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

Needle-tip electrocautery versus steel scalpel incision in neurosurgery: study protocol for a prospective single-centre randomised controlled double-blind trial

INTRODUCTION

Electrocautery is used widely in surgical procedures, but making skin incision has routinely been performed with scalpel rather than electrocautery, for fear that electrocautery may cause poor incision healing, excessive scarring and increased wound complication rates. More and more studies on general surgery support the use of electrocautery for skin incision, but research comparing the two modalities for scalp incision in neurosurgery remains inadequate. This trial aims to evaluate the safety and efficacy of needle-tip monopolar for scalp incision in supratentorial neurosurgery compared with steel scalpel.

METHODS AND ANALYSIS

In this prospective, randomised, double-blind trial, 120 eligible patients who are planned to undergo supratentorial neurosurgery will be enrolled. Patients will be randomly assigned to two groups. In controlled group scalp incision will be made with a scalpel from the epidermis to the galea aponeurotica, while in intervention group scalp will be first incised with a steel scalpel from the epidermis to the dermis, and then the subcutaneous tissue and galea aponeurotica will be incised with needle-tip monopolar on cutting mode. The primary outcomes are scar score (at 90 days). The secondary outcomes include incision pain (at 1 day, on discharge, at 90 days) and alopecia around the incision (at 90 days), incision blood loss and incision-related operation time (during operation), incision infection and incision healing (on discharge, at 2 weeks, 90 days).

ETHICS AND DISSEMINATION

This trial will be performed according to the principles of Declaration of Helsinki and good clinical practice guidelines. This study has been validated by the ethics committee of West China Hospital. Informed consent will be obtained from each included patient and/or their designated representative. Final results from this trial will be promulgated through publications.

TRIAL REGISTRATION NUMBER

ChiCTR2200063243.

Comparing the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery

Background

Due to the sensitivity of the surgical site and a higher probability of injury, the use of a scalpel and electrocautery to create an incision in the spine is discussed. In this study, we will compare the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery.

Materials and methods

This study was conducted in Iran as a randomized controlled trial with double-blinding (1,401). Sixty candidates for spine surgery were randomly divided into two groups of 30 using electrocautery (A) and a scalpel (B) based on available sampling. The VAS scale was used to assess postoperative pain. The duration of the incision and intraoperative blood loss were recorded. The infection and fluid secretions were determined using the Southampton scoring scale. Utilizing the Manchester scar scale, the wound healing status was evaluated. The SPSS version 16 software was used for data analysis (t-test, Mann-Whitney U, ANOVA).

Results

The electrocautery group had substantially lower bleeding, pain, and wound healing rates than the scalpel group (P > 0.05). However, the electrocautery group had significantly longer surgical times, more secretions, and a higher infection rate than the scalpel group (P > 0.05). In terms of demographic and clinical characteristics, there was no significant difference between the two groups (P < 0.05).

Conclusion

Electrocautery reduces postoperative hemorrhage and, potentially, postoperative pain in patients. However, as the duration of surgery increases, so does the duration of anesthesia, and patient safety decreases. Additionally, the risk of infection increases in the electrocautery group compared to the scalpel group, and the rate of wound healing decreases.

Clinical Trial Registration

https://www.irct.ir/, identifier (IRCT20230222057496N1).

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.

Cutting electrocautery versus scalpel for surgical incisions: a systematic review and meta-analysis

BACKGROUND

Although cutting electrocautery can be superior to the scalpel in reducing blood loss and incisional time, several reports associated electrocautery with higher rates of wound infection, impaired healing, and worse cosmesis. We performed this systematic review and meta-analysis to compare cutting electrocautery versus scalpel for surgical incisions.

MATERIALS AND METHODS

We conducted a computerized literature search of five electronic databases and included all published original studies comparing cutting electrocautery and scalpel surgical incisions. Relevant data were extracted from eligible studies and pooled as odds ratios (ORs) or standardized mean difference (SMD) values in a meta-analysis model, using RevMan and Comprehensive Meta-analysis software.

RESULTS

Forty-one studies (36 randomized trials, four observational, and one quasirandom study) were included in the pooled analysis (6422 participants). Compared with the scalpel incision, cutting electrocautery resulted in significantly less blood loss (SMD = -1.16, 95% CI [-1.60 to -0.72]), shorter incisional (SMD = -0.63, 95% CI [-0.96 to -0.29]) and operative times (SMD = -0.59, 95% CI [-1.12 to -0.05]), and lower pain scores (SMD = -0.91, 95% CI [-1.27 to -0.55]) with no significant differences in terms of wound infection rates (OR = 0.92, 95% CI [0.74-1.15]) or overall subjective scar score (SMD = -0.49, 95% CI [-1.72 to 0.75]).

CONCLUSIONS

Surgical incision using electrocautery can be quicker with less blood loss and postoperative pain scores than the scalpel incision. No statistically significant difference was found between both techniques in terms of postoperative wound complications, hospital stay duration, and wound cosmetic characteristics. Therefore, we recommend routine use of cutting electrocautery for surgical incisions.

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.

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.

Diathermy versus scalpel in transverse abdominal incision in women undergoing repeated cesarean section: A randomized controlled trial

AIM

The aim of this study was to evaluate the volume of blood loss, wound incision time and wound complication according to use of scalpel or electrosurgery during the creation of transverse abdominal incisions during repeated cesarean section (CS).

MATERIAL AND METHODS

A randomized controlled trial was carried out at Ain Shams University Maternity Hospital. We recruited 130 women with a history of one previous CS at the time of their planned lower-segment CS. Participants were randomized to anterior abdominal wall opening from subcutaneous tissue till the peritoneum by either the use of scalpel with disposable blade (No. 22) or diathermy using the standard diathermy pen electrode. The main outcome measures were the volume of blood loss from skin incision to the end of the peritoneal incision, the operative time and wound complication.

RESULTS

We observed a highly significant difference between the two groups in blood loss (median [interquartile range], 11 [8-15.25] g for the diathermy group vs 20 [18-23] g for the scalpel group, P < 0.001) and skin-to-peritoneum incision time (median [interquartile range], 7 [5-7.25] min for the diathermy group vs 10 [7-11] min for the scalpel group, P < 0.001). The postoperative pain was less in the diathermy group but wound complications showed no statistical difference.

CONCLUSION

The use of diathermy in the opening of anterior abdominal wall during CS decreases blood loss and operative time but has no impact on postoperative pain or wound complications.

Craniosynostosis incision: scalpel or cautery?

There is an ongoing debate regarding the optimal instrument for scalp incisions: the scalpel or electrocautery. The argument generally focuses on improved healing after an incision made with a knife and decreased bleeding when using electrocautery. This study compares the use of scalpel and electrocautery in making coronal incisions for patients undergoing surgical correction of craniosynostosis. The outcome metric used is wound healing within 6 months after surgery. All patients presenting to the University of North Carolina Children's Hospital with craniosynostosis between July 1, 2007 and January 1, 2010 requiring a coronal incision for surgical correction were prospectively enrolled. In all of these patients, half of the coronal incision was made with knife; the other half, with needle tip cautery. Side of the incision was specified at the time of surgery in the operative report. Patients were excluded from the study if the instrument for incision was not specified or if only 1 modality was used for the entire incision. Sixty-eight patients underwent cranial vault reconstruction, of which 58 met inclusion criteria. Of the 58 matched pairs, 55 were analyzed statistically. The 3 excluded cases were those who had midline complications. There were 17 wound complications (15%): 8 in the knife group, 6 in the cautery group, and 3 at midline (with indeterminate side for the problem). We found no statistically significant difference in wound healing between incisions made with a knife or with electrocautery.

Diathermy versus Scalpel Incision in a Heterogeneous Cohort of General Surgery Patients in a Nigerian Teaching Hospital

Background:

The anecdotal fear of using cautery for surgical incisions is still common in surgical practice despite recent evidences. The aim of this study is to compare the results of electrocautery and the scalpel in skin incisions.

Materials and Methods:

This is a prospective randomized double blind study conducted in the Department of Surgery, of a teaching hospital in Ibadan. Patients were randomized to have either scalpel or electrocautery incisions. The duration used in making the skin incision; the incisional blood loss and the ensuing length and depth of the wound were noted. Postoperative pain; duration of wound healing and the occurrence of surgical site infection were also noted.

Results:

There were 197 patients consisting of the scalpel group (n = 98) and the electrocautery group (n = 99). The ages ranged from 16 to 73 years. The demography, case distribution and body mass index were similar in both groups. The mode of presentation was predominantly elective. The incision time was shorter in the electrocautery group (P < 0.001). The blood loss was less with the diathermy compared to the scalpel (6.53 ± 3.84 ml vs. 18.16 ± 7.36 ml, P < 0.001). The cumulative numerical rating scale score for pain was 12.65 (standard deviation [SD] 8.06) and 17.12 (SD 9.49) in the diathermy and scalpel groups respectively (P < 0.001). There was no statistically significant difference in wound infection and wound closure (epithelialization time) (P = 0.206).

Conclusion:

The use of electrocautery in making skin incision is associated with reduced incision time, incisional blood loss, and postoperative pain.

Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions

Background

Controversy exists about whether cutting diathermy for skin incisions leads to a cosmetically inferior scar. Cosmetic outcomes were compared between skin incisions created with cutting diathermy versus scalpel. Wound infection rates and postoperative incisional pain were also compared.

Methods

This was a randomized double-blind trial comparing cutting diathermy and scalpel in patients undergoing bowel resection. Scar cosmesis was assessed at 6 months after surgery by a plastic surgeon and a research associate using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Patients also used POSAS to self-evaluate their scars. Wound infections within 30 days were recorded, and incision pain scores were measured on the first 5 days after operation.

Results

A total of 66 patients were randomized to cutting diathermy (31) or scalpel (35). At 6 months, there was no significant difference between the diathermy and scalpel groups in mean(s.d.) VSS scores (4·9(2·6) versus 5·0(1·9); P = 0·837), mean POSAS total scores (19·2(8·0) versus 20·0(7·4); P = 0·684) or subjective POSAS total scores (20·2(12·1) versus 21·3(10·4); P = 0·725). Neither were there significant differences in wound infection rates between the groups (5 of 30 versus 5 of 32; P = 1·000). Pain scores on day 1 after operation were significantly lower in the diathermy group (mean 1·68 versus 3·13; P = 0·018), but were not significantly different on days 2–5.

Conclusion

Cutting diathermy is a cosmetically acceptable technique for abdominal skin incisions. There is no increased risk of wound infection, and diathermy may convey benefit in terms of early postoperative wound pain. Registration number: NCT01496404 (http://www.clinicaltrials.gov).

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.

Effect of triclosan-coated sutures on surgical site infection after gastric cancer surgery via midline laparotomy

PURPOSE

Surgical site infection (SSI) after open abdominal surgery is still a frequently reported nosocomial infection. To reduce the incidence of SSI, triclosan-coated sutures with antiseptic activity (Vicryl Plus) were developed. The aim of this study was to analyze the effect of Vicryl Plus on SSI after gastric cancer surgery via midline laparotomy.

METHODS

A total of 916 patients who underwent gastric cancer surgery at Samsung Medical Center between December 2009 and September 2011 were prospectively collected. We examined the occurrence of SSI (primary endpoint), assessments of wound healing (secondary endpoint). They were evaluated postoperatively on days 3, 7, and 30.

RESULTS

Of the 916 patients, 122 were excluded postoperatively by screening (out of the study protocol, adverse events, etc.). The remaining 794 patients were enrolled and monitored postoperatively. The cumulative SSI incidence was 11 cases (1.39%; 95% confidence interval [CI], 0.77-2.50) on day 30. Seromas were most frequently detected in wound healing assessments, with a cumulative incidence of 147 cases (18.51%; 95% CI, 15.98-21.39) on day 30.

CONCLUSION

The use of triclosan-coated sutures (Vicryl Plus) for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery.

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.

Practical techniques to enhance the safety of health care workers in office-based surgery

BACKGROUND

Office-based surgery is commonly practiced in different specialties for a variety of procedures. During these procedures, the health care worker (HCW) is exposed to a large number of pathogens that can be bloodborne, including the hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). These pathogens can be transmitted through needlesticks or sharp injuries to intact skin or by backsplash of contaminated body fluids onto mucous membranes or injured skin.

OBJECTIVES AND CONCLUSIONS

This article reviews the published techniques designed to protect the HCW from such hazards. These techniques are classified into preoperative, intraoperative, and postoperative. Preoperative measures include general protective measures, organization of the surgical field, and consideration of alternative treatments in high-risk patients. Intraoperative techniques deal with safe handling and transferring of sharp instruments, working without using sharps, and protection from backspray injuries. Postoperative measures address proper disposal of used sharps.

Abdominal wall infections with in situ mesh

BACKGROUND

Synthetic mesh is used commonly in the repair of abdominal wall hernias. Infection at the surgical site where mesh is present poses a formidable clinical problem.

METHODS

The current surgical literature was reviewed to formulate accepted approaches to the management of hernia repairs with infected mesh.

RESULTS

Prevention of mesh infection is best achieved by judicious use of systemic antibiotics. Topical antibiotics often are used without convincing evidence to support their value. Laparoscopic repairs have lower infection rates than open repairs. Evidence is lacking to support lower rates of infection with mesh of specific composition or with antibacterial agents that coat the mesh. The diagnosis of mesh infection is principally a clinical one. Repairs of infected mesh usually necessitate antibiotics and removal of the foreign material. Clinical judgment is required for attempts at salvaging portions of the mesh. Component separation or biological materials may be used in those circumstances for hernia repair in which large defects are created by removal of the infected synthetic material.

CONCLUSIONS

Prevention of mesh infections remains the best strategy. Clinical judgment is essential in determining the degree of mesh removal. Continued clinical studies are necessary to improve the outcomes of established mesh infection in hernia repairs.

Antibacterial [corrected] coating of abdominal closure sutures and wound infection

BACKGROUND

Poor wound healing and the development of infection in incisional wounds continue to be among the most common complications of open abdominal surgery. Various bacteria may contaminate not only the tissue in the operative wound, but also the actual suture material. To prevent the contamination of suture material in surgical wounds, triclosan-coated polyglactin 910 suture materials with antibacterial activity (Vicryl plus) was developed. The aim of this study was to ascertain if the use of Vicryl plus reduced the number of wound infections after midline laparotomy comparing to polydioxanon suture (PDS II).

METHODS

We performed 2,088 operations in our department between October 2004 and September 2006 via midline incision. In the first time period (TP1), a PDS II loop suture was used. In the second time period (TP2), we used Vicryl plus. All variables were recorded prospectively in a database. The primary outcome was the number of wound infections. Risk factors for poor wound healing were collected prospectively to compare the 2 groups.

RESULTS

Using a PDS loop suture for abdominal wall closure in TP1, 10.8% of patients with wound infections were detected. The number of patients with wound infections decreased in TP2 using Vicryl plus for abdominal wall closure to 4.9% (P < .001) despite no other changes in protocols of patient care. Other risk factors for the development of site infections were comparable in the 2 groups.

CONCLUSION

The use of antibiotic-coated loop suture for abdominal wall closure can decrease the number wound infections after abdominal surgery.

Trends in surgical wound healing

The understanding of acute and chronic wound pathophysiology has progressed considerably over the past decades. Unfortunately, improvement in clinical practice has not followed suit, although new trends and developments have improved the outcome of wound treatment in many ways. This review focuses on promising clinical development in major wound problems in general and on postoperative infections in particular.

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.

Sharpless Surgery: A Prospective Study of the Feasibility of Performing Operations using Non-sharp Techniques in an Urban, University-based Surgical Practice

CONTEXT

Percutaneous injuries occur frequently during surgical procedures and represent a significant occupational hazard to operating room personnel.

OBJECTIVES

To evaluate the feasibility of performing select general surgical procedures using a combination of non-sharp devices and techniques to replace the conventional use of scalpels and needles.

DESIGN, SETTING, AND PARTICIPANTS

Candidate procedures for which sharpless techniques could replace conventional scalpels and suture needles were identified preoperatively in an urban, university-based general surgical practice over a 1-year period (June 2003-June 2004). Non-sharp techniques included monomeric 2-octyl cyanoacrylate adhesive, electrocautery, tissue stapler, and minimally invasive instrumentation. Conventional scalpels and suture needles were readily available and used whenever necessary.

MAIN OUTCOME MEASURES

We rated the feasibility of performing specific procedures without sharps. We also documented the rate of overall reversion to sharps during operations on patients that had been identified preoperatively as candidates for sharpless surgery.

RESULTS

Of 358 procedures performed in the general surgery university practice, 91 were identified preoperatively as appropriate for sharpless surgery. Of these, 86.8% (79/91) were completed without the use of sharps, including 13/22 (59.1%) open laparotomy procedures, 20/22 (90.9%) laparoscopic procedures, and 46/47 (97.8%) soft tissue procedures. Intraoperative reversion to sharps occurred in 12 cases when deemed necessary by the surgeon.

CONCLUSIONS

Select common procedures can be performed entirely with sharpless techniques, eliminating the risk to surgical personnel associated with intraoperative percutaneous injuries.

El cierre de laparotomía en la línea alba

The midline laparotomy is among the most common ways of accessing the peritoneal cavity. This approach is not only used for surgery of the digestive tract but is also extensively applied in vascular, gynecology and urological surgery. When this surgical procedure is conducted in an emergency setting, and depending on the type of surgery (clean and /or contaminated), the incidence of complications may be particularly high, especially when acute dehiscence of the wall occurs (evisceration). Furthermore, the rate of herniation related to midline laparotomy is still high at approximately 16% of cases. Despite efforts to evaluate different suture techniques, suture threads (reabsorbable or non-reabsorbable) and general factors that may interfere with the repair process, the incidence of complications associated with this approach has not been reduced. After multiple studies including meta-analyses, the outcome of laparotomy closure has not essentially improved. We should therefore consider the use of new ways of closing the abdomen in selected patients that might somehow reinforce the surgical wound and notably reduce the incidence of short- and medium-term complications. One such method could perhaps be the use of a biomaterial to support and strengthen conventional sutures.