Surgery Without a Scalpel?

Dear Readers: Complications can increase the clinical quality of life and economic burden of patient surgery. Causes may originate from patient, surgeon, technique and/or environmental variables associated with pre-, intra-, and/or post-operative management. Gradually, research is clarifying the effects and interactions of all these variables to improve outcomes for patients undergoing surgery. As new techniques emerge, they are tested in randomized controlled trials (RCTs) for evidence of efficacy and safety. This Evidence Corner reviews two such RCTs that evaluate safety and efficacy of two electro-surgical techniques for cutting tissue. Will either replace the scalpel or scissors? Only time and further research will tell. Laura Bolton, PhD, FAPWCA Adjunct Associate Professor Department of Surgery, UMDNJ WOUNDS Editorial Advisory Board Member and Department Editor

Diathermy or Scalpel for General Surgery

     Reference: Shamim M. Diathermy vs. scalpel skin incisions in general surgery: double-blind, randomized, clinical trial. World J Surg. 2009;33(8):1594–1599.      Rationale: Thermal surgery offers an alternative to conventional surgery with a scalpel.      Objective: Compare measured outcomes of general surgery incisions made using diathermy versus scalpel.      Methods: A prospective, double-blind, RCT compared outcomes of elective or emergency general surgery performed using either diathermy (n = 185) or surgical scalpels (n = 184) at Fatima Hospital-Baqai Medical University and Shamsi Hospitals in Karachi, Pakistan, from January 2006 to December 2007. The only excluded patients were those with missing data or those lost to post-surgical follow up. Investigators measured and analyzed surgical wound classification, length and depth of incision, time to make the incision, duration of operation, incisional blood loss, postoperative pain, length of hospital stay, time to heal and postoperative complications.      Results: Time to make the incision was shorter with less blood loss during surgery and lower patient-reported pain levels during the first 48 hours after surgery for the diathermy group (P Electrocautery or Scissors for Cutaneous Flaps      Reference: Barbaros U, Erbil Y, Aksakal N, et al. Electrocautery for cutaneous flap creation during thyroidectomy: a randomised, controlled study. J Laryngol Otol. 2008;122(12):1343–1348.      Rationale: Fear persists that electrocautery may delay wound healing and increase the likelihood of infection.      Objective: Evaluate risk factors for complications following cutaneous flap surgery performed using electrocautery or scissors during thyroidectomy.      Methods: A prospective RCT compared the incidence of post surgical complications for cutaneous flap dissections made for thyroidectomies using electrocautery (n = 126) or scissors (n = 113) in an acute care University Hospital in Turkey. Within each group effects of age, gender, body mass index, American Society of Anesthesiology score, flap tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function, and surgeon experience were correlated with the rate of post-operative wound complications.      Results: Electrocautery patients experienced 7.9% complications, a similar incidence to the 10.6% experienced by patients whose surgery was performed with scissors (P = 0.74). Within groups, significant risk factors for post surgical complications were: higher body mass index (P = 0.0001), deeper wound depth (P = 0.0001), greater tissue flap weight (0.0001), and more advanced age (P = 0.036). Patients with a body mass index of more than 27.5 kg/m2 were 13.7 times more likely to experience a post-operative wound complication.      Authors’ Conclusions: When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors.

Clinical Perspective

     Alternatives to steel instruments for surgical procedures such as laser ablation,¹ electrocautery, or diathermy seem to be earning a place in the surgical armamentarium. While more well-conducted, double-blind RCTs are needed in a wider variety of surgical procedures, these two studies represent important steps to clarify effects of electro-surgery. Though these techniques are not without risk, strict adherence to safety protocols helps reduce associated risks to patient and surgical staff, such as burn or electrical injury or plume inhalation.² Consistent post-surgical risks have not been reported. A recent Cochrane review³ of RCTs comparing scalpel versus no-scalpel vasectomy surgery reported that the no-scalpel technique reduced operating time, bleeding, infection, hematoma formation, and patient-reported pain without altering effectiveness of the procedure, reinforcing the findings of Shamim for general surgery. More RCTs and clearer operational definitions are needed to determine the optimal frequency, intensity, and wave forms for laser or electro-surgery,¹ but it appears that these and other non-scalpel alternatives may improve patient outcomes for some common operations.