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Natl J Maxillofac Surg
Natl J Maxillofac Surg
NJMS
Natl J Maxillofac Surg
National Journal of Maxillofacial Surgery
0975-5950
2229-3418
Wolters Kluwer - Medknow India

NJMS-15-233
10.4103/njms.njms_194_22
Original Article
To assess and compare the outcomes of the cutaneous neck dissection incision taken by colorado microdissection needle, surgical blade and cutting electrocautery in patients with oral squamous cell carcinoma: A prospective study
Mishra Priyatam
Bhola Nitin
Agarwal Anchal
Mathur Mrinalini
Pillai Saurabh
Chakraborty Raj K.
Kangloo Shubhanshi
Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Wardha, Maharashtra, India
Address for correspondence: Dr. Priyatam Mishra, Fellow, Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Wardha, Maharashtra, India. E-mail: priyatam.mishra@gmail.com
May-Aug 2024
24 7 2024
15 2 233238
08 11 2022
03 6 2023
05 6 2023
Copyright: © 2024 National Journal of Maxillofacial Surgery
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Aim:

To assess and compare the outcomes of the cutaneous neck dissection incisions taken by Colorado microdissection needle, surgical blade and cutting electrocautery in patients with oral squamous cell carcinoma.

Materials and Methods:

A prospective, randomized control, comparative study was carried out on 21 patients. These patients were divided into 3 groups containing 7 patients in each group. The intra operative and post operative outcomes were evaluated. Statistical analysis was done by using descriptive and inferential statistics using Chisquare test, Fisher’s Exact Test, one way ANOVA and multiple comparison Tukey Test and software used in the analysis were SPSS 27.0 version and GraphPad Prism 7.0 version and P < 0.05 is considered as level of significance.

Results:

The time taken for placing cutaneous skin incision and blood loss was more in the surgical blade group as compared to the Colorado microdissection needle and electrocautery. Statistically no significant difference between the three group while comparing the cutaneous neck incision healing and post operative scar formation.

Conclusion:

This study proves the superiority of the Colorado microdissection needle in terms of time taken and blood loss with similar aesthetic outcome in terms of cutaneous wound healing and post operative scar formation when compared to surgical blade and cutting electrocautery.

Colorado microdissection needle
electrocautery
incision
POSAS scale
REEDA scale
surgical blade
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pmcINTRODUCTION

India accounts for one-third of oral cancer and is considered the world capital in oral cancer.[1] The first line of treatment in oral cancer is surgery which includes resection of the tumor, neck dissection, and reconstruction of the defect followed by postoperative radiation and chemotherapy. Neck dissection requires the placement of cutaneous incisions. Hippocrates used the term “macairion” which is derived from the old Lacedaemonian sword the “machaira”[2] to describe an incision. Incision placement is the procedure in which a cut or slit is given to expose the underlying structures. The gold standard for incision placement is the surgical blade. An incision with the surgical blade results in bleeding from the surgical site, so to achieve coagulation the general practice is to inject vasoconstrictor locally at the surgical site. The vasoconstrictor when injected into body has its own systemic effects and may be contraindicated in some patients. William T. Bovie developed electrocautery in the 19th century.[3,4] Reduced blood loss, dry and rapid separation of tissues along with no use of vasoconstrictor are potential advantages of electrocautery.[5] Despite its advantage of achieving hemostasis, surgeons are still skeptical while using the electrocautery for placing skin incisions as it is construed that the thermal dissipation of heat results in increased postoperative pain and delayed wound healing.[6] To overcome this problem a fine-tipped electrocautery named Colorado microdissection needle was developed for placing cutaneous incisions. The advantages of the Colorado microdissection needle include placement of incisions without vasoconstrictor, a significant reduction in intraoperative blood loss, clear dissection field, and decreased thermal dissipation because of a thin needle.[7] The disadvantage of the Colorado microdissection needle is that the tip is expensive and disposable so it is difficult to use it in rural care centers and lower-end setups due to financial constraints.

In this study, we aim to assess and compare the intra and postoperative outcomes of cutaneous neck dissection incisions taken by Colorado microdissection needle, surgical blade, and cutting electrocautery in patients with oral squamous cell carcinoma.

MATERIALS AND METHODS

The present prospective, randomized, single-blind study was conducted on 21 patients who were planned to be operated for oral squamous cell carcinoma requiring neck dissection and were randomly divided into three groups using the lottery method of randomization. Ethical Clearance was obtained from Institutional Ethical Committee with Ref no. DMIMS(DU)/IEC/2022/730 dated 10/02/2022.

Group A: Colorado microdissection needle [Figure 1]

Figure 1 Colorado microdissection needle

Group B: Surgical blade [Figure 2]

Figure 2 Surgical blade

Group C: Cutting electrocautery [Figure 3].

Figure 3 Electrocautery

The patients were informed about the procedure in their local language and an informed, written consent was taken. A detailed case history was taken and a thorough clinical examination was carried out. After obtaining pre-anesthetic fitness for the surgical procedure under general anesthesia, the patients were posted for the procedure. All the cases were operated by a single surgeon to avoid bias.

Intraoperatively, following aseptic protocol skin incisions were marked over the patient’s neck. In group B, 2% lignocaine with adrenaline was infiltrated and after a 7-min interval incisions were placed, while no vasoconstrictor was used in group A and group C. The incision time was measured in seconds with a stopwatch [Figure 4]. Incision time was measured from the beginning of the cutaneous neck dissection incision to exposure of the platysma muscle.

Figure 4 Stopwatch

Intraoperative blood loss was measured in grams using the weightage method [Figure 5]. The dry gauze was weighed on an electric weighing machine preoperatively and the weight was noted in grams. Only these were used for mopping the surgical field while placing the incisions. Once the platysma was exposed all the gauzes used were weighed again. The difference in the weight was the blood loss.

Figure 5 Weighing Scale

Calculation

Initial weight = a g

No. of gauze used = n

Final weight = b g

Blood loss = b-(n x a)

*1 g of blood = 1 mL of blood

After the end of the surgery, the protocol of the hospital for postsurgical patients was followed.

Postoperatively, cutaneous wound healing was observed with the REEDA scale [Figure 6] on the 7th, 14th, and 30th postoperative days and the scar was assessed with POSAS scale [Figure 7] on the 14th and 30th postoperative days.

Figure 6 Redness, oedema, ecchymosis, discharge and approximation of the edges of the lesion assessment scale

Figure 7 Patient and observer scar assessment scale

OBSERVATION AND RESULTS

The mean age of patients in groups A, B, and C were 51.28 ± 7.22, 50.42 ± 9.48, 51.28 ± 8.82 years respectively. 16 males and 5 females were included in the study. The mean time taken for placing the cutaneous neck incision among patients of group A was 110.14 ± 9.51 s, in group B it was 208.71 ± 11.65 s, and in group C it was 125.28 ± 7.80 s. By using one-way ANOVA statistically significant difference was found in time taken among the patients of three groups (F = 205.96, P = 0.0001). On comparing the time taken among patients of the three groups by using the Tukey’s multiple comparison test statistically significant difference was found between group A and group B (P = 0.0001), between group A and group C (P = 0.025), and between group B and group C (P = 0.0001) [Graph 1].

Graph 1 Incision Time

Mean blood loss among the patients of group A was 0.33 ± 0.09 g, in group B it was 4.32 ± 0.65 g, and in group C it was 0.41 ± 0.08 g. By using one-way ANOVA statistically significant difference was found in blood loss among the patients of the three groups (F = 242.44, P = 0.0001). On comparing blood loss among the patients of the three groups by using Tukey Multiple Comparison Test statistically significant difference was found between group A and group B (P = 0.0001), between group B and group C (P = 0.0001), and no significant difference was found between group A and group C (P = 0.910) [Graph 2].

Graph 2 Blood Loss

In group A, healing was optimal in 3 (42.86%) patients, suboptimal in 3 (42.86%) patients and compromised in 1 (14.29%) patient on post-op day 7. It was optimal in 7 (100%) patients on post-op days 14 and 30. In group B, healing was optimal in 1 (14.29%), suboptimal in 5 (71.43%), and compromised in 1 (14.29%) patient on post-op day 7. It was optimal in 7 (100%) patients on post-op days 14 and 30. In group C, healing was optimal in 3 (42.86%) patients, suboptimal in 3 (42.86%) patients, and compromised in 1 (14.29%) patient on post-op day 7. It was optimal in 4 (57.14%) patients, suboptimal in 1 (14.29%) patient and compromised in 2 (28.57%) patients on post-op day 14, whereas it was optimal in 7 (100%) patients on post-op day 30. By using Chi-square test statistically no significant difference was found in cutaneous wound healing among patients of the three groups on post-op day 7 (c2-value = 1.87, P = 0.75), day 14 (c2-value = 7, P = 0.12) and day 30 [Graph 3].

Graph 3 Intergroup comparison of cutaneous wound healing on 7, 14, and 30 post-op days

In group A normal skin was present in 7 (100%) patients on post-op days 14 and 30. In group B normal skin was present in 7 (100%) patients on post-op days 14 and 30. In group C normal skin was present in 5 (71.43%) patients and inconspicuous scar was present in 2 (28.57%) patients on post-op day 14 while normal skin was present in 7 (100%) patients on post-op day 30. By using the Chi-square test statistically no significant difference was observed in between the three groups while comparing the postoperative scar (P = 0.75) [Figures 8 and 9].

Figure 8 Postoperative Scar Evaluation on Day 14. (a) Colorado microdissection needle, (b) Surgical blade, (c) Electrocautery

Figure 9 Postoperative Scar Evaluation on Day 30. (a) Colorado microdissection needle, (b) Surgical blade, (c) Electrocautery

DISCUSSION

Oral cancer is the sixth most common cancer and it constitutes 2% of the total death resulting from cancer.[8] Neck dissection needs placement of the cutaneous incision over the neck. Several surgical incisions and its modification are present for neck dissection. The cutaneous neck dissection incisions are often designed as per the need and preference of the operating surgeon. Placement of cutaneous incision can be done by the surgical blade, cutting electrocautery or Colorado microdissection needle.

In the present study, it was noted that cutting electrocautery and Colorado microdissection needle took significantly less time for incision placement as compared to the surgical blade. Surgical blade takes a longer incision time because it requires several exchanges of instruments with the coagulation diathermy specifically in the subcutaneous plane for achieving hemostasis. Dixon and Watkin[9] in their study compared the electrosurgical incision with the scalpel incision in cholecystectomy and reported that the mean incision time in electrosurgical skin incision was 260 secs while in the surgical blade, it was 412 secs which is similar to the present study.

On comparing the mean intraoperative blood loss statistically significant difference was found in between the three groups. The blood loss was less in the Colorado microdissection needle and the cutting electrocautery group due to its coagulative property. Chau et al.[10] in his study electrocautery versus surgical blade found that the blood loss while using the surgical blade was 17 g and in the electrocautery group, it was 5.72g. Byrne et al.[11] compared the diathermy with a surgical blade and observed that the blood loss in diathermy was three times lesser than the use of surgical blade. Similar results were obtained in our study. Statistically, no significant difference was noted in terms of cutaneous wound healing and postoperative scar.

Aird LN et al.[12] in the systematic review and meta-analysis of randomized controlled trial compared the skin incisions made by electrocautery and a scalpel where they concluded that there was a significant difference found in terms of wound infection rate and scar cosmesis. Chau JK et al.[10] compared the cosmetic and patient-specific outcomes of different incision methods given with the steel scalpel and electrocautery and found out that there was no significant difference in cosmetic and patient-specific outcomes. Ragesh KV et al.[13] in the prospective randomized control trial compared the outcomes of the skin incision placed by cautery and scalpel where he concluded that there was no significant difference found in the post-operative pain, post-operative infection, and scar. Similarly, Ismail et al.[14] in his systemic review and meta-analysis to compare cutting electrocautery with the scalpel for surgical incisions observed no significant difference in terms of wound healing and overall subjective scar.

CONCLUSION

Cutting electrocautery and Colorado microdissection needle is quick and provides a clear field of dissection with minimum blood loss as compared to the surgical blade while placing cutaneous incisions for neck dissection in patients with oral squamous cell carcinoma.

Declaration of patient consent

The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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