It is Time to Change Method of Skin Incision From Scalpel to Electrocautery.
Conditions: Skin Injury
Sponsor: University of Catania

  
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IT IS TIME TO CHANGE METHOD OF SKIN INCISION 
FROM SCALPEL TO ELECTROCAUTERY 
Prof. Isidoro Di Carlo 
Co-Authors: Adriana Toro; Chiara Mazzone; Iacopo Sarva'; Emanuele Gaspare Fontana; Alessandro Terrasi; Rapisarda 
Martina 
23 January 2023

  
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KEY WORDS  
Electrocautery, scalpel, skin incision,  
  
ABSTRACT  
The use of electrocautery to incise the skin is still debated. Aim of the present study is to contribute 
at the use of electrocautery for skin incision as safe procedure both for patients and surgeons.  
  
PATIENTS AND METHOD  
Patients submitted to abdominal surgery, in which the skin have been incised by electrocautery from 
2016 to 2021 have been considered. Sex, age, kind of disease, kind of incision have been considered 
at moment of surgical procedure. In the post-operative period wound infection, post operative pain, 
healing time, cosmetic results have been also considered.  
  
RESULTS  
A total of 281 patients (119 females, 162 males) with a median age of 60 years were scheduled for 
abdominal surgery. Most of the patients have submitted to surgical procedures involving the small 
and large intestine (160 patients, 56.9 %). Others patients were operated for liver, gallbladder, 
spleen or pancreas (41 patients, 14.5 %), esophagus stomach or duodenum (4 patients, 1.4%) 
disease. Finally, some patients undergone to hernioplasty (57 patients, 20.2 %). The majority of 
procedures were performed with a laparotomy incision (248), the others with laparoscopy (33). The 
incidence of wound related complications was 2 %, and all these 6 patients had peritonitis due to a 
perforation of a viscus. These 6 patients have been excluded from the scar evaluations. Patients 
refer pain classified as 1-2 in a numerical rating scale from 0 to 10.  Wound has healed in about 710 
days, and result was judged excellent both by patients and surgeons. Cosmetic results have been 
evaluated 2 weeks and 6 months after from surgical procedure. All the patients have been satisfied 
of their scar.  
  
CONCLUSIONS   
In spite of its limitations this study supports the use of electrocautery for skin incision. Nevertheless 
the knowledge electrocautery mechanism are of utmost importance to archive these results.  
  
  

  
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INTRODUCTION  
Electrosurgery was introduced in the clinical practice for the first time in 1926 by Harvey Cushing (1) 
and since then it gradually has become a more and more one of the most used devices in surgical 
practice (1).   
The use of an electrode, delivering pure sinusoidal current during cutting diathermy incision, allows 
to divide tissue by cell vaporization without damage to adjacent areas (2).  
Even if evidence suggests that diathermy can be used safely for skin incision (3), most surgeons use 
scalpel for skin incisions and coagulation diathermy for deeper tissues (4).  
The aim of this retrospective study is the evaluation of wound infections, the healing time, the 
postoperative pain of patients submitted to a skin incision using the electrocautery. We will analyze 
also the cosmetic results judged both by surgeons and patients.   
  
  
  
 

  
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PATIENTS AND METHOD   
Patients submitted to abdominal surgery in which the incision of the skin have been done by 
electrocautery, from 2016 to 2021, have been considered. Sex, age, kind of disease in relation to the 
organ affected and type of surgical procedure and related incision have been investigated. Patients 
with diabetes mellitus, coagulation disorders and those submitted to a treatment of steroids and 
anticoagulant; patients previously operated with scar in the site of the second operations, or with 
anemia or with active source of infection in any part of the body where excluded from the study.   
The skin incision has been classified into laparotomic or laparoscopic, in elective or emergency 
surgery. The laparotomic included large (large midline as xipho-umbilical or umbilical pubic incision, 
subcostals or pararectal) and small (small midline no more than 7 cm, inguinal, McBurney) skin 
incisions. The laparoscopic on the opposite involve incisions from minimum of 1 cm or less for 
introduction of trocars, and a maximum of 10 cm to extract organ. The subcutaneous layer has been 
closed using an interrupted suture using Vycril®3-0 on the opposite the skin suture has been done 
using metallic clips.  
All patients have been submitted to general or spinal anesthesia. Antibiotic prophylaxis was done, 
following the guidelines related to the disease (5). Patients submitted to hernioplasty of 
laparoscopic cholecystectomy or any procedure in which the literature have reached a consensus 
any antibiotic treatment including the prophylaxis have not been done (5).  
  
The outcomes considered are wound infections, post-operative pain, healing time, cosmetic results. 
The post operative pain has been related to the administration of paracetamole 1 gr every 12 hours 
for the first 3 days. The healing time and cosmetic results have been evaluated both during the 
hospitalization or in the out patients clinics, after 10 from surgical procedure at moment of ablation 
of metallic clips, and/or 20 days after the surgical incision with final clinical evaluations of the scar.  
Finally considering the medical records and operative reports, patients were contacted 6 months 
later by phone by resident in surgery ask them to evaluate their scar. The patient was asks simple 
to define their scar as acceptable and consequently patient satisfied or not acceptable so patient 
not satisfied.   
We, also, consider the reported injury to surgeons or theater workers during the surgical procedure. 
Particularly we have reported the burns from hole in the gloves related to an absent respect of the 
isolated generator circuit  
  

  
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The skin incision has been done using the following rules: the cutting diathermy have been used to 
incise the skin. If bleeding comes from the dermis, the coagulation diathermy has been shortly used 
using the tip of the headpiece, without forceps. To incise the skin we have used a Valleylab force TX 
Medtronic Italy equipped with standard diathermy pen electrode, set on cutting mode for skin at  
20 KHz sinusoidal current and on coagulation mode at K40 Hz both for skin and for deeper tissues  
(6).   
Electrosurgery works by electrons’ handling on living tissue using an alternating current density 
sufficient to create heat within tissue cells to destroy them.  
It is mandatory to consider the mode of use electrosurgery. In the cutting mode, a continuous 
current produce extreme heat causing vaporization so the conversion of the cells into steam. When 
we use the electrosurgery unit into cutting mode for the skin the cells vaporize and the tissue is 
divided with a minimum devitalization, the thermal damage is minimal and it is not propagated to 
neighboring cells. Differently the coagulation mode that cause high thermal damage and necrosis of 
adjacent cells.   
  
  
  
RESULTS  
A total of 281 patients (119 females, 162 males) with a median age of 60 years were scheduled for 
abdominal surgery. All the patients affected by one of the contraindications listed in materials and 
method have been excluded from the present study. We have collected the patients according to 
the site of origin of the disease. Most of the patients have submitted to surgical procedures involving 
the small and large intestine (160 patients, 56.9%). Others patients were operated for liver, 
gallbladder, spleen or pancreas (41 patients, 14.5%), esophagus stomach or duodenum (4 patients, 
1.4%) disease. Finally, some patients undergone to hernioplasty (57 patients, 20.2%). And at the 
least we have grouped as miscellaneous some patients undergoing procedures that concerned the 
subcutaneous or unspecified (19 patients, 6.7%) (table 1).  
Most of the procedures were performed with a laparotomy incision (248 patients, 88.3%), the others 
with laparoscopy (33 patients, 11.7%) as shown in table 2. Into the group of laparotomic incisions 
158 patients have a large incision and 93  have a small incision. In the group of laparoscopic in all 33 
patients we needed to widen the skin incision beyond the 10 mm necessary to introduce the trocar.  
203 patients of the total underwent emergency surgeries and 78 patients elective operations.   

  
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The incidence of wound related complications was 2%, this percentage related to infections were 
recorded in patients undergoing emergency surgery with laparotomic incisions and all these 
patients had peritonitis due to a perforation of a viscus. These 6 patients have been excluded from 
the scar evaluations.  
Patients refer pain classified as 1-2 in a numerical rating scale from 0 to 10, with zero meaning “no 
pain” and 10 meaning “the worst pain imaginable (7). And this was just in the first 24 hours after 
the procedure. No one patients have reported pain after this period from the surgical procedure. 
During the follow-up controls, we noticed that the wound has healed in about 7-10 days, but at the 
end of the healing the aesthetic result was judged excellent both by patients and surgeons.  
Cosmetic results have been evaluated by surgeons in out patients clinics 2 weeks after from surgical 
procedure. 6 months later all the remnant 275 have been submitted to telephonic interwiew and all 
the patients have defined the cosmetic results acceptable. Consequently, all these patients have 
been satisfied from the surgeon work.  
No incidental burns of the hands of surgeons have been reported. Finally no scalpel have been used 
and no accidental puncture have been reported.  
  
  
DISCUSSION  
The use of electrocautery is not still accepted worldwide from all surgeon as a safe method both for 
patients and surgeon to incise not only the different layers of the wall but also the skin.   
The number of surgeons using the electrocautery to incise the skin, remain very low as the majority 
of them continue to use the scalpel. Despite the electrocautery protect the surgeon and the team 
working at the operative table, both by direct injuries and the risk of blood disease transmission, 
the scalpel is still used for almost the 80% of the surgeons (8,9).  
The hypothesis that the electrocautery can reduce the tensile strength, can increase the rate of 
infection and an increased zone of wound necrosis histologically proved related to the scalpe use 
have been postulated in experimental studies (10). This suggestion has never proved clinically and 
seems more related to the use of coagulation diathermy more than cutting diathermy (10). In effect 
cutting diathermy produces rapid tissue vaporization; on the opposite the coaugulation diathermy 
cause charring and necrosis that may predispose to wound infection. So if the skin is incised with 
the cutting diathermy and the coagulation is reserved in this phase just to stop a small bleeding from 
dermis, these cited negative effect have never encountered in any study.   

  
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After the skin division the coagulation diathermy can be usually used to divide the deeper tissue. 
This technique has been applied in our casuistic. In this way there is no difference also in wound 
infections. This technical behaviour have to be stressed especially with young residents in order to 
adequately use the electrocautery with lowest possible generator setting to avoid complications.   
  
All the patients can be submitted to this technique in order to have beneficial effects. This method 
should be avoided in patients in which the wound infection can have a substantial risk factor not 
related to the kind of incision (6). In our study the wound infection has been related to the peritonitis 
that have been diagnosed in all the patients that intraoperatively reported a viscus hole. In this kind 
of patients operated in the set of the emergency the diathermy does not prevent from the wound 
infection, as reported in the literature. In our opinion all the remnant beneficial effect demonstrated 
in the literature, like reduction of bleeding, reduction in time of incision and so on, remain active 
and represents a valid reason to use the diathermy also in these patients. A hypothesis of future 
work, where only wound infection can be represented as complication, using a randomized study 
can clarify this aspect. If all the remnant advantages can be preserved, the electrocautery can be 
used in all the patients in which currently is no recommended.  
  
The use of scalpel causes the bleeding of the skin incised and this condition need the coagulation 
using the electrocautery. For this maneuver the surgeon needs to abandon the scalpel and to take 
another instrument. This can explain the loss of blood and also the time spent to do this change of 
instruments. This aspect is not detectable using the electrocautery. Moreover it is important to add 
at these sentences the fact the modern electrosurgical handpeace have two buttons one for cutting 
diathermy and the second one for coagulation diathermy. This condition does not need to exchange 
different instruments, as both cutting and coagulation can be done just changing the button of the 
same handpeace. The subcutaneous bleeding may be controlled using just diathermy. This aspect 
does not alter the results that concern only the method used for the skin incision. In literature many 
articles have demonstrates that, the kind of coagulation of the deeper layer, do not affect the result 
of the skin in relation to the kind of incision used (11-16).  
  
There is no risk to increase the infection rate using the electrocautery as different meta-analysis 
have exclude this condition (4,17-18). Our results show a rate of wound complications included in 
the range from 1,9% (19) to 40 % (20) reported in a recent manuscript of Cochrane (21). In our report 

  
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the majority of our patients have been operated in emergency surgery and it is mandatory to 
consider the clinical conditions associated. They could have developed wound infection due to 
factors independent from the incision, such as wound contamination, peritonitis or other 
intrabdominal infections. Some patients that developed a wound infection were affected by cancer 
and this is one of the main causes of immunologicas disorders that can impact also in the result of 
these studies.  
  
The time of incision was not the aim of this study but is intuitive the shorter time for the 
electrocautery in relation to the scalpel. This meaning is not only intuitive but have been 
demonstrated scientifically by many studies (4). Many studies shown that the diathermy incision 
may be quicker to perform incision of the skin than scalpel (4,18,22). Scalpel incision can lead to 
bleeding of the dermis more frequently and involves the need to perform hemostasis with 
electrosurgical units, which not only takes longer, but can also cause infections. In fact the 
coagulation mode, as used in scalpel incision, cause a big thermal damage and necrosis of adjacent 
tissues (23).  
  
Another advantage of the use of diathermy is the absence or inappreciable postoperative pain. In 
effect the literature supports a small benefit in terms of early postoperative pain in the patients 
treated with diathermy skin incision rather than scalpel (3). We estimate the post-operative pain 
based on analgesic post-operative medications: the amount of orally administered analgesics was 
slightly less related to other patients of surgical unit operated with scalpel. Moreover when the 
patients in which the diathermy have been used to incise the skin, and he has been visited post 
operatively in the outpatients clinics, do not refer any record of post operative pain in their scar. 
The explanation of the very small amount of pain reported by the patients is probably due to the 
effect of the diathermy ablation that destroy the localized sensory nerve. This have also been 
explained by studies in which the group of patients treated by electrocautery required only half dose 
of analgesic in the post operative period (24). Other studies have well demonstrated that patients 
in which the skin have been incised with electrocautery have less pain 24 or 48 hours after the 
procedure in relation to patients in which the incision have been done using the scalpel (22). All our 
patients have, depending from nature of surgical procedure, a slight of more important analgesic 
medications. So we cannot affirm for sure that the slight pain recorded by patients is related to the 
kind of procedure adopted for skin incision, due to the interference of the antinflammatory 

  
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medications. What we can affirm is that the related pain after the procedure have been classified 
as very low or absent.   
  
Wound healing is another point of discussion. This study is not randomized with scalpel incision, but 
we can affirm that between the method to close the skin we have used the less refined. All the 
patients without complication have been clips removal in a maximum 10 days with a satisfied result 
both for surgeons and patients.  
The cosmetic result was unbelievable judged positively by all the patients interweaved by telephone 
call after 6 months. This was more appreciated result as no particular suture technique were applied 
as all the patients have been their skin sutured by metallic clips.  
  
In terms of cost it must also be considered that while the electrosurgical unit is an essential tool in 
all duration of surgical intervention, the scalpel is not used except to incise the skin, so it constitutes 
an unnecessary expense that could be avoided.  
  
The transmission of infections among health care workers has been associated with accidental 
inoculation injuries due to sharp instruments. Surgical scalpels are reported to be the second most 
frequent source of these accidental injuries after suture needle injuries in operating theatres (18) 
and is estimate that injuries due to the scalpel cause 18 % of all sharps injuries in the operating 
rooms (4). So considering the recent increase in bloodborne diseases makes exclusion of the scalpel 
represents an attractive option to eliminate disease related to the scalpel use (22).  
  
The safety of the work place remain a problem for all the person inside the operative room. The 
plume has still indicate as one of the problem when electrocautery in used for skin incision. The 
problems related to this plume is its contents (chemical and cellular debris) that can be both 
potential risks to spread bacterial, viral and chemical diseases, and the risk of carcinogenesis due to 
the presence of chemical that can have the potential for tumor development. In our experience to 
decrease this risk we use a double aspiration in order to decrease or eliminate the effect of plume 
during the skin or abdominal layer incision using the electrocautery. This is not a complete method 
to avoid the plume but in this way the plume remains limited to the aspirator and do not interest 
macroscopically the inhalation of all members of operative rooms.  
  

  
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During the use of electrocautery, the cleaning of the tip is strongly recommended. In fact this 
negligence can cause the growing of escar on the tip of the electrode and as consequence we can 
have arcing until the flaming of the escar. Usually the tip is cleaned with a scratch pad but this action 
can cause grooves in the tip electrodes and in this way the eschar can increase in size. So the 
recommendations are to clean the tip electrode with a sponge to avoid the damage of the tip and 
the increase of the eschar.  
  
  
  
CONCLUSIONS   
The present is a retrospective study with all limitations for this type of study. However the outcomes 
of this research  support the use of electrocautery for skin incisions.  
The undoubtedly advantages reported in this study in terms of wound infections, healing time, 
postoperative pain and cosmetic results in association with economic gain for saving in the purchase 
of scalpes, represent a formidable motivation for the surgeons to abandon the scalpel in favors of 
diathermy. Nevertheless the knowledge electrocautery mechanism are of utmost importance to 
archive these results.  
  
  
 

  
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Ethical approval Not 
applicable.  
  
Sources of funding  
There is no funding source.  
  
Author contribution  
Adriana Toro, Chiara Mazzone e Iacopo Sarva' contributed to the study design, Emanuele Gaspare 
Fontana, Alessandro Terrasi e Martina Rapisarda contributed to data collection, Adriana Toro 
contributed to data analysis and writing, Isidoro Di Carlo contributed to review .  
  
Research registration number  
1. Name of the registry: Not applicable.  
  
2. Unique Identifying number or registration ID: Not applicable.  
  
3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not 
applicable.  
  
Guarantor  
Isidoro Di Carlo  
  
Data sharing statement  
The data sets used and analyzed during the current study are available from the corresponding 
author upon reasonable request.  
  
Provenance and peer review  
Not commissioned, internally peer-reviewed.  
  
Declaration of competing interest There 
is no conflict of interest.  
  
  

  
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1. 
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future uses. J Am Coll Surg 2006;202:520-30.  
   
2. 
Shamim M. Diathermy vs. scalpel skin incisions in general surgery: double-blind, randomized, 
clinical trial. World J Surg 2009;33:1594-9.   
  
3. 
Aird LN, Bristol SG, Phang PT, Raval MJ, Brown CJ. Randomized double-blind trial comparing 
the cosmetic outcome of cutting diathermy versus scalpel for skin incisions. Br J Surg 2015;102:489-
94.   
  
4. 
Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus 
scalpel for skin incision. Br J Surg 2012;99:613-20.   
  
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Prakash LD, Balaji N, Kumar SS, Kate V. Comparison of electrocautery incision with scalpel 
incision in midline abdominal surgery - A double blind randomized controlled trial. Int J Surg 
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Soballe PW, Nimbkar NV, Hayward I, Nielsen TB, Drucker WR. Electric cautery lowers the 
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Groot G, Chappell EW. Electrocautery used to create incisions does not increase wound 
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Hussain SA, Hussain S. Incisions with knife or diathermy and postoperative pain. Br J Surg 
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Madden JE, Edlich RF, Custer JR, Panek PH, Thul J, Wangensteen OH. Studies in the 
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Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in 
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Aird LN, Brown CJ. Systematic review and meta-analysis of electrocautery versus scalpel for 
surgical skin incisions. Am J Surg 2012;204:216-21.  
  
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Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan 
S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen 
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Akazawa K, Yamanaka T, Shimokawa M. Impact of intra-abdominal absorbable sutures on surgical 
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for major abdominal incisions. Review. Cochrane Database Syst Rev 2017; 6: CD005987.  
  
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diathermy versus scalpel incision in elective midline laparotomy. Br J Surg 2001;88:41-4.   
  
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Soderstrom RM. Electrosurgical injuries during laparoscopy: prevention and management. 
Curr Opin Obstet Gynecol 1994;6:248-50.   
  
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Chrysos E, Athanasakis E, Antonakakis S, Xynos E, Zoras O. A prospective study comparing 
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Table 1. Patient’s pathology   
  

  
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Pathology site  
Patient’s number   
Ileus, appendix, colon, rectum  
160  
Esophagus, stomach, duodenum  
4  
Liver, gallbladder, pancreas, spleen  
41  
Abdominal wall  
57  
Miscellaneous  
19  
   
  
 

  
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Table 2. Surgical procedure  
  
Surgical procedure  
281  
-  
Laparotomy  
248  
-  
Laparoscopy  
33