General Anaesthesia Diathermy 68 79.8%
Scalpel 67
Spinal Anaesthesia Diathermy 5 5.7%
Scalpel 4
Local anaesthesia Diathermy 12 13.5%
Scalpel 11
Total number of cases 167 100%
Out of the 167 procedures done, 107 (64%) were classified as a clean procedure while 60 (35.9%) were classified as clean contaminated. General anaesthesia was administered in 79.8% while spinal and local anaesthesia were in 5.7% and 13.5% of patient respectively as shown in figure 2 above.
0 10 20 30 40 50 60 70 80
Local Anaesthe
sia
Spinal anaesthe
sia
General Anaesthe
sia
Percentage (%) 13.5 5.7 79.8
PERCENTAGE
MODE OF ANAESTHESIA
Analgesia was administered mainly via the intravenous route; given in 150 patients (94%), while 17 patients (5.9%) had oral analgesia.
There was no statistical significance /difference in both groups of patients with analysis of the following
a. Length of incision–Diathermy-10.8-14.0cm/Scalpel-10.4-13.8cm- (P =0.570).
b. Depth of incision –Diathermy-1.8-4.4cm/Scalpel-1.8-4.6cm- (P = 0.952).
Table 4g: Wound Infection Rate
Class of Surgery Wound
infection
p-value
Clean (107) Diathermy 52 1 0.206
Scalpel 55 3
Clean – Contaminated (60) Diathermy 31 5
Scalpel 29 8
Total Number of cases 167 17
Table 4h: Mode of Analgesia
Mode of Analgesia Mode of incision Number Percentage
Intravenous Diathermy 73 94%
Scalpel 77
Oral Diathermy 9 5.9%
Scalpel 8
Total Number of cases 167 100%
Comparison of Outcomes Variables (Quantitative) with Mode of Incision using Independent Student –Test.
The time for complete wound healing was comparable in both groups of patients with delay in wound closure in a total of 11 patients (6.6%); with 4 occurring in the diathermy group and 7 in the scalpel group respectively; these occurred mostly in the group of patients with wound infection and was not statistically significant (P=0.198). The incision time was noted to have been shorter in the diathermy group when compared to the scalpel group, it was 78.61±49.44 seconds and 130.42±71.76 seconds respectively (P< 0.001) (Table 4e).
The volume of blood loss when using the diathermy to make the skin incision was 6.53±3.84ml while in the scalpel group it was 18.16±7.36ml (P=0.011) (Table 4e).
Comparison of post- operative pain in both groups showed a cumulative numerical rating scale score of 12.65±8.06 in the diathermy group and 17.12±9.49 in the scalpel group (P= 0.001).
Table 4i: Statistical analysis of quantitative outcome variables with mode of incision.
*95% confidence interval is relative to the diathermy group.
*SD-standard deviation
*No-number
Outcome variable No. Mean±SD P-value
Incision time(sec) Diathermy Scalpel Total
84 83 167
78.61±49.44 130.42±71.76 104.20±66.66
0.001
Incision Blood Loss(ml) Diathermy
Scalpel Total
84 83 167
6.53±3.84 18.16±7.36 12.24±8.24
0.011
Post-Operative Pain Rating Diathermy
Scalpel Total
84 83 167
12.65±8.06 17.12±9.49 14.89±9.06
0.001
Table 4j: Mode of Healing versus Mode of Incision
Mode of Healing Mode of incision
Number Percentage P-value
Primary wound healing Diathermy 76 93.4% 0.210 Scalpel 80
Delayed wound healing Diathermy 4 6.6% 0.198 Scalpel 7
Total number of cases 167 100%
Statistical Analysis of Categorical Outcome Variable using Chi-test.
Wound infection occurred in a total of 17 patients (10.4%); with 6 occurring in the diathermy group and 11 in the scalpel group respectively. Their difference was not statistically significant (P= 0.206).
There was delay in wound closure in 11 (6.6%) patients; with 4 occurring in the diathermy group and 7 in the scalpel group respectively; these occurred in the patient who had wound infection and was not statistically significant (P=0.198)
Untoward event of use of diathermy
There was no incidence of diathermy burns, fire, electrocution or any other complication attributable to the use of diathermy during the period of the study.
Scar complication
There was no keloid or hypertrophic scar noted during the course of the study.
CHAPTER FIVE DISCUSSION
Several studies have shown that diathermy is increasingly being used for hemostasis, tissue dissection and cutting 2, 7, 8, 30. Similarly, diathermy has been shown to make hemostasis quick and satisfactory, reduce intra operative time and lastly produce an incisional wound that heals as well as one created by the cold scalpel2. In spite of the above, its use by surgeons is still sub-optimal. This reluctance is partly or wholly attributable to the belief that electro-cautery increases devitalized tissue within a wound, increases wound infection, increase scar formation and delays wound healing.
These concerns have not been substantiated by recent studies on skin incision techniques, which have shown faster operating times, reduced blood loss, reduced post-operative pain and lesser analgesia requirements with diathermy compared to scalpel incision92.The distribution of surgical cases is similar in both the scalpel and the diathermy group in this study. The spectrum of surgical cases is not unexpected. Mastectomy for breast carcinoma (25%) accounted for the highest proportion of the procedures performed in both groups, and this is consistent with the increased awareness and subsequent management of the disease. Herniorrhaphy for groin hernias (14.5%) and subtotal thyroidectomy for simple multinodular goiter followed thereafter for the diathermy group and scalpel group respectively. This is in slight contrast to the study by Shamim et al92, who had more of open cholecystectomy for cholelithiasis (16.2%) followed by herniorrhaphy for inguinal hernia (14.7) in
their own study. The disparity in highest number of cases done can be explained by the sub-specialization of the surgical units from which the patients were recruited and regional variation in the epidemiology of diseases.Slightly over a quarter (28.6%) of the patients recruited for the study had co-morbidities.
Hypertension ranked highest, it was seen in 16%, this falls within the 4 - 28%
prevalence reported by other authors93, 94, 95.
The study showed a significantly shorter incision time in the diathermy group than in the scalpel group, which is contrary to the findings from the study by Telfer et al96; they showed that there was no advantage with diathermy in relation to the incision time. However, this study corroborates the findings by various other authors2, 91, 96. In this study there was a reduction in the incisional blood loss in the diathermy group compared to the scalpel group, this is in concordance with the findings by Arsalan et al97. The mean blood loss in this study for the diathermy group was 1.53ml±3.84ml while theirs was 1.43±0.201ml. This is explained by the coagulative effect of the diathermy machine on the micro-circulation of the area that is immediately adjoining the area of the incision. The post-operative pain reported in the diathermy group was significantly lower than in the scalpel group in this study. The findings tally with the findings by Kearn’s et al whose study showed that diathermy is associated with significantly less early post-operative pain; the thermal effect of diathermy on the sensory nerve fibres, and subsequent disruption of transmission of nerve impulses has been theorized to be responsible for the
making skin incision. Arsalan et al however adjudged that there was an insignificant difference in both groups in terms of post-operative pain. The postoperative pain assessment was not compared with the site of surgery because of the varied sites of surgery and also the possible confounders had been withered down viz the analgesia was uniform, surgery was performed on only clean and clean contaminated cases and lastly the degree of intraoperative dissection may also impact on evolution of postoperative pain.
The wound infection rate was slightly higher in this study (10.4%) compared to the 5% reported by Arsalan S. et al, but the conclusion as was in this study was that it was statistically insignificant.
Franchi et al30 who had a larger and more cosmopolitan group of patients also concluded that there was no difference between the two groups with respect to early and late wound complications including wound infection.
Chrysos et al36 in their own study on prosthetic mesh inguinal hernioplasties also showed no difference in terms of wound infection. The time for complete wound healing were almost the same for both groups; this is akin to Shamim M's findings. There was no adverse event noted during the course of the study attributable to the use of diathermy.
Limitations
The last objective in which scar complications were compared was considered only within the short duration period of the study; by which time the wounds were still in the early maturation phase. To objectively assess for the occurrence of hypertrophic scars and keloids, one will need a minimum of two years. This will be done as a follow up to this study.
CONCLUSION
The use of diathermy in making skin incisions is associated with reduced incisional blood loss, incision time and post-operative pain. It has no effect on wound closure (epithelialization) and is not associated with any delay in wound healing. It has been adjudged safe in this study if used in the proper way and manner, with no side-effects.
RECOMMENDATIONS
In view of the above findings, the increasing use of the electrocautery should be encouraged by increasing availability of the machines; training personnel involved in the use and patient enlightening measures should also be incorporated Lastly, the benefits of reduction of sharps injury, also makes it more pertinent that electrocautery machines should be used more in the course of operating.
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APPENDIX I
QUESTIONNAIRE ON THE OUTCOME OF DIATHERMY SKIN INCISION VERSUS SCALPEL SKIN INCISION IN GENERAL SURGERY DIVISION OF THE
UNIVERSITY COLLEGE HOSPITAL, IBADAN.
Hospital number: ……..………...………..
Patients address at work:………..
Patients address at home:………..
Phone No.: ………. Age: ……….
Next of kin Address: ………..Sex: ……….
Next of kin phone number:………
Religion: Christianity Islam Others
Highest level of education attained: Primary Secondary Tertiary Occupation: ………..
Mode of presentation: Emergency Elective Diagnosis: ………
Co-morbidities: Diabetes Mellitus Hypertension
Heart disease Renal impairment
Protein malnutrition Jaundice Others: ………..
Medications (Premorbid) use ………..………
Medications (Steroid) use ……….………
Medications (Chemotherapy) use ………
Investigation results: FBC: PCV………. FBS/RBG…………..
WBC ………Clotting profile………..
Platelets………..
Urinalysis: ………
Plain X-rays: ……….………..………
CT scan: ……….………
MRI: ………..………
Contrast studies: ………
Serum protein: Total……….Albumin………
Mode of anesthesia: L.A. Subarachnoid Block Regional block General anesthesia
Operation performed: ………
Cadre of Surgeon :……….……….
Type of procedure: Clean Clean contaminated
Antibiotic prophylaxis: Yes No If yes, specify: ……….
Mode of incision: Diathermy Length of wound (cm) ………….
Scalpel
Previous surgical scar encountered: Yes No Incision time (sec):………
Incision blood loss (ml):……….
Wound depth (cm):………Operative time (min): ………
Wound contamination Yes No Break in Surgical Technique Yes No Use of drain: Yes No
Type: Passive Active
Material of closure: Fascia Subcutaneous Skin Change of clinical diagnosis (Intra-operative): Yes No
Post operative analgesia:………