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7th April - Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions

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the conclusions drawn about pain advantages were dubious on the other hand. there were not enough knowledge recorded of pain regimens to make that association as strong as it was implied in the paper and abstract

It improved post op pain but did not make note of the wide variety in pain management between patients

it sort of addresses that in the discussion where it says that the results cannot be extrapolated to cosmetically sensitive areas of the skin, but yeah I agree, potentially some different types of surgery other than abdominal would have produced more valid results?

I think good point on the sample size. The authors had two problems, firstly its a single centre study  (big trials in surgery normally require multiple centres internationally) and secondly they excluded any scar less than 3cm (that excludes a lot of laprascopic procedures)

the pain data from a pilot study point of view could be interesting, and if anything the authors could have probably highlighted better that this would be an avenue worth rigorous further exploration

If the study is significant with adequate power, but the sample size is still small, it'd be difficult to say if the significant result reflects a true outcome

they didn't seem to give a rationale for the exclusion of incisions <3cm. Any possible reasons for this?

However the paper did mention its drawbacks, for e.g. post op pain management being too heterogeneous to be included

Did anyone else feel that the lack of information of the training grade of the surgeons doing the procedure was significant?

@ Tomison I was wondering if they were doing it to try and have scars of similar size for a more reliable comparison between the scalpel incision and diathermy but they didn't seem to have an upper limit?

There was also a much higher proportion of laparoscopic procedures within both the diathermy and scalpel incision groups - the data for laparotomy scars is much less reliable given than there are only 15 total patients with laparotomies.

I was also wondering why they chose 6 months as a follow up point, might have been interesting  to see how they compared at different points in recovery

An upper limit could have improved the study and there would probably have been less variation in scar size

If they had more follow ups, maybe the drop out rate would have been higher, reducing sample size further?

the training grade of surgeons is definitely a factor missing, i hadn't thought of that. Also, doing some very quick reading about the Vancouver scar scale (one of the scales they used to assess the scars in this study) says that it is the most recognised scar assessment for burns; would this be significant in assessing the scars of abdominal surgery ?

Is the lack of information regarding skin closure significant?

To me it seemed a little odd to have predominantly laparoscopic procedures but then exclude wounds < 3cm, as if your looking for the best cosmetic result possible a small wound via a laparoscopic procedure would be the best

What did you make of the patient demographics? I thought it was a good attempt to take into account factors that influence wound healing and spread them equally within the two groups (to an extent; see DM and preop. chemo/radiotherapy). However, going back to the inadequacy of the size of the sample, the number of white people was way more than any other race.

I think it is significant Will. Do we know that it was the same surgeon throughout the whole case. If the surgeon was the same for the skin opening but then the closure was his registrar this could alter results

one thing i notice d about the sample size was that 9 patients withdrew from the trial, bringing the data set to 57 rather than the 66 they seem to focus on. would this not mean that the study was lacking the original power stated to be needed?

Also on calculation of the sample size, I also found it interesting how their calculation of score was based on a previous study, however that study was only for 37 patients (less than this study) and was not primarily focussed on the cosmetic outcome of the scar (Paper title: Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis.)

Do we also need more information on the techniques and suture types used on the skin closures?

@rachel they used staples, but may still need information on technique?

the caucasian population owas higer thatn other groups, but maybe that reflected the chances of keloid formation being higher in other ethnic groups, as well as just a generally higher caucasian population for this centre or this procedure? hard to say

I think we probably do Rachel. It says all skin incisions were closed with clips, but there is no mention of how the deeper tissues  were closed

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