How to reduce diathermy in tonsillectomy: description of technique and analysis of results

As the use of electrodissection in tonsillectomy increases, uncertainty remains concerning any association with postoperative haemorrhage. However, there is some evidence to suggest that the more diathermy is used the risk of postoperative haemorrhage increases. The technique of vessel dissection and diathermy tonsillectomy (VDDT) is described and the results of 335 consecutive cases are presented. The results are discussed in relation to bipolar diathermy tonsillectomy and microbipolar diathermy tonsillectomy and also the U.K. National Prospective Tonsillectomy Audit. It is concluded that VDDT has the advantages of cold dissection while reducing diathermy to a minimum.     

Disección fría y coagulación bipolar versus disección con bisturí armónico en la cirugía de los tumores benignos de la glándula parótida

IntroductionSurgical techniques for extirpation of tumours of the parotid gland have evolved significantly in recent years. Previous data suggest the use of Harmonic Scalpel reduced operative time, intraoperative blood loss, postoperative drain production, and incidence of facial nerve injury, in comparison to cold scalpel dissectionMaterial and methodsretrospective analysis of 2 group of patients operated using harmonic scalpel versus cold knife dissection and bipolar diathermy and compare operative time and post-surgical complication rate:, facial nerve injury, sialocele or salivary fístula formation, after parotidectomy for benign parotid tumours.Results108 patients were included. Regarding surgical time, the mean time to using Harmonic Scalpel was 114 ± 39 (Min: 60/Max: 240), and the mean time using bipolar diathermy was 135 ± 38 (Min: 90/Max: 285) and this was the only significant difference between the 2 techniques (p = .049).ConclusionsHarmonic scalpel is a safe and effective tool to perform parotid surgery in benign tumours. However, a shorter surgical time was the only advantage found over the traditional cold dissection and bipolar dissection method.     

Standard bipolar diathermy forceps vessel ligation is safe in thyroidectomy

Bleeding is a major complication of thyroid surgery. A retrospective study was performed comparing the outcomes of patients undergoing thyroid surgery where bipolar diathermy with standard bipolar forceps was used for vessel ligation (n = 64) compared to clamp-and-tie (n = 89). Fewer drains were inserted and patients were discharged earlier when standard bipolar diathermy was used for vessel ligation in hemithyroidectomies (P < 0.001). Complication rates were similar. The use of bipolar diathermy with standard forceps for vessel ligation in thyroid surgery has been shown to be as safe and effective as the clamp-and-tie technique, while resulting in earlier patient discharge. This technique is cost-efficient as it provides the advantage of reduced inpatient stay reported using bipolar vessel sealing devices or the harmonic scalpel, but without the additional expense.     

Key messages from the National Prospective Tonsillectomy Audit

OBJECTIVES: Investigation of the occurrence of postoperative hemorrhage after tonsillectomy and risk factors for these complications. STUDY DESIGN: Prospective National Audit with electronic web-based data collection from the National Health Service and independent hospitals in England and Northern Ireland. METHODS: Consenting patients undergoing tonsillectomy between July 2003 and September 2004 were included. A central database of patient and surgical variables was developed for analysis of primary and secondary postoperative hemorrhage and development of risk models for tonsillectomy complications. RESULTS: The Audit received data from 277 hospitals in England and Northern Ireland on 40,514 patients. Analysis was conducted on 33,921 (84%) who gave consent. Over the whole Audit 1,197 (3.5%) postoperative hemorrhages were recorded. One hundred eighty-eight (0.6%) patients sustained a primary hemorrhage and 1,033 (3%) a secondary hemorrhage (24 had both). Elevated hemorrhage rates were observed in tonsillectomies performed using diathermy for dissection and hemostasis compared with cold steel dissection and ties for hemostasis. National guidance issued midway through the Audit influenced practice and reduced hemorrhage rates. Risk models for postoperative hemorrhage were developed incorporating the effect of the guidance. For hemorrhage, compared with the cold steel group, bipolar diathermy tonsillectomy had an odds ratio of 2.47 (1.81-3.36), P < .0001, and bipolar diathermy scissors tonsillectomy an odds ratio of 3.20 (2.09-4.90), P < .0001. Use of bipolar diathermy for hemostasis only after cold steel dissection carried an intermediate risk, odds ratio 1.57 (1.16-2.13), P = .004. CONCLUSIONS: The results confirm that "hot" tonsillectomy techniques carry a substantially elevated risk of postoperative hemorrhage when diathermy is used as a dissection tool in tonsillectomy.     

Ligation versus bipolar diathermy for hemostasis in tonsillectomy: a comparative study

Tonsillectomy despite being less performed nowadays still is a very common surgery performed by ENT surgeons. The use of various modalities like bipolar diathermy, laser, cryosurgery, radiofrequency and ionic coblation for hemostasis in tonsillectomy remains controversial so far. A thorough scan of literature comparing the ligation with diathermy has been presented. In this prospective study, we analysed 50 patients undergoing tonsillectomy by dissection method. Right sided tonsillectomies act as study group (bipolar diathermy used) and left sided tonsillectomies as the control group (ligation for hemostasis used). The aim of our study is to compare the amount of blood loss, number of ligatures applied, average time taken and incidence of postoperative haemorrhage following the use of ligation and bipolar diathermy. The study found that diathermy hemostatic technique is associated with a quicker procedure, less intraoperative blood loss, comparable postoperative pain.     

Systematic review of the safety of electrosurgery for tonsillectomy

? In the meta‐analysis models, compared with cold steel dissection with ties/packs haemostasis (reference technique): ? Bipolar diathermy dissection and haemostasis was associated with statistically significant lower odds of primary haemorrhage (OR 0.13, 95% CrI 0.03 to 0.51), including primary haemorrhage requiring return to theatre (OR 0.002, 95% CrI <0.001 to 0.26). ? Coblation was associated with statistically significant higher odds of secondary haemorrhage requiring return to theatre (OR 33.82, 95% CrI 1.25 to 5676.00). ? Monopolar and bipolar diathermy dissection and haemostasis (OR 4.12, 95% CrI 1.12 to 14.67; OR 2.86, 95% CrI 1.12 to 8.02, respectively), coblation (OR 3.75, 95% CrI 1.29 to 12.12), and cold steel dissection with monopolar or bipolar diathermy haemostasis (OR 4.83, 95% CrI 1.56 to 15.95; OR 9.18, 95% CrI 3.09 to 30.53, respectively) were all associated with statistically significant higher odds of secondary haemorrhage. ? In deciding which technique to employ, factors to consider include patient characteristics, the underlying risk of primary or secondary haemorrhage, which is regarded as likely to be more serious, and the clinical significance of the observed differences in haemorrhage rates across techniques.     

Harmonic scalpel versus bipolar tonsillectomy: a double-blind clinical trial

This is a double bind clinical trial which evaluated harmonic scalpel versus bipolar diathermy tonsillectomy The study was conducted at Diyarbakir government hospital, Diyarbakir, Turkey. The study population comprised 144 patients, aged 4–18 years (mean 9 years  ± 4.12 SD). All patients underwent tonsillectomy with or without adenoidectomy. The indications for tonsillectomy were obstructive sleep apnea (84 patients [58.3%]) and chronic tonsillitis (60 patients [41.7%]). All 144 patients were randomly divided into two groups: bipolar dissection (81 patients [56.2%] with mean age 8.98 years ± 4.22) and harmonic scalpel (63 patients [43.8%] with mean age 9 years ± 4.02). BD group showed statistically significantly less intraoperative bleeding (< 0.05). There was no statistically significant difference on postoperative day 1 but a statistically significant difference was determined on postoperative days 4, 7 and 14. There was no statistically significant difference between the two techniques with regard to immediate and delayed bleeding. The mean operative time was the same in both the groups. Bipolar dissection group showed statistically significant less intraoperative bleeding than harmonic scalpel group. An analysis of postoperative pain scores showed that the harmonic scalpel group pain scores are lower than the bipolar dissection group on all recorded days, and no statistically significant complications was seen in both groups. The results of this study indicate that the HS technique is associated with lower pain scores with the same complication rates as the BD technique.     

Preliminary experiences with microscopic tonsillectomy

Experiences with a modified technique of tonsillectomy are described. The surgery is performed viewing the tonsil through the operating microscope and using the bipolar diathermy forceps for dissection and diathermy of blood vessels. In a pilot-study of 70 patients, the microscopic method was found to be an elegant technique which substantially reduced intra-operative blood loss and did not prolong surgery. Post-operative morbidity will be assessed in a further study.     

A prospective randomised single blinded study comparing harmonic scalpel tonsillectomy with bipolar tonsillectomy

OBJECTIVE: To compare the differences in pain, analgesic use and bleeding in children after tonsillectomy using either a harmonic scalpel or a bipolar diathermy surgical technique. METHODS: Children 6-15 years presenting for tonsillectomy were randomised to either a harmonic scalpel or bipolar diathermy surgical technique. Post-operative pain scores (VAS, 0-10) were recorded within 30 min of surgery and again at the 4h hospital discharge. A subsequent telephone interview daily for 7 days and then every second day until day 13 was used to monitor pain scores, analgesic use and tonsil bed bleeding. RESULTS: There were 204 children studied. The response rate over the first 7 days was 93% for the children in the harmonic scalpel group and 87% for the bipolar group. Children experienced moderate post-operative pain for the first 6 days, after which pain declined from 4-7 to reach a score of 1-2 by day 11. Children undergoing harmonic scalpel tonsillectomy (n=103) reported higher mean pain scores than those who underwent bipolar diathermy (n=101) for current pain (4.7 versus 4.2, p=0.002), worst pain of the day (6.9 versus 6.2, p<0.001) and pain on swallowing (5.9 versus 5.2, p<0.001) over the first 6 post-operative days. Analgesic use (acetaminophen, ibuprofen) was similar in both groups. Hospital readmission for bleeding in children who underwent harmonic scalpel was similar to those who underwent bipolar diathermy tonsillectomy (9% versus 11%) as was bleeding requiring surgical re-exploration (4% versus 2%). CONCLUSIONS: Tonsillectomy was associated with considerable pain for the first 6 post-operative days. Children undergoing harmonic scalpel tonsillectomy had a slight increase in pain compared to the bipolar diathermy group during this time. Both methods of tonsillectomy are effective and safe.     

Coblation tonsillectomy versus dissection tonsillectomy: postoperative hemorrhage

OBJECTIVES/HYPOTHESIS: Coblation tonsillectomy is a recently introduced surgical technique. To measure its benefits against traditional tonsillectomy techniques, it is necessary to compare their complication rates. The study aims to identify differences in reactionary and secondary hemorrhage proportions, comparing coblation with dissection tonsillectomy. STUDY DESIGN: Prospective observational cohort study. METHODS: Rates of reactionary and delayed postoperative hemorrhage were measured, comparing 844 coblation tonsillectomies with a control group of 743 tonsillectomies performed by blunt dissection with bipolar diathermy hemostasis. RESULTS: The secondary hemorrhage rate with coblation-assisted tonsillectomy was 2.25% compared with 6.19% in the control group (P <.05). The rate of secondary hemorrhage in children following coblation tonsillectomy was 0.95% compared with 4.77% in the control group (P <.05). The difference was also significant (P <.05) in the adult population (4.40% vs. 8.81%, respectively). No difference was found in the reactionary hemorrhage proportions. CONCLUSION: In the study, coblation tonsillectomy was associated with a lesser incidence of delayed hemorrhage, more significantly in the pediatric population. The new technique using tissue coblation for tonsil dissection offers significant advantages in the postoperative period compared with dissection tonsillectomy with bipolar diathermy hemostasis. Coblation is associated with less postoperative pain and early return to daily activities. Also, there are fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage with coblation. These results and the disposable nature of the coblation equipment promote coblation tonsillectomy as the authors' preferred dissection method.     

Endoscopic bipolar diathermy in the management of epistaxis: an effective and cost‐efficient treatment

Endoscopic bipolar diathermy in the management of epistaxis: an effective and cost‐efficient treatment Epistaxis is one of the most frequently managed otorhinolaryngological emergencies. This prospective study over a 4‐month period involved 38 adult patients presenting with epistaxis who underwent endoscopic bipolar diathermy under local anaesthesia. Thirty‐four (89%) of the 38 adults were successfully treated and 28 (74%) of the patients did not require admission. Based on a simple cost‐benefit analysis of savings made by avoiding admission, successful immediate treatment of these 28 patients led to a potential saving of at least £6804.00. We conclude endoscopic bipolar diathermy under local anaesthesia is an effective, safe and cost‐efficient modality of treatment in the management of adult epistaxis.     

Postoperative bleeding after diathermy and dissection tonsillectomy

OBJECTIVE: To analyze the incidence and pattern of bleeding after tonsillectomy performed by either cold dissection or diathermy. DESIGN: A prospective, nonrandomized cohort study of postoperative hemorrhage after tonsillectomy. METHODS: Monthly reporting of the number of tonsillectomies and postoperative bleeds from otolaryngologists working in rural areas of Victoria, Australia over a 2.5 year period. Criteria for bleeding were either 1) repeat anesthesia and surgery because of hemorrhage (including return to theater from the recovery room), or 2) readmission to hospital because of bleeding, or 3) blood transfusion to replace blood loss. Main outcome measures were the incidence, volume, and time course of postoperative hemorrhage. RESULTS: The number of bilateral tonsillectomies with removal by cold-blunt dissection was 3,087. In this group, there were 57 (1.85%) bleeds. The number of bilateral tonsillectomies with removal by diathermy dissection was 1,557. In this group, there were 37 (2.38%) bleeds. If cold dissection is taken as the "control" and diathermy tonsillectomy as the "treatment" group, the relative risk of bleeding after diathermy tonsillectomy is 1.30 (95% confidence interval 0.88-1.93). The pattern of bleeding after each technique differs significantly over time, with more reactionary bleeds in the dissection group and more bleeds between 4 to 7 postoperative days after diathermy. When bleeding occurred, it was in excess of 500 mL in 16% of dissection cases and 43% of diathermy tonsillectomies. CONCLUSIONS: The difference in the risk of bleeding after each technique did not reach statistical significance, but the temporal pattern of hemorrhage differed, and more bleeds exceeding 500 mL were seen in the diathermy group.     

Teenage and adult tonsillectomy: dose-response relationship between diathermy energy used and morbidity.

OBJECTIVE: To determine whether an increase in the use of bipolar diathermy energy to perform a tonsillectomy is associated with an increase in postoperative pain and haemorrhage. STUDY DESIGN: Prospective study. SETTING: District General Hospital. METHODS: In all, 101 patients above the age of 13 years who underwent a tonsillectomy that involved the use of bipolar diathermy during the study period were included. The cumulative amount of diathermy energy used to perform each tonsillectomy was calculated with the help of a digital stop clock timing device connected to the diathermy foot-pedal. MAIN OUTCOME MEASURES: Postoperative pain scores and the incidence of secondary haemorrhage were recorded for each patient at four points in time following surgery, up to the tenth postoperative day. The haemorrhage rates were categorised into three groups (no bleeding, minor bleeding and major bleeding) according to severity. Associations between the diathermy energy used to perform each tonsillectomy and the corresponding postoperative pain scores and secondary bleeding rates were investigated. RESULTS: There was a statistically significant positive relationship between the total amount of bipolar diathermy energy used per tonsillectomy and the pain scores at all the four recorded points in time (r(s) = 0.44-0.72, P < 0.001). When the median energy consumption in the three groups (no bleeding, minor bleeding and major bleeding) were compared using the Kruskal-Wallis test, we found that there was limited evidence of a difference between the groups, but this was not statistically significant at the 5% level [H (2) = 5.374, P = 0.065, 99% CI 0.058-0.071]. CONCLUSIONS: Increased use of bipolar diathermy during the performance of a tonsillectomy is associated with a statistically significant increased amount of postoperative pain. The dose-response relationship between diathermy energy and postoperative bleeding is less clear. This suggests that there could be other important factors such as surgical instrument characteristics and degree of tonsillar adherence that have an additional influence and are therefore possible areas for future research.     

The ultrasonically activated scalpel versus bipolar diathermy for tonsillectomy: a prospective, randomized trial

Among patients undergoing tonsillectomy, the ultrasonic scalpel has been reported to lead to less intraoperative blood loss than cold dissection, and less postoperative pain and faster recovery than monopolar electrocautery. However, the ultrasonic scalpel has not been compared with bipolar diathermy. The present study was a prospective, randomized, single-blind trial, comparing these two techniques with respect to postoperative pain. Twenty-one adults underwent tonsillectomy on one side using the ultrasonic scalpel, and on the other using bipolar diathermy. Pain scores were obtained on postoperative days 1, 2, 7 and week 3. There was no difference between the two treatments at any of the time points (P = 0.6047, 0.4018, 0.6047 and 0.5000, respectively). Inability to control bleeding with the ultrasonic scalpel resulted in the rescue use of an alternative technique of haemostasis in 14 cases. We conclude that the use of the ultrasonic scalpel in adult tonsillectomy is likely to be limited by its substantial costs and difficulties with haemostasis.     

Bipolar diathermy or ligation for haemostasis in tonsillectomy? A prospective study on post-operative pain.

Forty-nine children for tonsillectomy were entered in a prospective controlled single blind study to compare the post-tonsillectomy morbidity of bipolar diathermy as opposed to ligation for haemostasis. We found no significant difference in post-operative discomfort nor reactionary or secondary haemorrhage in the two methods used. This is the first controlled trial where bipolar, rather than unipolar diathermy is used, and compared with ligation in the operation of tonsillectomy.     

Ultrasonically activated scalpel compared with electrocautery in tonsillectomy

The occurrence of postoperative bleeding, the quantity of operative bleeding and the duration of operation were retrospectively evaluated in 407 patients who underwent tonsillectomy within a 32-month period. They were operated on with either an ultrasonically activated scalpel (UAS), bipolar diathermy (BPD) or blunt dissection with monopolar diathermy (MPD) with the following results. (1) Primary bleeding was more common with MPD: MPD 7.1% vs. BPD 2.4% (p < 0.01) vs. UAS 1.0% (p < 0.001). Secondary bleeding was more common with UAS: UAS 19.6% vs. MPD 14.5% (p < 0.001) vs. BPD 14.5% (p < 0.01). There was no statistical significance in the differences between overall postoperative bleeding rates. (2) There was statistically significantly less operative bleeding with UAS:UAS 24.8 ml vs. MPD 58.7 ml vs. BPD 43.8 ml. (3) On the other hand, the operation time was on average longer with UAS: UAS 32.3 min vs. MPD 18.4 min vs. BPD 22.1 min. Our results suggest that UAS offers no significant advantage over MPD or BPD in tonsillectomy other than minimal operative bleeding possibly due to longer duration of operation.     

Bipolar diathermy tonsillectomy

Tonsillectomy is an operation performed by various techniques. We have developed a bipolar diathermy dissection technique that allows a low intra-operative blood loss without an increase in complications. The average blood loss was less than 4 ml in 100 patients. Most were able to drink and eat by 4 and 10 hours respectively. There was no increase in analgesic requirements. No primary haemorrhage was recorded; three patients had a secondary haemorrhage. The technique allows accurate coagulation of blood vessel and is an easy procedure to learn.     

Endoscopic bipolar diathermy in the management of epistaxis: an effective and cost-efficient treatment

Epistaxis is one of the most frequently managed otorhinolaryngological emergencies. This prospective study over a 4-month period involved 38 adult patients presenting with epistaxis who underwent endoscopic bipolar diathermy under local anaesthesia. Thirty-four (89%) of the 38 adults were successfully treated and 28 (74%) of the patients did not require admission. Based on a simple cost-benefit analysis of savings made by avoiding admission, successful immediate treatment of these 28 patients led to a potential saving of at least pound 6804.00. We conclude endoscopic bipolar diathermy under local anaesthesia is an effective, safe and cost-efficient modality of treatment in the management of adult epistaxis.     

Radiofrequency bipolar submucosal diathermy of the inferior turbinates

Fifty nonatopic patients with chronic hypertrophic rhinitis and suffering from chronic nasal obstruction due to hypertrophied inferior turbinates were subjected to bipolar submucosal diathermy using a radio frequency unit and a bipolar turbinate probe. One year postoperatively, 76% of patients showed significant improvement of their nasal breathing and another 16% reported partial improvement. The minimal cross sectional has also significantly increased from 0.58 +/- 0.05 cm2 to 0.72 +/- 0.04 cm2 and the decongestive effect was statistically significant. Electron microscopic examination of the nasal mucosa at the end of the follow up period revealed intact healthy epithelium as well as intense fibrosis of the underlying stroma. The results of the work showed that bipolar submucosal diathermy is a safe, effective outpatient procedure that does not require nasal packing or expensive instrumentation. The procedure can be repeated, if necessary, according to the patient's needs.     

Peritonsillar infiltration with tramadol improves pediatric tonsillectomy pain

Pain control in pediatric patients undergoing tonsillectomy remains a dilemma. Tramadol is reported to be an effective analgesic. This prospective, double-blinded, placebo-controlled study was performed to evaluate the analgesic efficacy and safety of submucosal infiltration of tramadol on postoperative pain in children after standard bipolar diathermy tonsillectomy. Following standard bipolar diathermy tonsillectomy was performed, 40 patients were randomized to receive submucoasl infiltration with 2 mg kg⁻¹ tramadol in 3 ml of normal saline (1.5 ml per tonsil) or normal saline only. The patients in each group were compared postoperatively with regard to the quality of pain control using the objective pain scale (OPS), sedation score and their analgesic requirements. Peritonsillar infiltration of tramadol (group 2) provided superior postoperative analgesia to placebo (group 1) for 4 h after surgery. In addition, group 1 received significantly more doses of paracetamol than group 2 in order to maintain analgesia in the first 12 h after recovery from anesthesia. Peritonsillar infiltration of tramadol appears to be an effective method of providing superior analgesia in the postoperative period when compared to placebo.