Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 2  |  Page : 453--457

Scalpel versus diathermy skin incisions in cesarean sections


Nasser K AbdElaal1, Hamed E Ellakwa1, AllaaEldin F Elhalaby1, AbdElhameed E Shaheen1, Ahmed H Aish2,  
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Ministry of Health, Shoubra, Cairo, Egypt

Correspondence Address:
Ahmed H Aish
Berket Elsabia, Menoufia
Egypt

Abstract

Objective The aim was to compare the use of diathermy versus scalpel in making skin incision during cesarean section to judge the variations in postoperative pain, incision time, incisional blood loss, operative time, wound healing, and wound complications. Background Surgical scalpels are traditionally used for making skin incisions during cesarean delivery. The evolutions in electrosurgical devices bring an alternative method for making skin incision by the usage of cutting diathermy. Patients and methods This was a prospective, randomized comparative study conducted during the period from March 2016 to February 2017 on 200 patients; 100 patients had skin incisions using the surgical scalpel, while 100 patients had skin incisions with diathermy. The comparison between the two groups was done regarding postoperative pain, incision time, incisional blood loss, operative time, wound healing, and wound complications. Results We observed a significant difference between the two groups regarding incision time (P < 0.001), incisional blood loss (P < 0.001), operative time (P < 0.001), and postoperative pain (P < 0.001), where these parameters were less in the diathermy group. No significant difference was observed between the two groups regarding wound healing (P = 0.387) and wound infection rates (P = 0.468). Conclusion The use of diathermy for skin incisions to perform cesarean section in this study was associated with reduced incisional blood loss, incisional time, operative time, and postoperative pain. It had no effect on wound complications, and was not associated with any delay in wound healing. We can conclude that the usage of diathermy in making skin incision during cesarean section in this study achieved better results than scalpel incision.



How to cite this article:
AbdElaal NK, Ellakwa HE, Elhalaby AF, Shaheen AE, Aish AH. Scalpel versus diathermy skin incisions in cesarean sections.Menoufia Med J 2019;32:453-457


How to cite this URL:
AbdElaal NK, Ellakwa HE, Elhalaby AF, Shaheen AE, Aish AH. Scalpel versus diathermy skin incisions in cesarean sections. Menoufia Med J [serial online] 2019 [cited 2019 Nov 20 ];32:453-457
Available from: http://www.mmj.eg.net/text.asp?2019/32/2/453/260929


Full Text



 Introduction



Cesarean section is one of the most frequent and major surgical procedures performed worldwide[1], and it has various operative techniques. The surgical techniques for performing cesarean delivery have changed from time to time, from surgeon to surgeon, and these changes involved both uterine and skin incisions[2]. Surgical scalpels are traditionally used in making skin incisions. Diathermy incisions, on the contrary, are less popular among the surgeons. It has been hypothesized that the application of extreme heat may result in significant postoperative pain and poor wound healing[3]. There has been a widespread use of diathermy for hemostasis, but fear of production of large scars and improper tissue healing has restricted their usage in making skin incisions[4]. Nowadays, electrodes used in making diathermy incision generate a pure sinusoidal current which produces cleavage in the tissue planes without creating damage to the surrounding areas; this is one of the reasons of less damage inflicted to the tissues leading to minimal scar formation[5].

The aim of this study was to compare the use of diathermy versus scalpel in making skin incision during cesarean section to judge the variations in postoperative pain, incision time, incisional blood loss, operative time, wound healing, and wound complications.

 Patients and Methods



This study was approved by the ethics committee of the Faculty of Medicine, Menoufia University. Patients were counseled in detail regarding the merits and demerits of both the incisions, and informed consent was taken from all patients for the procedure to be undertaken. This randomized, comparative study was conducted on patients who attended the Obstetrics and Gynecology Department of Menoufia University Hospital during the period from March 2016 to February 2017 and who underwent elective cesarean section. A total of 200 patients were included in our study. The patients were randomized into two groups: in group A 100 patients had diathermy skin incision, while the 100 patients in group B had scalpel skin incision.

The sample size was estimated using the G*Power software version 3.1.2 (Institut für Experimentelle Psychologie, Heinrich Heine Universität, Düsseldorf, Germany). It was estimated that a sample size of 100 patients in each group would achieve a power of 0.8 to detect an effect size of 11.63[5], when the α-error was 0.05. The test statistic used for calculation was the independent samples Student's t-test.

Inclusion criteria and randomization

We enrolled in our study all the pregnant women expecting elective cesarean section in the inpatient ward of the Department of Obstetrics and Gynecology of Menoufia University Hospital from March 2016 to February 2017. Postoperatively, all candidates were kept under follow-up for 24 h to assess the postoperative pain, then, after discharge from the hospital, they attended the outpatient clinic during the first week for wound assessment. Cesarean section indications in our study were: prior cesarean deliveries, maternal request, contracted pelvis, cephalopelvic disproportion, fetal malpresentations, and multiple pregnancies. Patients were randomized into two groups and allocation of patients into scalpel or diathermy group was done by computerized randomization using the Research Randomizer program (Institute for Healthcare Improvement, Boston, MA 02109 USA). Numbered, closed envelopes were used to hide the patient group assignment. These envelopes were opened in the operating suite just before the start of the operation.

The exclusion criteria were patients with incomplete data, patients who were lost to follow-up, urgent cesarean delivery (to avoid the accompanying variability and the special circumstances related to the urgent cesarean section that may affect our study results), diabetes mellitus, anemia, cardiopulmonary disease, hepatic impairment, renal disease, and immunocompromised patients.

All patients were subjected to the following: for all patients of the study history was taken, general examination, abdominal examination (assessment of fundal level for fetal dating) and investigations (complete blood count, prothrombin time, partial thromboplastin time, international normalized ratio, urine analysis, and ultrasonography for fetal dating) were done and recorded for exclusion of patients with any medical disorder or any contraindication to general anesthesia. All the operations were performed under general anesthesia for good assessment of postoperative pain. Antibiotic prophylaxis was used (intravenous cefradine, 1 g) at the time of induction of anesthesia. According to each group, the skin and subcutaneous tissue were incised with scalpel or a diathermy pen electrode (Eschmann E30 Electrosurgical Unit, Health Care Equipment and Supplies Ltd, Staines, United Kingdom) set on the cutting mode delivering pure sinusoidal current of 360 kHz by a low-transverse incision till parietal peritoneum which was opened bluntly. The uterus was opened with ordinary scalpel in both groups. Coagulation diathermy was used for hemostasis, while large subcutaneous veins were secured and ligated in patients of both groups. Closure was in layers (uterus, peritoneum, muscles, and sheath). Subcutaneous tissue was sutured with vicryl 2-0, and skin was sutured subcuticularly with proline 2-0 with no subcutaneous drain. The incision time was defined as the start of the skin incision till the intended operation site was reached with complete hemostasis. Incisional blood loss being the blood loss that occurred strictly during the period of skin incision, and this was calculated as the differences between the dry and wet weight of the swabs (1 mg = 1 ml). Postoperative analgesia was administered through the intramuscular route using diclofenac sodium (75 mg/dose). A single dose was administered for all patients on admission to postanesthesia care unit and other doses were administered according to the severity of pain. Postoperative wound assessment both for healing and surgical site infection were assessed concurrently on the first week postoperatively in the outpatient clinic. The presence of a healing ridge with adequate tensile strength was used as an index of a healing wound, while the Southampton wound scoring system was used to denote the presence or absence of an infection.

Primary outcome variable was postoperative pain which was measured using visual analog scale (VAS), while secondary outcome variables were incision time, incisional blood loss, operative time, wound healing, and wound complications. Pain was assessed using the VAS. VAS is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end as shown in [Figure 1]; the patient marks on the line at the point that they feel represent their perception of their current state. The VAS score is determined by measuring in millimeters from the left hand end of the line to the point that the patient marks[6].{Figure 1}

Statistical analysis

Data were collected, coded, revised, and entered to the statistical packages for social sciences (IBM-SPSS, Chicago, Illinois, USA), version 20. The data were presented as number and percentages for the qualitative data, mean, SD, and ranges for the quantitative data with parametric distribution and median with interquartile range for the quantitative data with nonparametric distribution. χ2-Test was used in the comparison between the two groups with qualitative data and Fisher's exact test was used instead of the χ2-test when the expected count in any cell was found to be less than 5. Independent t-test was used in the comparison between two means with parametric distribution and Mann–Whitney test was used for nonparametric distribution. P value was considered significant if less than 0.05.

 Results



A total of 200 patients were included in the study: 100 patients had skin incised with scalpel, while 100 patients had skin incised with diathermy (cutting mode). Demographic characteristics of patients revealed that the mean of age in the diathermy group was 28 years ranging from 21 to 35 years, while in the scalpel group was 28.5 years ranging from 20 to 36 years. Also, the mean of body mass index in the diathermy group was 28.8 kg/m2, while in the scalpel group was 29 kg/m2. Furthermore, there was no significant difference between the two groups regarding age (P = 0.151) and BMI (P = 0.638) [Table 1]. Comparison between diathermy and scalpel groups regarding pain scores measured by the VAS revealed that there was high statistically significant differences between scalpel and diathermy patients at 1, 4, 8, 16, and 24 h postoperatively, whereas the pain scores were less in the diathermy incision patients with a differences of 11.6, 11.6, 14.9, 12.1, 10.5, respectively (P < 0.001) [Table 2]. There was a high statistically significant difference as regards incisional blood loss between scalpel and diathermy groups with a 10 ml less blood in the latter (P < 0.001). Also, there was a high statistically significant difference as regards incision time between scalpel and diathermy groups with a 56.5 s less in the latter (P < 0.001), and a high statistically significant difference as regards the operative time also noted between scalpel and diathermy groups with a 3.5 min less in the latter (P < 0.001) [Table 3]. As regards analgesic consumption, comparison between diathermy and scalpel groups was done and there was a significant difference in two doses of analgesic consumption as it was significantly higher in the diathermy group (P < 0.001), while as regards three doses of analgesic consumption it was significantly higher in the scalpel group (P < 0.001). There was no significant difference between diathermy and scalpel groups regarding wound infection (P = 0.468) and seroma (P = 0.694). Also, there was no significant difference between the two groups regarding cosmetic acceptability (P = 0.229) and mode of healing (P = 0.387) [Table 4].{Table 1}{Table 2}{Table 3}{Table 4}

 Discussion



Surgical scalpels are traditionally used in making skin incisions; diathermy incisions on the contrary are less popular among the surgeons. It has been hypothesized that application of extreme heat may result in significant postoperative pain and poor wound healing because of excessive tissue damage and scarring, respectively; moreover, skin incision with the use of diathermy entails increased risk of wound infections in the presence of an underlying prosthetic material[3]. Different studies and meta-analyses comparing diathermy with scalpel for incisions proved different. This is due to the observation that there is no change in wound complication rate or postoperative pain with the use of diathermy[7]. Several studies have shown that diathermy is increasingly being used for making skin incisions, securing hemostasis, dissecting tissue planes and cutting. It facilitates hemostasis, reduces overall intraoperative time, and lastly produce a wound that heals similarly as the one created by the scalpel[4],[8]. In this study we compared scalpel versus diathermy in skin incision during the cesarean section regarding incision time, incisional blood loss, operative time, postoperative pain, wound healing, and wound complications. The present study showed a significantly shorter incision time in the diathermy group compared with the scalpel group with a 56.5 s difference, this was in agreement with that of Priya et al.[8], both showed a significantly shorter incision time in the diathermy group. Conversely, our findings were in contrast to those of Prakash et al.[9], as the latter suggested no added advantage with diathermy skin incision in terms of the incision time, this contradiction was most probably due to a smaller number of patients in their study (82 patients). Also, operative time in the current study showed a significant difference between diathermy and scalpel, being shorter in diathermy. In the present study, diathermy incision was associated with significantly less blood loss than scalpel incision; the mean blood loss in the diathermy group was 12.44 ± 1.83 ml, while in the scalpel group was 22.34 ± 4.80 ml. The reduced incisional blood loss in the diathermy group was in concordance with the studies by Arsalan et al.[10], Ayandipo et al.[5], and Ismail et al.[11]. This was due to the coagulative effect of diathermy on the microcirculation of the area immediately adjoining the area of the incision. As regards pain intensity, the VAS showed statistically significant differences between scalpel and diathermy at 1, 4, 8, 16, and 24 h postoperatively, where the pain scores were less in the diathermy incision patients with a differences of 11.6, 11.6, 14.9, 12.1, 10.5, respectively. This was consistent with the study byRagesh et al.[12] that compared postoperative pain in patients having knife or diathermy skin incision during hernia surgery. Also, in accordance with Priya et al.[8], our results pointed to a significantly reduced postoperative pain in the diathermy group, this is due to the thermal effect of diathermy on the sensory nerve fibers with the subsequent disruption of transmission of nerve impulses. Cell vaporization caused by the application of a pure sinusoidal current leads to immediate tissue and nerve necrosis without significantly affecting the adjoining structures[13]. On the other hand, Prakash et al.[9] compared the diathermy incision with scalpel incision for midline laparotomy and reported that the two techniques were similar in concern of postoperative pain. Regarding wound infection, in the present study there was no significant difference between the two groups, this went contradictory to other studies[14],[15]which pointed out that electrocautery had lowered the postoperative threshold for infection. Furthermore, the findings that there were no difference in wound healing and wound infection were in consistency with the study by Aird et al.[16]; their study compared both the techniques in making skin incision during bowel resection and stated that cutting diathermy was a cosmetically acceptable technique for abdominal skin incisions without increased risk of wound infection. The mean duration for complete wound healing was similar for both groups; this was in consistency with a previous study[5] which stated that there was no difference in the duration of wound healing between diathermy and scalpel skin incisions.

 Conclusion



The use of diathermy for skin incisions in cesarean section in this study was associated with reduced incisional blood loss, incisional time, operative time, and postoperative pain. It had no effect on wound complication rates, and was not associated with any delay in wound healing. We can conclude that proper usage of diathermy in making skin incision during cesarean section in this study achieved better results than scalpel incision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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