Abstract
Tonsillectomy is a commonly performed surgery in otolaryngological practice. Owing to the possibility of postoperative bleeding, it is considered as one of the major surgical procedures. Various techniques have been advocated, however dissection and electrocautery are the most commonly used techniques in tonsillectomy. The objective was to study and compare the relative efficacy using two methods of tonsillectomy- bipolar electrocautery versus silk ligation. This prospective study included 50 patients who underwent tonsillectomy. Patients were randomly divided into two groups. In Group A, left tonsillar fossa haemorrhage was controlled by ligation, while in Group B, bipolar diathermy was used to control bleeding of right tonsillar fossa. Comparison was done in terms of time taken for hemostasis, amount of intra-operative blood loss and post-operative pain. 130 (72.22%) male and 50 (27.77%) females were included. Group A included 20 cases while Group B included 30 cases. The mean time taken for hemostasis in Group A patients was 40.5 ± 4.4 min as compared to 25.3 ± 6.2 min in Group B patients. The mean blood loss on cautery side was 49.5 ± 4.5 ml and that on the ligation side was 68.6 ± 5.3 ml. Post-operative pain was significantly more in Group B patients as compared to Group A patients. Bipolar diathermy is a quicker and faster method to achieve hemostasis with little intraoperative blood loss as compated to silk ligation.
Keywords: Tonsillectomy, Bipolar electrocautery, Silk ligation
Introduction
Tonsillectomy is a commonly performed surgery in otolaryngological practice. Owing to the possibility of postoperative bleeding, it is considered as one of the major surgical procedures.
Various techniques for tonsillectomy include dissection and snare method, electrocautery, guillotine excision, ligature tonsillectomy, harmonic scalpel tonsillectomy, cryosurgery and ablation method [1–4]. However, dissection and electrocautery are the most commonly used techniques in tonsillectomy [5].
The vital and most crucial phase in the entire tonsillectomy surgery is establishing hemostasis. Studies have shown that risk of hemorrhage is seen to be higher in adults as compared to pediatric patients [6, 7]. Intraoperative bleeding can be effectively controlled by bipolar electrocautery in a shorter time span however, there is a risk of post-operative necrosis and formation of infected slough which may lead to secondary hemmorhage [8, 9]. Use of ligatures in tonsillectomy is an effective technique for achieving haemostasis, but it takes more time to control bleeding resulting in more blood loss and increase operative time. Because of the ligature, muscle fibres in the tonsillar bed may become entrapped, increasing pain in the immediate aftermath of surgery [4, 10].
The purpose of this study was to evaluate and compare the effectiveness of bipolar electrocautery and suture ligation for preventing bleeding during tonsillectomy in our institute.
Materials and Methods
This prospective study was conducted in the Department of Otorhinolaryngology, GS Medical College and Hospital, Hapur over a period of one year between January 2022 to January 2023. A total of 50 patients who underwent tonsillectomy were enrolled for the study. Patients were divided into two groups. In Group A, left tonsillar fossa haemorrhage was controlled by ligation, while in Group B, bipolar diathermy was used to control bleeding of right tonsillar fossa. Comparison was done in terms of time taken for hemostasis, amount of intra-operative blood loss and post-operative pain. The ethical clearance for the study was obtained from the Institutional Ethical Committee.
Inclusion Criteria:
Patients aged between 5 and 40 years.
Patients with chronic or recurrent episodes of tonsillitis.
Enlarged obstructive tonsils causing breathing difficulty, snoring, difficulty in swallowing and obstructive sleep apnea.
Exclusion Criteria:
Patients < 5 years or > 45 years of age.
Patients with acute tonsillitis or respiratory tract infections.
Patients with bleeding disorders; cleft palate; those on anti-coagulants; uncontrolled medical illness; anemia; acute infections; hypertensive patients or any suspected malignancy of tonsils.
Results
Of 50 patients enrolled in the study, 26(52%) were males and 24(48%) were females. The age of patients ranged between 5 and 40 years with the mean age of 12.5 ± 2.06 years. Males were more commonly affected than females [Table 1].
Table 1.
Age-Sex distribution
| Age (in years) | Sex | Total | |
|---|---|---|---|
| Males | Females | ||
| < 10 | 7 | 4 | 11 |
| 10–20 | 8 | 7 | 15 |
| 20–30 | 6 | 8 | 14 |
| 30–40 | 5 | 5 | 10 |
| Total | 26(52%) | 24(48%) | 50 (100%) |
The mean time taken for hemostasis in Group A patients was 40.5 ± 4.4 min as compared to 25.3 ± 6.2 min in Group B patients. Statistically significant difference was found between the study groups with p-value < 0.0001 [Table 2].
Table 2.
Mean time taken for hemostasis
| Mean time taken (in minutes) |
Group A (ligation side) | Group B (cautery side) | p-value |
|---|---|---|---|
| Mean | 40.5 | 25.3 | |
| Standard Deviation | 4.4 | 6.2 | < 0.0001 |
The mean blood loss on cautery side was 49.5 ± 4.5 ml and that on the ligation side was 68.6 ± 5.3 ml with a p-value of < 0.0001 and hence statistically significant [Table 3].
Table 3.
Amount of blood loss
| Amount of blood loss (in ml) | Group A (ligation side) | Group B (cautery side) | p-value |
|---|---|---|---|
| Mean | 68.6 | 49.5 | < 0.0001 |
| Standard Deviation | 5.3 | 4.5 |
Visual analogue scale (VAS) was used to evaluate post-operative pain that was significantly more in Group B patients as compared to Group A patients. On postoperative day (POD) 1, the mean VAS score in Group A patients was 2.6 ± 0.4, while in Group B patients was 4.8 ± 1.5. On POD 3, the mean VAS score in Group A patients was 1.8 ± 0.2, as compared to 2.7 ± 0.9 in Group B patients. On POD 3, the mean VAS score in Group A patients was 0.74 ± 0.2, as compared to 1.5 ± 0.6 in Group B patients [Table 4].
Table 4.
Comparison of post operative pain
| POD 1 | POD 3 | POD 7 | ||||
|---|---|---|---|---|---|---|
| Group A | Group B | Group A | Group B | Group A | Group B | |
| Visual Analogue Scale (Mean Value) | 2.6 | 4.8 | 1.8 | 2.7 | 0.74 | 1.5 |
| Standard Deviation | 0.4 | 1.5 | 0.2 | 0.9 | 0.2 | 0.6 |
No primary or secondary hemorrhage was seen in any of the patients in our study.
Discussion
Although tonsillectomy is a routinely performed surgery worldwide, it’s indications and surgical techniques have undergone a conceptual change over the years. Intraoperative and postoperative bleeding is most dreadful complication in tonsillectomy patients [11]. According to estimates, 1 death occurs after each 20 000 tonsillectomy surgeries [12]. Many techniques have been advocated for tonsillectomy, however none of them is considered to be gold standard.
The two most popular techniques for limiting bleeding during and after tonsillectomy are electrocautery and suture ligation, with mixed success. In our study, time taken to achieve hemostasis on ligation side was 40.5 ± 4.4 min as compared to 25.3 ± 6.2 min on bipolar electrocautery side. In a similar study done by Moonka P, time taken for hemostasis on the cautery side was 15.5 min while that on the ligation side was 22.8 min [10]. A study done by Choy et al. [13] found that bipolar electrocautery take less time to control intraoperative bleeding and hence less anesthesia time which is also similar to our study. Sahib A et al., [14] in their study on 180 patients compared silk ligation with bipolar diathermy and concluded that less operative time is taken to achieve haemostasis with bipolar diathermy method (15 min) as compared to silk ligation (30 min).
Our study concluded mean blood loss on cautery side was 49.5 ± 4.5 ml and that on the ligation side was 68.6 ± 5.3 ml. Similar observation was noticed in a study done by Naik et al. [15] wherein the amount of blood loss on cautery side was less than 65 mL while on the ligation side, it was more than 70 mL. Sharma K et al. also concluded that as compared to suture ligation, bipolar diathermy greatly reduced the amount of blood loss [16]. This can be attributed to the fact that ligation takes more time to achieve hemostasis as compared to bipolar electrocautery.
Visual analogue scale (VAS) was used to evaluate post-operative pain on POD-1, POD-3 and POD-7 in our study. We noticed that cautery side had more pain on POD-1 which decreased over time on POD-3 and POD-7. Similar results were concluded by study done by Moonka P et al. [10] in which the bipolar cautery side had more pain on the first day as comparable with ligation side. Pinder et al. also observed that post-operative pain was more on diathermy side than the ligation side [17]. Similar to our study, varios studies in literature done Beriat et al., Khan et al., Mofatteh et al., MacGregor et al. found increased post-operative pain with bipolar diathermy method [18–21]. However, in contrast to our results, Khan AF et al., did not find any significant difference in post-operative pain between the two methods of achieving hemostasis [22].
Conclusion
For a safe procedure to be performed and to lower both intra-operative and post-operative complications, the surgeon must have a thorough understanding of the anatomy of the oropharynx. Ligation technique not only requires additional time resulting in increasing intraoperative blood loss, but also lengthens the time spent under general anaesthesia. Hence, we draw the conclusion that bipolar diathermy is the superior method for hemostasis in tonsillectomy since it is faster and has little intraoperative blood loss.
Funding
None.
Declarations
Ethical Approval
Ethical clearance was taken by Institutional Ethical Committee.
Conflict of interest
There are no potential conflicts of interest.
Human and Animal Rights Statement
No animals or human participants were injured in the study.
Informed Consent
A written informed consent was taken from the patients in the study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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