The right method for midline laparotomy: what is the best choice for wound healing?

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.

Pilonidal sinus disease: Preliminary case-control study on heat-related wound dehiscence

Background

Pilonidal disease is a morbid condition of the young population, that could impair quality of life with a high cost for the health care system. No consensus exists on optimal surgical treatment, even if several techniques have been proposed. In this preliminary case-control study we compared excision by knife and diathermy to investigate if wound dehiscence could be related to heat spreading during excision of the sinus.

Materials and method

Between January 2017 and February 2018, 29 patients underwent to sinus excision.16 patients underwent sinus excision by diathermy (named “Hot” group, case-group) while 13 patients underwent excision by the knife as the control group (named “Cold” group). The temperature data were recorded for both groups. Were considered primary and secondary outcomes.

Results

the cold group has worse outcomes in operative time and blood loss, but better results in post-operative pain at first day and first control, number of weekly and total dressings until healing, time for full wound recovery, days to return to work, patient feeling feedback and scar aspect. Wounds healed within 8–12 days were 84.6% in the Cold group and 18.8% in the Hot one. I° Dindo-Clavien complications were respectively 15.4% and 100.0% for the Cold and Hot group. No differences were recorded for II° Dindo-Clavien complications and in days of hospitalization.

Conclusion

cold excision of the sinus pilonidalis has better results both in terms of precarious healing and quality of life, probably because the tissues are not subjected to diathermocoagulation damage and therefore the healing occurs more quickly. (United States National Institutes of Health, www.clinicaltrial.gov, number NCT 03764657, www.researchregistry.com UIN 5003).

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Pilonidal sinus disease.

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Cold and Hot surgical procedures.

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Wounds healed within 8–12 days were 84.6% in the Cold group and 18.8% in the Hot one. I° Dindo-Clavien complications were 15.4% for the Cold and 100.0% for the Hot group.

Randomized, clinical trial on diathermy and scalpel incisions in elective general surgery

BACKGROUND

Since a long time skin incisions have routinely been made with scalpels. Now a day there is a shift in trend from this method to electrosurgical skin incisions. However, fear of bad scars and improper wound healing has prevented its wide spread use. This Study aimed to compare both methods of skin incisions for different variables.

OBJECTIVES

The aim of this study was to examine incisional time, blood loss during incision and postoperative wound complications and pain with both methods of skin incision.

PATIENTS AND METHODS

A prospective, comparative and randomized study was conducted at different hospitals of Hyderabad and Nawabshah, Pakistan from 1(st) of December 2009 to 30(th) of November 2011. The study included patients of either sex above the age of five years with general surgical pathology who were to undergo surgery. these candidates were randomly put into two groups. In Group A patients incision was made with a scalpel and in group B with diathermy. Data was analyzed for age, sex, comorbid illness, incisional time, blood loss during incision making and postoperative pain and wound complications.

RESULTS

A total of 283 patients completed the follow-up and were included in the final analysis. Group A comprised of 143 (50.53%) patients; 83 (58%) males and 60 (42%) females with a mean age of 36.03 years. Amongst the 140 patients of group B, there were 85 (60.7%) males and 55 (39.3%) females with a mean age of 36.52 years. Twenty-five (17.48%) patients of group A and 27 (19.28%) of group B had comorbid illnesses. Mean incision time was 8.9025-sec/cm(2) for group A and 7.3057 sec/cm(2) for group B patients. Mean blood loss during incision making was 1.8262 mL/cm(2) and 1.1346 mL/cm(2) for group A and B patients, respectively. Pain was 5.2957 for group A patients on day one and 3.1181 for group B patients. Pain score was 2.1049 and 1.6206 on day two and 0.8191 and 0.7192 on day five, for group A and B patients, respectively. Postoperative wound complications were noticed in 26 (18.18%) patients of group A and 22 (15.71%) patients of group B.

CONCLUSIONS

Diathermy incision is a safe and expedient technique. It takes less time than scalpel incision and loss of blood is also lower during incision. Diathermy is associated with lesser post-operative pain and complications than the scalpel incision. Diathermy should be method of choice in general elective surgery.

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.

Use of an ultrasonic blade facilitates muscle repair after incision injury

BACKGROUND

The ultrasonic Harmonic Blade cuts and coagulates soft tissue at temperatures lower than conventional electrosurgery. This study investigated whether improved hemostatic control and reduced collateral damage in skeletal muscle incisions translates into improved myofiber regeneration, reduced fibrosis and faster muscle recovery.

MATERIALS AND METHODS

Transections in the left gastrocnemius muscles of mice were made with the Harmonic Blade, and contralaterally, with either cold steel scissors or electrosurgery. Histology up to 8 wk after surgery was performed to evaluate myofiber regeneration and fibrosis. Tissue inflammation (Gr1+ neutrophils) and vascularization (CD31+ capillaries) were assessed immunohistochemically at 1 wk .

RESULTS

Overall the Harmonic Blade showed significantly higher level of muscle regeneration than cold steel. Fibrosis for both the Harmonic Blade and cold steel decreased three-fold over the 8 wk period, while electrosurgery yielded significantly increasing fibrosis through wk 4 before declining. At 1 wk post-surgery the Harmonic Blade induced less inflammation than electrosurgery, and higher vascularization than electrosurgery and cold steel.

CONCLUSIONS

Harmonic Blade-incised tissue showed accelerated vascularization, slight reduction of inflammation, enhanced muscle regeneration and decreased scarring, demonstrating a more effective healing process than electrosurgery.

Electrocautery causes more ischemic peritoneal tissue damage than ultrasonic dissection

BACKGROUND

Minimizing peritoneal tissue injury during abdominal surgery has the benefit of reducing postoperative inflammatory response, pain, and adhesion formation. Ultrasonic dissection seems to reduce tissue damage. This study aimed to compare electrocautery and ultrasonic dissection in terms of peritoneal tissue ischemia measured by microdialysis.

METHODS

In this study, 18 Wistar rats underwent a median laparotomy and had a peritoneal microdialysis catheter implanted in the left lateral sidewall. The animals were randomly assigned to receive two standard peritoneal incisions parallel to the catheter by either ultrasonic dissection or electrocautery. After the operation, samples of microdialysis dialysate were taken every 2 h until 72 h postoperatively for measurements of pyruvate, lactate, glucose, and glycerol, and ratios were calculated.

RESULTS

The mean lactate-pyruvate ratio (LPR), lactate-glucose ratio (LGR), and glycerol concentration were significantly higher in the electrocautery group than in the ultrasonic dissection group until respectively 34, 48, and 48 h after surgery. The mean areas under the curve (AUC) of LPR, LGR, and glycerol concentration also were higher in the electrocautery group than in the ultrasonic dissection group (4,387 vs. 1,639, P=0.011; 59 vs. 21, P=0.008; 7,438 vs. 4,169, P=0.008, respectively).

CONCLUSION

Electrosurgery causes more ischemic peritoneal tissue damage than ultrasonic dissection.