doi:10.1111/jog.12776 J. Obstet. Gynaecol. Res. Vol. 41, No.

10: 15411546, October 2015

Diathermy versus scalpel in transverse abdominal incision in

women undergoing repeated cesarean section: A randomized
controlled trial

Ahmed E. H. Elbohoty, Mostafa F. Gomaa, Mohamed Abdelaleim, Magdi Abd-El-Gawad

and Mohamed Elmarakby
Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Abbasia, Cairo, Egypt

Abstract
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 signicant difference between the two groups in blood loss (median [interquartile
range], 11 [815.25] g for the diathermy group vs 20 [1823] g for the scalpel group, P < 0.001) and
skin-to-peritoneum incision time (median [interquartile range], 7 [57.25] min for the diathermy group vs 10 [711]
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.
Key words: cesarean section, diathermy, scalpel.

Introduction hysterectomy4 and in a wide scope of non-gynecologic

Electrosurgery is the use of an alternating current
through tissue resistance to raise tissue temperature to
achieve vaporization or the combination of desiccation
and protein coagulation.1,2 It is commonly used in der-
matological, cardiac, plastic, ocular, spine, otorhinolar-
yngological, orthopedic, urological, neurosurgical and
general surgery procedures.2 Previous studies showed
encouraging results about using the vessel-sealing elec-
trosurgical systems in abdominal hysterectomy,3 vaginal
surgical procedures.5,6
The reported complications for electrosurgery include
burns at the patient plate,7 explosion and re,8 surgical
smoke,9 direct coupling,10 capacitive coupling11 and in-
sulation failure.8 The dangers of electrosurgery in mini-
mal access surgery are increased by the conned,
enclosed conditions that apply in a laparoscopic proce-
dure.7 Accidental burns can be prevented by cleaning
the skin and applying conductive gel to enhance the con-
tact with the return electrode.8

Received: November 7 2014.

Accepted: May 8 2015.
Reprint request to: Professor Mostafa F. Gomaa, Ain Shams University Maternity Hospital, Abasia Square, Abbasia, Cairo, Egypt. Email:
mostafafouadg@gmail.com

2015 Japan Society of Obstetrics and Gynecology 1541

A. E. H. Elbohoty et al.
Ventricular brillation may result from using electro-
surgery on patients with pacemakers and it may also
switch the pacemaker off,12 so bipolar applications
might minimize possible complications.13 When using
monopolar electrosurgery on patients with prosthetic
conductive joints, the electrical circuit should be as far
as possible away from the conductive joint.14
Cesarean section (CS) is the delivery of a living baby
by a surgical incision through the anterior abdominal
wall and uterus and has been associated with severe ma-
ternal morbidity and mortality in the past.15 Once anes-
thetic and antiseptic measures were rmly established,
obstetricians were able to focus on improving the tech-
niques employed in CS.16
Different operative techniques have been described
in the steps of CS with many pros and cons for each
procedure. The skin incision may be vertical, midline,
paramedian,17 transverse lower abdominal, Pfannenstiel,18
Joel-Cohen,19 Pelosi,20 Maylard,21 Mouchel or Cherney.17
Some authors tried to compare the use of dia-
thermy versus scalpel during anterior abdominal wall
incision and many of them showed that electrocautery
incision is better than scalpel incision in terms of time
taken for the incision, pain levels, wound healing and
blood loss.22,23
The scar of a lower-segment CS is the most common
scar encountered in obstetric practice and its cosmetic ef-
fect is one of our concerns. Thus, the aim of our work
was to compare the wound-related blood loss and the
rates of wound complications in surgical incisions made
with a scalpel and incisions made using electrosurgery
during a 6-month period in the Department of Gynecol-
ogy and Obstetrics in Ain Shams University.
Methods
The current study was a randomized controlled trial
(RCT) including 130 patients who were admitted to
Ain Shams University Maternity Hospital for a repeat
CS throughout the period from March to September
2013. All patients included in the study were pregnant
with singletons and planned to have a repeat elective
lower-segment CS at 3839 weeks gestation due to hav-
ing had one previous CS. Patients requiring midline inci-
sion, on anti-coagulant therapy or with known allergy to
cephalosporin antibiotic were excluded from the study.
Cardiac patients on pacemakers and patients with
chronic diseases expected to affect wound healing, such
as diabetes, hypertension, liver diseases, chronic anemia
and renal impairment, were also excluded.
1542
After approval of the Ethics Committee of Ain Shams
University, women with one previous CS through trans-
verse incisions and requiring an incision to be made over
the previous CS scar, which healed by primary intention,
and with body mass index (BMI) of 18.529.9 kg/m2
were approached to participate in this study. All CS were
carried out by the same surgeon. Those women were
given a handout explaining the study and a signed and
informed consent was obtained from all of them.
Sample size was calculated using STATA 11, setting the
type-1 error () at 0.05 and the power (1-) at 0.8. From a
previous study24 that measured the mean and standard
deviation for blood loss in diathermy incisions versus
scalpel incisions, we calculated an effect size of 0.5,
which made a sample size of 64 cases sufcient for each
group, and then the gure was rounded to 65.
Allocation of the study women was based on comput-
erized randomization using SPSS 21 to either scalpel inci-
sion (with disposable blade [No. 22] used to incise skin
till the peritoneum) or diathermy incision (with dispos-
able scalpel blade [No. 22] to incise the skin and then
deeper tissue incision was made by diathermy using
standard diathermy pen electrode). Sequentially num-
bered sealed opaque envelopes were used to conceal the
group assignment. These envelopes were opened in the
operating room just before the surgical procedure (Fig. 1).
All women received intravenous antibiotic prophy-
laxis according to the Ain Shams guideline, 1 g of
cefradine given at the time of incision. All CS were car-
ried out by the same surgeon who is ranked as a lecturer
of obstetrics and gynecology at Ain Shams University.
Diathermy incisions were carried out using a small at
blade pen electrode, set on cutting mode and delivering
a 120-Watt (max) sinusoidal current. Electrosurgical cut-
ting was performed without pressure or mechanical dis-
placement. The skin blood vessels were usually small
and hemostasis was usually satisfactory after the appli-
cation of pressure. Bleeders were controlled by using
diathermy, on coagulating mode, and applied to a hemo-
stat on the vessel to avoid skin necrosis and blistering.
Incisions made by the scalpel were done by the tradi-
tional method, with proper hemostasis by application
of pressure to skin blood vessels and by ligating the sub-
cutaneous bleeders.
A sterile metallic ruler was used for measuring wound
thickness from the skin till the peritoneum after opening
the peritoneal cavity in all patients.
After the operation and during the postoperative pe-
riod, paracetamol (10 mg/mL) 50-mL vial was adminis-
tered by i.v. infusion for analgesia on demand according
to the patients need with a 500-mg dose.
2015 Japan Society of Obstetrics and Gynecology

Figure 1 Flow diagram of single-
blind randomized controlled trial
of diathermy versus scalpel in ce-
sarean section.
The primary objective was to compare the volume of
blood loss during the interval from the beginning of skin
incision to the end of peritoneal incision. Dry surgical
mops were used exclusively for the incision and were
weighed pre- and postoperatively in a sterile manner
using weighing scales with a resolution of 2 g. No suc-
tion was used while making the incision.
Secondary objectives were incision time (interval be-
tween beginning of skin incision and completion of peri-
toneal incision), wound complications (bursting edema,
seroma, hematoma, infection, dehiscence [wound failure]
and skin burn ecchymosis) and postoperative surgical
wound pain.
Bruising edema is dened as accumulation of uid in
tissue, seroma is dened as swelling due to accumula-
tion of serum and hematoma is dened as swelling due
to blood accumulation.
Results
A total of 167 women were recruited in the study and
assessed for eligibility. Thirty of them were excluded
for not meeting the inclusion criteria and for refusal of
participation. In the study, seven patients were lost
2015 Japan Society of Obstetrics and Gynecology
Diathermy vs scalpel in cesarean section
during follow-up as they did not attend their appoint-
ments due to living in other cities. Analysis was done
on an intention-to-treat basis (Fig. 1).
During the study, no patients with excessive intraop-
erative blood loss were recorded and no cases were
complicated by post-partum endometritis. No signi-
cant difference was found between the median and in-
terquartile ranges (IQR) for age in the two groups
(28.8 [2134] years in the scalpel group and 27.6
[2038] years in the diathermy group). There was also
a non-signicant difference between the two groups as
regards BMI (median [IQR], 29 [28.429.4] kg/m2 vs
29.3 [28.6 29.5] kg/m2 in the scalpel and diathermy
groups, respectively [Table 1]). No signicant difference
was found in wound thickness between the two groups
(Table 2). Other demographic characteristics are shown
in Table 1.
We found a highly signicant difference in blood loss
(median [IQR], 11 [815.25] g vs 20 [1823] g, P < 0.001
[Table 2, Fig. 2]) and skin-to-peritoneum incision time
(median [IQR], 7 [57.25] vs 10 [711] min, P < 0.001
[Table 2, Fig. 3]) between the two groups, favoring the
use of diathermy.
We also found that the number of analgesic doses
needed and days needed for wound healing were
1543
A. E. H. Elbohoty et al.

Table 1 Demographic characteristics of the patients included in the study

Variable Scalpel group (n = 65) Diathermy group (n = 65) Statistics P-value
Age (years) 28.8 (2134) 27.6 (2038) 3.281 0.077
Weight (kg) 80 (7983) 80 (7883) 1932.5 0.993
Height (cm) 167 (165169) 167 (164168.3) 2110.5 0.399
Body mass index (kg/m2) 29 (28.429.4) 29.3 (28.629.5) 1836.5 0.196
Gestational age (weeks) 38 (3839) 38 (3839) 1911.0 0.288
Data are presented as median (interquartile range). Estimated with the independent-sample t-test. Estimated with the MannWhitney U-test.

Table 2 Operative data of the study groups

Variable Scalpel group (n = 65) Diathermy group (n = 65) U-statistic P-value
Blood loss (g) 20 (1823) 11 (815.25) 640.0 <0.001
Skin-to-peritoneum incision time (min) 10 (711) 7 (57.25) 928.5 <0.001
Wound thickness (cm) 4 (3.754.5) 4.5 (44.5) 1557.0 0.098
Data are presented as median (interquartile range). Estimated with the MannWhitney U-test.

Figure 2 Box plot showing blood loss in the two study

groups. Box represents interquartile range. Middle line
across box represents median. Error bars represent min-
imum and maximum values excluding outliers.
signicantly lesser in the diathermy group (P < 0.001);
however, there were no signicant differences
(P > 0.05) between the two groups as regards: wound in-
fection, wound ecchymosis, wound hematoma, wound
seroma and wound dehiscence (Table 3).
Discussion
CS is one of the most frequent major surgical procedures
performed worldwide,25 and it has various operative
techniques, some of which have been evaluated in
RCT.26 To our knowledge, no studies to date have focused
on comparing diathermy versus scalpel incisions in CS.
In the current RCT, we compared wound-related
blood loss and the incidence of wound complications
Figure 3 Box plot showing skin-to-peritoneum incision
time in the two study groups. Box represents interquar-
tile range. Middle line across box represents median. Er-
ror bars represent minimum and maximum values
excluding outliers.
in CS incisions made with a scalpel versus incisions
made using electrosurgery. Electrosurgery, often referred
to as surgical diathermy, plays a vital role in limiting the
blood loss during surgery and is considered to be an ef-
cient mode of dissection.
Although wound thickness was comparable between
the two groups in the present study, we found a signi-
cantly lower blood loss and skin-to-peritoneum incision
time in the diathermy group compared with the scalpel
group.
Several studies have compared the use of diathermy
to the traditional scalpel in skin incision22,23,2732 in
midline abdominal wall incisions. Most of those studies
proved the superiority of diathermy over scalpel

1544 2015 Japan Society of Obstetrics and Gynecology


Table 3 Postoperative data of the study groups
Variable Scalpel group (n = 65)
Number of needed analgesic doses
Days needed for wound healing (days)
Wound infection
Wound ecchymosis
Wound hematoma
Wound seroma
Wound dehiscence
Data are presented as median (interquartile range) or number (%). Estimated with the MannWhitney U-test. Estimated with Fishers exact test.
regarding wound-related blood loss and wound incision
time.27,28,3032
Contrary to our results, Sinha and Gallagher29 com-
pared diathermy with scalpel incisions in 101 patients
who underwent midline laparotomy, and they showed
that there was no advantage with diathermy over scalpel
regarding the incision-related time. This difference might
be due to the different type of incision (midline versus
transverse).
In the current study, we found signicantly lower
postoperative pain in the diathermy group, and this is
supported by Franchi et al.33 in a multicenter study com-
paring diathermy versus cold scalpel in midline abdom-
inal incision for uterine malignancies. Our results are
also in concordance with several studies.23,28,30,31,34,35
The need for less analgesia in the diathermy group might
be due to the lower incidence of minor bleeders and the
absence of ligatures used to control bleeding in the scal-
pel group.
On the other hand, Siraj et al.24 compared the dia-
thermy incision with scalpel incision for midline laparot-
omy, and reported that the two techniques are similar in
postoperative pain. Similar results were also previously
reported.36 In an earlier study, Pearlman et al.37 also
observed comparable postoperative pain and wound
healing in all incisions whether given by scalpel or by
electrodiathermy.
As regards wound complications in the present study,
no signicant difference was found between the two
groups. The relation between postoperative abdominal
incision problems and opening subcutaneous tissues
with electrocautery or scalpel has been evaluated in
many studies, which reported comparable rates of
wound complications.27,36,3840 Similar results were also
reported for thoracotomy incision in elective surgery.31,41
In contrast to the present study, Amin et al. showed
that electrocautery incisions were associated with more
wound complications than scalpel incisions in patients
who underwent cholecystectomy and this difference
might be due to the different type of incision.42 In an
2015 Japan Society of Obstetrics and Gynecology
Diathermy vs scalpel in cesarean section
Diathermy group (n = 65) Statistics P-value
4 (44) 3 (24) 1224.0 <0.001
7 (79) 5 (55) 673.0 <0.001
1 (1.5%) 0 1.0
1 (1.5%) 0 1.0
1 (1.5%) 0 1.0
0 1 (1.5%) 1.0
1 (1.5%) 0 1.0
earlier study Soballe et al.43 reported that electric coagu-
lation increases the incidence of indurated margins, in-
fections, and weakness of the wound cut in comparison
with the knife.
We can conclude that proper usage of diathermy with
correct frequency adjustment and proper training to the
surgeons will denitely give better results than scalpel
incision.
A major limitation of our study is that while short-
term outcomes may favor diathermy, we have no data
on long-term outcomes, such as scarring at next cesar-
ean, which should be tested in further studies.
We recommend the use of electrocautery as an alterna-
tive to scalpel in CS because of its speed, simplicity and
availability in theaters without the fear of affecting
wound healing or increasing incidence of infection.
Disclosure
All authors declare that there is no conict of interest.
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2015 Japan Society of Obstetrics and Gynecology