electrosurgery for skin incisions has been controversial due to concerns of delayed healing, excessive scarring, and increased infection. Recent studies using modern electrosurgical generators that produce pure sinusoidal “CUT” waveforms have shown reductions in thermal damage along incisions made with these devices compared with their predecessors. This study compares scar formation in incisions made using a cold steel scalpel (CSS) or the ACE Blade and Mega Power Generator (ACE system, Megadyne Medical Products, Draper, Utah) from patient and blinded observer perspectives.

Methods:

Subjects seeking plastic surgery were enrolled in the study. Incisions on one side of each subject’s body were made with a CSS while equivalent incisions on the contralateral side were made with the ACE system. Differences between incision methods were evaluated by assessment of scar formation by observers and assessment of patient satisfaction relating to scar formation at 120 days postsurgery.

Results:

Observers rated incision vascularization, pigmentation, thickness, and relief. The mean observer score (± SD) of incisions made with the ACE system was 11.1 ± 4.4 while that of incisions made with the CSS was 10.8 ± 3.7 (P < 0.0001). Patients rated incision pain, itching, discoloration, stiffness, thickness, and irregularity. The mean patient score of incisions made with the ACE system was 9.4 ± 9.2 while that of incisions made with the CSS was 9.3 ± 8.5 (P < 0.0001).

Conclusions:

Results showed noninferior wound healing/scar formation in skin incisions made with the ACE system compared with incisions made with a CSS.

Use of electrocautery for coagulation and wound complications in Caesarean sections

Objective. To evaluate the safety of electrocautery for coagulation during Caesarean sections. Study Design. A randomized, controlled, clinical pilot study was performed at a university maternity hospital. After admission for delivery and decision to perform a C-section, volunteers were randomized to either the intervention group (use of electrocautery for coagulation) or nonintervention group. The women were examined at the time of postpartum discharge (day 3), at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were calculated. Results. No significant differences were found between the two groups. Only 2.8% of patients in the intervention group developed surgical wound complications during hospitalization. However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84–2.60). Conclusion. Further studies should confirm whether the use of electrocautery for coagulation does not increase the risk of surgical wound complications in patients undergoing Caesarean sections.

Scalpel versus electrosurgery for abdominal incisions

BACKGROUND

Scalpels or electrosurgery can be used to make abdominal incisions. The potential benefits of electrosurgery include reduced blood loss, dry and rapid separation of tissue, and reduced risk of cutting injury to surgeons, though there are concerns about poor wound healing, excessive scarring, and adhesion formation.

OBJECTIVES

To compare the effects on wound complications of scalpel and electrosurgery for making abdominal incisions.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 24 February 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2); Ovid MEDLINE (1950 to February Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 23 February 2012); Ovid EMBASE (1980 to 2012 Week 07); and EBSCO CINAHL (1982 to 17 February 2012). We did not apply date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effects on wound complications of electrosurgery with scalpel use for the creation of abdominal incisions. The study participants were patients undergoing major open abdominal surgery, regardless of the orientation of the incision (vertical, oblique, or transverse) and surgical setting (elective or emergency). Electrosurgical incisions included those in which the major layers of abdominal wall, including subcutaneous tissue and musculoaponeurosis (a strong sheet of fibrous connective tissue that serves as a tendon to attach muscles), were made by electrosurgery, regardless of the techniques used to incise the abdominal skin and peritoneum. Scalpel incisions included those in which all major layers of abdominal wall including skin, subcutaneous tissue, and musculoaponeurosis, were incised by a scalpel, regardless of the techniques used on the abdominal peritoneum.

DATA COLLECTION AND ANALYSIS

We independently assessed studies for inclusion and risk of bias. One review author extracted data which were checked by a second review author. We calculated risk ratio (RR) and 95% confidence intervals (CI) for dichotomous data, and difference in means (MD) and 95% CI for continuous data. We examined heterogeneity between studies.

MAIN RESULTS

We included nine RCTs (1901 participants) which were mainly at unclear risk of bias due to poor reporting. There was no statistically significant difference in overall wound complication rates (RR 0.90, 95% CI 0.68 to 1.18), nor in rates of wound dehiscence (RR 1.04, 95% CI 0.36 to 2.98), however both these comparisons are underpowered and a treatment effect cannot be excluded. There is insufficient reliable evidence regarding the effects of electrosurgery compared with scalpel incisions on blood loss, pain, and incision time.

AUTHORS' CONCLUSIONS

Current evidence suggests that making an abdominal incision with electrosurgery may be as safe as using a scalpel. However, these conclusions are based on relatively few events and more research is needed. The relative effects of scalpels and electrosurgery are unclear for the outcomes of blood loss, pain, and incision time.

Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision

Background

Skin incisions have traditionally been made using a scalpel. Cutting diathermy, a more recent alternative, is thought to increase the risk of infection, impair healing and decrease cosmesis. Recent studies suggest otherwise, claiming that diathermy may offer potential advantages with respect to blood loss, incision time and postoperative pain. The aim of this meta-analysis was to compare skin incisions made by either scalpel or cutting diathermy.

Methods

A systematic literature search and review was performed for studies published from January 1980 until June 2011. Randomized clinical trials comparing scalpel and cutting diathermy for skin incisions of any operation were included. Primary outcomes included wound complication rate, blood loss, incision times and pain scores.

Results

Fourteen randomized trials met the criteria for inclusion in the meta-analysis, providing outcome data for a total of 2541 patients (1267 undergoing skin incision by cutting diathermy and 1274 by scalpel). The median length of follow-up across all studies was 6 weeks (range 4 days to 19 months). Compared with a scalpel incision, cutting diathermy resulted in significantly less blood loss (mean difference 0·72 ml/cm2; P &lt; 0·001) and shorter incision times (mean difference 36 s; P &lt; 0·001), with no differences in the wound complication rate (odds ratio 0·87; P = 0·29) or pain score at 24 h (mean difference 0·89; P = 0·05).

Conclusion

Skin incisions made by cutting diathermy are quicker and associated with less blood loss than those made by scalpel, and there are no differences in the rate of wound complications or postoperative pain.

Non-thermal plasma induces apoptosis in melanoma cells via production of intracellular reactive oxygen species

Non-thermal atmospheric pressure dielectric barrier discharge (DBD) plasma may provide a novel approach to treat malignancies via induction of apoptosis. The purpose of this study was to evaluate the potential of DBD plasma to induce apoptosis in melanoma cells. Melanoma cells were exposed to plasma at doses that did not induce necrosis, and cell viability and apoptotic activity were evaluated by Trypan blue exclusion test, Annexin-V/PI staining, caspase-3 cleavage, and TUNEL® analysis. Trypan blue staining revealed that non-thermal plasma treatment significantly decreased the viability of cells in a dose-dependent manner 3 and 24 h after plasma treatment. Annexin-V/PI staining revealed a significant increase in apoptosis in plasma-treated cells at 24, 48, and 72 h post-treatment (p < 0.001). Caspase-3 cleavage was observed 48 h post-plasma treatment at a dose of 15 J/cm(2). TUNEL® analysis of plasma-treated cells demonstrated an increase in apoptosis at 48 and 72 h post-treatment (p < 0.001) at a dose of 15 J/cm(2). Pre-treatment with N-acetyl-L: -cysteine (NAC), an intracellular reactive oxygen species (ROS) scavenger, significantly decreased apoptosis in plasma-treated cells at 5 and 15 J/cm(2). Plasma treatment induces apoptosis in melanoma cells through a pathway that appears to be dependent on production of intracellular ROS. DBD plasma production of intracellular ROS leads to dose-dependent DNA damage in melanoma cells, detected by γ-H2AX, which was completely abrogated by pre-treating cells with ROS scavenger, NAC. Plasma-induced DNA damage in turn may lead to the observed plasma-induced apoptosis. Since plasma is non-thermal, it may be used to selectively treat malignancies.

Effect of surgical traumas on microcirculation

Background:

Adequate microcirculation in different tissues maintains the physiological function and heals surgical wounds. In any surgical procedure, the commonly used instruments are cautery, tissue forceps, and clamps. The fact that their inappropriate use produces an adverse effect on microcirculation is often not realized. By this study, we could demonstrate live, the effect of these surgical traumas.

Methods:

The study was conducted on the inferiorly based fasciocutaneous flap with a fascial extension in patients with a distal leg defect. The extended fascial flap was mounted on a glass slide and observed for live microcirculation under ×160 magnification. Three methods were used: (a) cautery in low power, (b) microcrushing forceps to crush the vessels, and (c) noncrushing clamps at the base of the fascial flap.

Results:

It was observed that the vessels are well protected within the deep fascia. Once the fascia was pierced the current damaged the vessel wall. As the wattage was increased, it caused charring of the tissue and multiple vessels ultimately leading to cessation of blood flow. Once the vessel wall was crushed by forceps, blood extravasated in a variable intensity depending upon the size of the vessel. Clamping led to gradual slowing of blood flow with microclot formation. In certain vessels, there was discontinuity in the blood column and ultimately the blood flow stopped.

Conclusion:

This study showed live demonstration of the effect of surgical traumas on microcirculation. It should guide the surgeons to select the use of appropriate instruments which will cause minimal damage to vascularity and thereby lead to a better surgical outcome.

Electrocautery for cutaneous flap creation during thyroidectomy: a randomised, controlled study

Background:

Although electrocautery has been used widely in surgery, the fear of delayed wound healing and infection persists. We aimed to evaluate the risk factors for wound complications and the rate of wound complications, comparing the use of electrocautery or scissors in cutaneous flap creation during thyroidectomy.

Design:

The study group comprised 239 consecutive patients scheduled for thyroidectomy.

Subjects:

Patients were randomly assigned to cutaneous flap dissection by either electrocautery (group one, n = 126) or scissors (group two, n = 113). Age, gender, body mass index, American Society of Anesthesiology score, tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function and surgeon experience were recorded and compared with the rate of post-operative wound complications in both groups.

Results:

There were no significant differences between the overall rate of post-operative wound complications, comparing groups one and two (7.9 vs 10.6 per cent, respectively; p = 0.74). Significant positive correlations were found between wound complication and age (Spearman's rank coefficient (rs) = 0.135, p = 0.036), body mass index (rs = 0.379, p = 0.0001), cutaneous tissue depth (rs = 0.677, p = 0.0001) and tissue weight (rs = 0.643, p = 0.0001). According to logistic regression analysis, a body mass index of more than 27.5 kg/m2 was associated with a 13.7-fold increased rate of post-operative wound complications.

Conclusion:

When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors. Such electrocautery does not increase the risk of wound complications in thyroid surgery.

Healing of abdominal wall aponeurosis of rats after incision with either cold scalpel or electrocautery

PURPOSE: To compare the healing of abdominal wall aponeurosis of rats after incision with either cold scalpel or electrocautery. METHODS: Twelve male adults Wistar inbreed rats weightin 258-362g entered the experiment. They were randomly divided in two groups, control group (N= 6) and experimental group (N= 6). All animals underwent anesthesia followed abdominal wall incision with either cold scalpel (controls) or electrocautery (experimental group). The animals were killed on the 10th day and necropsied. Tissue samples containig the abdominal wall aponeurosis were sent for both histological study and hydroxyproline content assay. RESULTS: The histological study showed no significant difference between the two groups. Hydroxiproline content in experimenral group (128,56 [78,98-198,92] µg /100m) was not significantly different from control group (140,27 [116,20-166,59] mg /100ml; p = 0.53). CONCLUSION: Healing of abdominal wall after dieresis with either cold scalpel or electrocautery are equivalent and do not differ.

Intraoperative handling and wound healing: controlled clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture)

BACKGROUND

Coated polyglactin 910 suture with triclosan was developed recently in order to imbue the parent suture, coated polyglactin 910, with antibacterial activity against the most common organisms that cause surgical site infections (SSI). Because such alterations could alter the physical properties of the suture, this study sought to compare the intraoperative handling and wound healing characteristics of coated polyglactin 910 suture with triclosan and traditional coated polyglactin 910 suture in pediatric patients undergoing various general surgical procedures.

METHODS

This was a prospective, randomized, controlled, open-label, comparative, single-center study. Pediatric patients (age 1-18 years) undergoing various surgical procedures were randomized in a 2:1 ratio to treatment with either coated polyglactin 910 suture with triclosan or coated polyglactin 910 suture. The primary endpoint was the surgeon's assessment of the overall intraoperative handling of coated polyglactin 910 suture with triclosan and traditional coated polyglactin 910 suture without triclosan. The secondary endpoints included specific intraoperative suture handling measures and wound healing assessments. The suture handling measures were (1) ease of passage through tissue; (2) first-throw knot holding; (3) knot tie-down smoothness; (4) knot security; (5) surgical handling; (6) surgical hand; (7) memory; and (8) suture fraying. Assessment of wound healing included the following: Healing progress, infection, edema, erythema, skin temperature, seroma, suture sinus, and pain. Adverse events were recorded.

RESULTS

Scores for intraoperative handling were favorable and not significantly different for both sutures, although coated polyglactin 910 suture with triclosan received more "excellent" scores (71% vs. 59%). Wound healing characteristics were comparable for both sutures except for pain on postoperative day 1. Significantly fewer patients treated with polyglactin 910 suture with triclosan reported pain on day 1 than patients who received the other suture (68% vs. 89%, p = 0.01). The overall incidence of adverse events was 18%; none was devicerelated.

CONCLUSIONS

Coated polyglactin 910 suture with triclosan performed as well or better than traditional coated polyglactin 910 suture in pediatric patients undergoing general surgical procedures. The incidence of postoperative pain was significantly less in patients treated with coated polyglactin 910 suture with triclosan than the traditional suture. We speculate that polyglactin 910 suture with triclosan, by inhibiting bacterial colonization of the suture, reduced pain that can be an indicator of "subclinical" infection. Coated polyglactin 910 suture with triclosan may be a useful alternative in patients at increased risk of developing SSI.

It's time to challenge surgical dogma with evidence-based data

Surgical training is an apprenticeship with surgical techniques passed from one physician to another. Often these techniques are based more on surgical dogma than scientific evidence. Despite surgical dogma to the contrary, electrocautery is the preferred technique for wound creation, and peritoneal closure has no significant advantage over nonclosure. No method of handling the subcutaneous tissue is clearly superior; however, suture closure appears to have some advantages in preventing wound disruption. Subcuticular suture closure results in less pain and better patient satisfaction, and it is more cost-effective than surgical staples. These surgical techniques, as well as many others, need to be subjected to rigorous, randomized prospective trials. It is incumbent on each physician to ensure that his or her surgical techniques are evidence based and not simply the result of adherence to surgical dogma.

A 28-day study of the effect of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 suture with triclosan) on wound healing in guinea pig linear incisional skin wounds

BACKGROUND

This study evaluated the effect of coated polyglactin 910 suture with triclosan on tissue response and wound healing over a 28-day period on full-thickness linear wounds in the hairless guinea pig model.

METHODS

In situ wound strength was assessed, and histopathologic effects on tissue response and wound healing were evaluated. Four (1.9 cm) full-thickness incisional wounds were created on the dorsolateral region (two left and two right, approximately 3 cm apart) in 40 Hartley male hairless guinea pigs (400-500 g). A 1.9-cm segment of suture material was implanted "length-wise" into the incision and the sites closed with simple interrupted closure with 3-0 nylon sutures. The test material was 2-0 coated polyglactin 910 suture with triclosan and the control material was 2-0 Coated VICRYL* Suture (coated polyglactin 910 suture). On days 3, 7, 14, and 28 postimplantation (n = 10/time interval), body weights were recorded, tissue specimens harvested, and bursting strength testing performed.

RESULTS

There was no significant difference (P > 0.05) in bursting strength between the study groups for any of the time intervals studied. The bursting strengths (mm Hg) for the sutures with triclosan were 95.8 (day 3), 268.8 (day 7), 542.6 (day 14), and 633.8 (day 28). Both materials demonstrated comparable tissue response to implantation, and there were no significant differences (P > 0.05) observed in wound healing based on cellular response and collagen formation and orientation.

CONCLUSION

Based on the in vivo biomechanical testing and histological results, no evidence of impedance to wound healing was detected.

Comparative healing of surgical incisions created by a standard "bovie," the Utah Medical Epitome Electrode, and a Bard-Parker cold scalpel blade in a porcine model: a pilot study

A comparative study of skin incision healing using a standard "bovie" and a new design electroscalpel, Utah Medical Products Epitome Electrode (Midvale, UT), was conducted in a porcine model. Wounds were evaluated objectively at 14 and 28 days after surgery using wound bursting strength measurements and histologic wound scoring. Each electrosurgical device was compared with wound healing of cold scalpel incisions as the gold standard using the same criteria. Statistical differences of healing between the bovie and the Epitome indicating preferential healing for the Epitome wounds were demonstrated for bursting strength at 14 days (p = 0.002). Comparisons of the measured "zone of coagulation necrosis" produced by the electroscalpels demonstrated significantly decreased thermal tissue damage favoring the Epitome (p = 0.0003). Greater differences in wound healing favoring the cold scalpel occurred in comparisons of bovie with cold scalpel than Epitome with cold scalpel, and overall results demonstrated healing for the Epitome wounds closely approximated that for cold scalpel. The authors conclude that this new generation electroscalpel provides measurable improvements in incisional wound healing compared to established electrosurgical technology.

A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision

BACKGROUND

Although studies in animals demonstrated a better wound healing after abdominal incision with cold scalpel than with electrocautery, clinical experiences did not confirm these findings. The purpose of this study was to compare early and late wound complications between diathermy and scalpel in gynecologic oncologic patients undergoing midline abdominal incision.

METHODS

Patients undergoing midline abdominal incision for uterine malignancies were divided into two groups according to the method used to perform the abdominal midline incision: cold scalpel and diathermy in coagulation mode. Early and late complications were compared. Logistic regressions were used for statistical analysis.

RESULTS

Nine hundred sixty-four patients were included, of whom 531 were in the scalpel group and 433 in the electrocautery group. Both groups were similar with respect to demographic, operative, and postoperative characteristics. Univariate analysis revealed a higher incidence of severe wound complications in the scalpel group than in the electrocautery group (8 of 531 versus 1 of 433, P <0.05). After adjustment for confounding variables (eg, age, body mass index) no differences were found between groups.

CONCLUSIONS

Scalpel and diathermy are similar in terms of early and late wound complications when used to perform midline abdominal incisions. Therefore the choice of which method to use remains only a matter of surgeon preference.

Electric cautery lowers the contamination threshold for infection of laparotomies

BACKGROUND

Interplay between wound resistance factors and bacterial innoculum determines the risk of surgical infection. Since cautery causes more damage than the scalpel, our hypothesis is that lower numbers of bacteria are required to infect wounds made by electric cautery than to infect wounds made with a scalpel.

METHODS

Abdominal fascia was incised in 375 rats by cold knife, cutting current, or coagulation current. Wounds were innoculated with increasing numbers of bacteria and histologically scored at 7 days for necrosis, inflammation, and abscess.

RESULTS

Coagulation current causes more inflammation, necrosis, and abscesses than the scalpel at all bacterial levels. Electric cutting current is intermediate, causing more damage than the scalpel only after contamination reached 10(5). Above this threshold most wounds were infected in all groups.

CONCLUSIONS

Electric coagulation current should be used only when the need for meticulous hemostasis outweighs the considerably increased risk of infection. Electric cutting current is less destructive but also less hemostatic; indications for its use are difficult to identify.

Electrosurgery in the head and neck

Electrosurgery is widely used in the practice of otolaryngology-head and neck surgery. Despite its popularity, few training programs give formal education in the optimal use of electrosurgical instruments. This article reviews the history, physics, and tissue effects of these commonly used devices. Armed with this knowledge, the head and neck surgeon can take full advantage of electrosurgery's ability to dissect tissues with precision and minimal blood loss.

Acute wound failure

The causes and treatment of acute failure of the abdominal incision are reviewed, along with a summary of studies on fascial healing. Emphasis is placed on taking large bites of tissue during closure to prevent dehiscence. Patient-related risk factors are viewed as less important in the causation of wound failure.

The role of sutures and fibrin sealant in wound healing

Sutures and fibrin sealant are important surgical aids for facilitating wound closure and creating an optimal setting for wound healing. Most commonly, sutures are used to close wounds because suture material provides the mechanical support necessary to sustain closure. A wide variety of suturing material is available, and the surgeon can choose among sutures with a range of attributes to find the one best suited to his or her needs. Considerations when choosing an appropriate suture for wound closure and healing include strength of suture, holding power of tissue, absorbability, risk of infection, and inflammatory reaction associated with the suture material. Other factors to be considered include type of incision, suturing technique, and appearance of wound site. Fibrin sealant, in contrast, is a biologic tissue adhesive that can function as a useful adjunct to sutures. Fibrin sealant can be used in conjunction with sutures or tape to promote optimal wound integrity, or it can be used independently to seal wound sites where sutures cannot control bleeding or would aggravate bleeding. This adhesive can effectively seal tissue planes and eliminate potential spaces. Fibrin sealant has been used clinically in many surgical applications, although an FDA-approved commercially available product does not yet exist in the United States. Clinically, fibrin sealant has resulted in a low rate of infection and has promoted healing. Further study is needed to determine the best fibrin sealant mixtures both to achieve hemostasis and to encourage healing. It may even be desirable to use different sealant formulations for particular clinical situations.

Abdominal incisions from creation to closure

Many of the techniques involved in creating and closing a surgical incision are based on tradition. Over the last several decades, randomized studies have addressed some of the steps in this process. Animal data and human data often have conflicting results. Randomized trials in human subjects indicate: 1) The incision can be made with one, rather than two, scalpels. 2) There is no advantage to using a laser rather than a scalpel when creating the incision. 3) Subcutaneous Penrose drains carried through the incision increase the infection rate. Closed suction drains in the subcutaneous space are rarely indicated. 4) The surgeon does not need to close peritoneum. 5) Time can be saved by closing the fascia in a continuous rather than interrupted fashion without causing an increase in postoperative wound separation or hernia formation. 6) Closing Camper's fascia after a cesarean delivery reduces the incidence of wound separation. 7) The cosmetic appearance of an incision is not improved by closing skin in a subcuticular rather than interrupted fashion.

Sharp Dissection, Electrosurgery, and Argon-Enhanced Electrosurgery in Porcine Skin Flaps

Sharp scalpel dissection, electrosurgery, and argon-enhanced electrosurgery (argon beam coagulation) were used to elevate random pedicled skin flaps in a randomized, blinded fashion with a porcine model. A total of 72 flaps on 9 pigs were examined. Flap survival was quantified, and histology was also reviewed 2 and 6 weeks after surgery. No significant difference among the three techniques was noted in terms of area or length of surviving flaps. There were also no histologic differences noted with regard to fibrosis, inflammatory infiltrate, or necrosis. We conclude that the use of electrosurgery during surgical dissection of random pedicled skin flaps is not detrimental to wound healing or tissue survival, and it provides benefits such as decreased blood loss, absence of the need for sharp instruments in the surgical field, and faster operative times.