Comparison of bipolar scissors and bipolar forceps in tonsillectomy. (Original Article).

Abstract

Bipolar diathermy scissors tonsillectomy is a relatively new surgical technique. We conducted a prospective study of 90 patients to compare this technique with bipolar forceps tonsillectomy. We found that the use of the bipolar scissors required significantly less operating time (mean: 3.03 min less) and allowed patients to resume eating solid food more rapidly (mean: 40.35 min earlier). Bipolar scissors tonsillectomy was safe, and there were no intraoperative complications or primary hemorrhages. A postoperative follow-up telephone survey revealed that patients who underwent scissors tonsillectomy experienced no more morbidity than did the forceps group during the first 2 weeks after surgery. We conclude that bipolar scissors tonsillectomy is a safe and rapid technique that can be used successfully as an outpatient procedure.

Introduction

Bipolar forceps tonsillectomy was first described in 1994 by Pang et al. (1) More recently, a new technique performed with bipolar scissors was described by Isaacson and Szeremeta (2) and by Saleh et al. (3) The scissors allow for simultaneous cutting and electrocoagulation. We conducted a prospective study to compare outcomes with bipolar scissors and bipolar forceps.

The design of the bipolar tonsillectomy scissors (PowerStar Bipolar Scissors; Ethicon; Somerville, N.J.) is a modification of the Metzenbaum scissors that are used in gynecology (figure). The fine-tipped scissors measure approximately 7 inches (177.8 mm) in length. They are completely insulated except for the distal 10 mm.

Surgical technique

Patients who undergo scissors tonsillectomy are prepped in the standard fashion and administered general anesthesia. Patients are placed in the supine position, and a Boyle Davis mouth gag supported by Draffin bipods is inserted. Diathermy is applied to the initial incision point at the superior pole with the points of the scissors virtually closed. The dissection then proceeds inferiorly.

The key to scissors tonsillectomy is to cut slowly while simultaneously applying the diathermy current. Any large vessels that are encountered can be electrocoagulated by placing the vessel between the blades prior to cutting. Bleeding points can be cauterized in the same way as they are with bipolar forceps. When bleeding occurs, it is rare that the surgeon must switch from scissors to forceps.

Patients and methods

From October 1998 through March 1999, 90 consecutive tonsillectomy patients were entered into the study. The study group included 75 patients aged 3 to 15 years (younger group) and 15 patients aged 16 to 32 years (older group). Half the patients were randomly assigned to bipolar scissors dissection (36 younger patients and 9 older); they ranged in age from 3 to 25 years (mean: 9.4). The remaining 45 patients (39 younger and 6 older) underwent bipolar forceps dissection; they ranged in age from 3 to 32 years (mean: 9.3). Three of the authors took part in this study as surgeons--one consultant (J.K.) and two specialist registrars (P.K. and P.T.). The indication for surgery was the treatment of either recurrent tonsillitis or sleep apnea.

The length of the operation was measured from the time the first incision was made to the time that hemostasis was deemed to be complete. Postoperatively, the nursing staff offered food and drink at regular intervals to all patients and recorded the time of each patient's first oral intake of fluids and solids; the nurses also noted the number of doses of analgesia each patient took and documented the time that each was taken. The nurses were blinded to the method of dissection that each patient had undergone.

Upon discharge, each patient was prescribed acetaminophen and codeine phosphate; the amount of analgesia prescribed was based on each patient's weight. Discharge antibiotics were not routinely prescribed. Follow-up telephone surveys were later carried out to assess whether patients experienced any complications during the first 2 postoperative weeks. The results were statistically analyzed by the Mann-Whitney U test.

Results

Operating time. The mean duration of operating time was significantly shorter in the scissors group than in the forceps group--9.50 and 12.53 minutes respectively (p = 0.003) (table 1).

Resumption of oral fluid and solid intake. The mean amount of time that passed before patients could resume intake of oral fluids and solids was used as a crude indicator of pain severity. Although there was no significant difference between the two groups with respect to fluid intake, there was a significant difference with respect to solid food intake--an average of 141.27 minutes in the scissors group and 181.62 minutes in the forceps group (p = 0.009) (table 2). Two patients (2.2%)--one in each group--were kept in the hospital overnight because their oral nutrition intake was inadequate.

Immediate postoperative analgesia. The analgesic requirements before discharge were similar in the two groups, ranging from 0 to 3 postoperative doses. The mean number of doses was 1.42 in the scissors group and 1.51 in the forceps group (p>0.05).

Telephone follow-up. The telephone survey disclosed that six of the 90 patients (6.7%) experienced secondary hemorrhage post-tonsillectomy--two in the scissors group and four in the forceps group (table 3). Three of these patients (3.3%) were readmitted for treatment of secondary hemorrhage.

The survey also revealed that 25 patients (27.8%) required further consultation during the first 2 weeks after surgery; 13 of them consulted their general practitioners and 12 returned to the hospital for review. Of these patients, seven in the scissors group and 10 in the forceps group were prescribed antibiotics. Overall, the scissors group did no worse than the forceps group during the first 2 postoperative weeks.

Discussion

There has been much debate about which of the several methods of tonsillectomy is best. Laser tonsillectomy, ultrasonic surgical aspiration, microsurgery, diathermy, and conventional blunt dissection all have their advantages.

Laser tonsillectomy has been shown to result in less pain and bleeding than the other methods. (4,5) However, it is costly and it is unsuitable as an outpatient procedure because a large proportion of patients are unfit for discharge 6 hours postoperatively. (6)

Tonsillectomy with an ultrasonic surgical aspirator is said to reduce trauma to surrounding tissue, but it, too, is expensive because it requires the use of disposable supplies. (7)

Andrea described the use of the operating microscope during tonsillectomy and reported that it provides excellent visualization for accurate dissection and that it is associated with excellent hemostasis and a decrease in postoperative pain. (8) It is also a good way to teach students because a camera can be attached to the microscope. (9) However, the use of the microscope lengthens the amount of operating time required.

Electrodissection tonsillectomy is rapidly growing in popularity because it is associated with excellent hemostasis. During electrocautery, heat is used to denature the protein of the vessel wall, thereby coagulating and sealing the vessel. (1) In our study, there was negligible blood loss with both types of diathermy dissection, and therefore we did not specifically measure it. Other authors have reported mean blood losses of less than 5 to 30 ml during electrodissection, compared with mean losses of between 34 and 190 ml during blunt dissection. (1,10-12)

Another advantage of electrodissection is that it requires less operating time. The length of bipolar forceps tonsillectomy has been reported to be 11.2 minutes, compared with 19.9 minutes required for classic blunt dissection/snare tonsillectomy. (13) We found that the duration of surgery was even shorter with bipolar scissors. In our series, the mean operating time was 9.50 minutes with bipolar scissors and 12.53 minutes with bipolar forceps--a statistically significant difference (p = 0.003).

Some have argued that the disadvantage of diathermy tonsillectomy is that it results in more postoperative pain than does blunt dissection. (10,12,14) However, this finding was not reproduced in a study by Pang, in which postoperative morbidity following bipolar forceps dissection was low. (13) By recording the time to oral fluid and solid intake as a crude indicator of pain severity, we found that the bipolar scissors group began eating an average of 40.35 minutes sooner than did the forceps group--again, a statistically significant difference (p = 0.009). This finding suggests that early postoperative pain was less severe in the scissors group, although the two groups had similar analgesic requirements (~1.5 doses) before discharge.

Reported rates of secondary hemorrhage following tonsillectomy vary widely--between 1.0 and 9.9% (10,12,15-18) The rate has been reported to be only 1 to 2% when investigators counted only those patients who required hospital readmission, but it was as high as 9.9% when patients were specifically asked about all bleeding events, including minor ones. In our study, only one patient in the scissors group was readmitted for a secondary hemorrhage; one other patient experienced a minor secondary hemorrhage that did not require readmission. With efforts at cost-cutting prompting the trend toward outpatient tonsillectomy, efforts to foster faster recovery while maintaining safety have become an important consideration. In view of the costs of readmission, the fact that scissors tonsillectomy failed only one patient suggests that it is a cost-effective procedure. As for the instrument itself, bipolar scissors are relatively inexpensive, and each unit can be used repeatedly until the edges become dull.

All three surgeons in this study preferred bipolar scissors tonsillectomy to the forceps procedure because it is a more precise and elegant technique. Because scissors tonsillectomy allows for simultaneous dissection and coagulation, the degree of tissue trauma and burning is lessened. By contrast, after forceps dissection the tonsillar fossae exhibited a charred appearance. Prior to their design modification, standard gynecologic Metzenbaum scissors used for tonsillectomy were prone to cause inadvertent bum injuries to the base of the tongue. In our series, the modified scissors caused no such harm.

We conclude that bipolar scissors tonsillectomy is a rapid and safe technique that minimizes blood loss and postoperative pain.

Table 1. Length of operating time (min) in the two groups by surgeon

Surgeon      Scissors   Forceps

Registrar 1
 Range       5 to 17    9 to 35
 Mean        9.65       13.05

Registrar 2
 Range       6 to 17    8 to 27
 Mean        9.55       13.46

Consultant
 Range       5.5 to 17  7 to 22
 Mean        9.25       10.85

Total
 Range       5 to 17    7 to 35
 Mean        9.50 *     12.53 *
 Median      9          11

* Statistically significant difference (p = 0.003).
Table 2. Time to first fluid and solid intake in minutes

         Scissors   Forceps

Fluid

 Range   15 to 170  14 to 225
 Mean    45.87 *    46.22 *
 Median  35         33

Solid

 Range   54 to 267  42 to 390
 Mean    141.27 +   181.62 +
 Median  130        176

* Not a statistically significant difference (p = 0.80).

+ Statistically significant difference (p = 0.009).
Table 3. Results of the telephone survey (N = 90)

Postoperative ([less than or equal  Scissors   Forceps
 to]2 wk) outcome                    n (%)      n (%)

Experienced secondary hemorrhage     2 (4.4)    4 (8.9)

Readmitted to the hospital           1 (2.2)    2 (4.4)

Consulted general practitioner      6 (13.3)   7 (15.6)

Consulted hospital physician        5 (11.1)   7 (15.6)

Were prescribed an antibiotic       7 (15.6)  10 (22.2)
   By general practitioner          5 (11.1)   5 (11.1)
   By hospital physician             2 (4.4)   5 (11.1)

Acknowledgments

The authors thank the ENT theater nursing staff at Mayday University Hospital and the nursing staffs in the Dolphin Day Unit and the Coulsdon One ward for their assistance with the data collection. We also thank Molly Britton for collecting the data sheets and Melissa Wright for her assistance with the statistical analysis.

References

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