Efficacy of Diathermy Skin Incision for Open Inguinal Hernia Surgery - An Interventional Study

INTRODUCTION

Inguinal hernia repair, one of the most routinely performed surgeries globally, exceeds 20 million procedures annually.^[1] In India, studies estimate the national prevalence of inguinal hernia to be between 1.5 and 2 million cases, with a higher incidence in men compared to women.^[2] Surgical skin incisions can be made with a scalpel or diathermy. While scalpel incisions involve the use of a sharp blade, diathermy employs heat for tissue incision, potentially offering benefits such as reduced haemorrhage and rapid tissue separation.^[3]

For a long period of surgical practice, the scalpel has been known as a gold-standard tool for making surgical incision.^[4] It enables surgeons to easily obtain an incision of the desired depth without any electrical burn injuries and damage to the neighbouring tissues.^[5,6] Nonetheless, excessive blood loss and the incidence of the injuries to the working staff have been extensively reported.^[7,8] The diathermy/electrocautery was first used in the 1900s as a surgical incision tool that relies on an alternating current source that causes cleavage and coagulation without harming adjacent tissues.^[9] In addition to making muscular and fascial incisions, the instrument also regulates homeostasis.^[10]

Despite its potential advantages in various surgical procedures, the use of diathermy for skin incisions is still limited due to concerns about burn-related wound complications and inadvertent damage to deeper structures.^[11,12] While existing research, including a systematic review and meta-analysis, suggests that diathermy incisions are associated with decreased blood loss and quicker incision times compared to scalpel incisions,^[13] further exploration is needed across diverse general surgical cases. Our study aimed to bridge this gap by conducting a comprehensive analysis of electrocautery skin incisions, comparing them to traditional scalpel incisions and considering factors such as incision time, early postoperative pain, postoperative wound complications, and wound healing.

MATERIAL AND METHODS

This prospective randomised comparative study included 100 patients who presented with inguinal hernia at the Karnataka Medical College and Research Institute, Hubli, Karnataka, from June 2023 to June 2024. Adult patients age 18–60 years who were undergoing elective Lichtenstein tension-free inguinal hernia repair were randomised using the envelope method into two groups, according to which they undergo skin incision either by diathermy or scalpel. All the patients were operated on under spinal anesthesia, 3–3.5 ml of bupivacaine 0.5% heavy with 60 µg of buprenorphine in the L3-L4/L2-L3 space. Postoperatively all patients were given paracetamol 1 g tid intravenous injection and rescue analgesic tramadol 100 mg in 100 ml normal saline intravenous injection. The variables considered for this study are incision time, early postoperative pain, postoperative wound complications, and wound healing, and the results were analysed.

Inclusion criteria: (1) All patients diagnosed as inguinal hernia clinically on admission and posted for elective Lichtenstein tension-free inguinal hernia repair between the age groups of 18–60 years. (2) Patients who agreed to participate in the study and gave written consent. Exclusion criteria: (1) Complicated inguinal hernia, like irreducible hernia, obstructed hernia, strangulated hernia, bilateral inguinal hernia, or recurrent inguinal hernia. (2) Patients with comorbidities like immunosuppressed, diabetes mellitus, and on steroids and anticancer therapy.

After taking the detailed history and clinical examination to find out the various modes of presentation and the reasonable risk factors and the informed consent, the patients were allocated into two groups (50 in each group). Diathermy group: The skin incision was made with an electrocautery needle using pulse sine wave current in “cut” mode and a power setting of 40 W. Scalpel group: The skin incision was made with scalpel, and bleeding was controlled by forceps coagulation using a pulse sine wave on a power supply of thirty watts. These two groups were compared for the intraoperative incision time, early postoperative pain, postoperative wound complications, and wound healing.

The time taken for skin incision was noted using a standard electronic stopwatch with milliseconds, separately for diathermy and scalpel incisions. Postoperative pain was recorded up to 48 hours using the visual analogue scale (VAS) at 6, 12, and 24 hours.^[14] Postoperative analgesia details were also recorded. The patient was referred to the surgery out patient department (OPD) at the end of the first week for suture opening, where wound complication, infection, and healing were assessed.

Statistical analysis: Statistical analysis used the paired t test, chi-square test, and Mann-Whitney U test. A p-value of <0.05 was considered statistically significant.

RESULTS

This study included 100 patients: 50 in each group [Table 1]. The ages of the patients ranged from 18 to 60 years, with a mean age of the patients of 44.94 years and 43.82 years in the diathermy and scalpel groups, respectively [Figure 1]. In the diathermy group, 50 patients were males. In the scalpel group, 49 patients were male and 1 patient was female in scalpel group showing male predominance in both the groups.

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Figure 1:

Mean age of the patients in the study groups.

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Out of 50 patients who underwent diathermy incision, the mean incision time was 5.26 seconds. The mean incision time in the other 50 patients with scalpel incision, the mean incision time was 6.72 seconds. Incision time was less in the diathermy group than in the scalpel incision group, with a statistically significant difference between the two. (p-value <0.001) [Table 2 and Figure 2].

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Figure 2:

Incisional time.

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Postoperative pain was assessed by visual analogue scale at 6, 12, and 24 hours at the first post operative day of surgery. It was found that the mean postoperative pain score was higher in the scalpel group, which were statistically significant [Table 3, Figures 3-5].

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Figure 3:

6th hour early postoperative pain.

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Figure 4:

12th hour early postoperative pain.

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Figure 5:

24th hour early postoperative pain.

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There were no postoperative wound complications in either of the groups, and the wound healing was normal in both groups.

DISCUSSION

There is still a debate regarding the application of electrocautery for the initial skin incision, even though it has been shown to be safe and effective for dissecting subcutaneous tissue and muscle layers. Recent diathermy studies present promising outcomes, indicating faster operating times, reduced blood loss, lower postoperative pain, and diminished analgesic requirements compared to scalpel incisions.^[2,3,15]

Few studies have raised concerns about wound healing and have shown more wound infections in the electrocautery group.^[16,17] The concern regarding tissue injury associated with electrocautery can be traced back to the groundbreaking work of Peterson A in faciomaxillary surgery,^[18] Mann W and Klippel CH in paediatric surgery,^[19] Kamer FM and Cohen A in rhytidoplasty,^[20] and Tobin HA in blepharoplasty.^[21] These pioneers demonstrated that electrocautery usage resulted in minimal scarring and yielded excellent surgical outcomes. Subsequently, skin incisions in general surgery were reported by Dixon AR and Watkin DF in patients undergoing inguinal herniorrhaphy and cholecystectomy.^[22]

In a study by Samuel RM and Kshirsagar AY, a comparative study between scalpel versus electrocautery incisions in abdominal surgeries. The International Journal of Health Sciences.2022;6(S2), 3107–3116 concluded that incision time and incisional blood loss are lesser in electrocautery incisions when compared to scalpel incisions. This is an encouraging fact in view of the routine use of electrocautery for taking abdominal incisions after observing all necessary aseptic precautions. Hence, electrosurgical instruments can be used as an alternate safer option for surgical incisions. Based on the observations made in the study, diathermy incisions are just as likely to become infected as scalpel incisions. Also, postoperative wound pain in patients was quite similar in incisions made with electrocautery and scalpel. The rate of wound complication and postoperative pain was insignificant among both the incision techniques.

In this study, we compared the incisional time, early postoperative pain, wound complications, and wound healing using diathermy versus scalpel for inguinal hernia repair surgeries. The use of diathermy reduced postoperative pain but did not influence the rate of wound complications. Positive associations were found regarding early postoperative pain as statistical analysis showed significant p-values. In accordance with previous studies, our results suggested a significantly reduced incisional time and early postoperative pain in the diathermy group.