CLINICAL OUTCOME OF LIGATION VERSUS BIPOLAR DIATHERMY IN TONSILLECTOMY

Abstract

Introduction : Tonsillectomy refers to the surgical procedure of removing palatine tonsils and is one of the common surgical procedures performed by an otorhinolaryngologist. Although tonsillectomy is considered a relatively simple procedure, one of the most common challenges faced by a surgeon is achieving hemostasis. Effective hemostasis is very important and unsuccessful hemostasis can lead to shock, increased operating time, aspiration of blood, and delay in the healing process. There are many ways in which post-operative hemostasis can be achieved which vary from gauze pack pressure in tonsillar fossa, application of adrenalin packs, bipolar diathermy, application of ligature, and ligasure vessel sealing system. Among these bipolar electrocautery and ligation of bleeding vessels are the most commonly used techniques. But the advantage of one method over the other is still a grey area. In this study we compare the post-operative clinical outcomes in terms of post-operative pain, intraoperative and post-operative bleeding, amount of blood loss during surgery, and return to routine daily activities post-surgery with the usage of ligation technique versus electro cauterization by bipolar diathermy for achieving hemostasis. Aim Of Study : To compare the outcome of ligation versus bipolar cautery during hemostasis during tonsillectomy with regard to post-operative pain, amount of blood loss during surgery and post operative bleeding if any and return to routine daily activities. Materials and methods : Under strict aseptic precautions, adenoidectomy in indicated cases was performed under general anesthesia and nasopharynx was packed with ribbon gauze ensuring haemostasis. Tonsillectomy was performed under general anesthesia by Dissection and snare method. The patients was randomly separated into two groups, Group A and Group B. Group A patients underwent tonsillectomy and in them haemostasis xx was achieved by Ligation of the bleeding vessel. Group B patients will underwent tonsillectomy and in them haemostasis was achieved by Cuadra Bipolar electrocauterization. Intraoperatively the amount of blood loss was calculated in Group A and Group B by adding the total blood collected in the suction bottle after discarding the blood during adenoidectomy plus the weight difference in the plain soaked cotton ball and gauze balls used for pressure hemostasis and documented. The post operative bleeding if any was documented and compared between Group A and Group B.After the surgery all patients in both the groups was given standard analgesics (Paracetamol , Aceclofenac or Ibubrufen) and antibiotic (Amoxycillin+clavulanic acid injections according to hospital antibiotic policy). Post tonsillectomy pain was analyzed by visual analogue scale (VAS)(ANNEXURE I) for adults and children more than 7 years old and Wong-Bakers FACES(ANNEXURE II) pain scale for children of 3-7 years old. In all patients in Group A and Group B, post operative pain was documented on 1st, 4th, 7th and 14th postoperative day and compared and documented. The analgesia requirement in the first 24 hours was documented and compared between the two groups. The patients time of recovery period and return back to their routine activity was also documented and compared among the two groups . Statistical analysis: Data was entered using Microsoft Excel and analyzed using the Statistical Package for Social Science (SPSS) standard version 20. All socio-demographic and clinical characteristics of the patient was summarized using Mean (SD) for continuous variables and proportions (%) for categorical variables. Comparison of continuous variable (blood loss, VAS scores for pain) across the two groups (ligation vs diathermy) was performed using the student’s t test. Comparison of categorical variables across study groups was done using Chi square test. P-value of <0.05 was considered statistically significant. xxi RESULTS : The mean age of patients in the ligation group was 16.46 years (SD = 12.51), while the mean age in the bipolar cautery group was 12.17 years (SD = 7.65). There was no significant difference in mean age between the groups (p = 0.088). The mean blood loss in the ligation group was 42.60 ml (SD = 5.09), whereas the mean blood loss in the bipolar cautery group was 43.46 ml (SD = 8.20). There was no significant difference in mean intraoperative blood loss between the groups (p = 0.601). This study evaluated postoperative pain on days 1, 4, 7, and 14 after tonsillectomy using ligation versus bipolar cautery. On day 1, the mean pain score was 7.57 (SD = 0.50) in the ligation group and 7.51 (SD = 0.51) in the bipolar cautery group, with no significant difference (p = 0.637). By day 4, the mean pain score was significantly lower in the ligation group at 2.43 (SD = 0.88) compared to 3.37 (SD = 0.81) in the bipolar cautery group, with a significant difference (p < 0.0001). On day 7, the ligation group again had a significantly lower mean pain score of 0.11 (SD = 0.32) versus 0.57 (SD = 0.50) than the bipolar cautery group, with a significant difference (p < 0.0001). By day 14, both groups had a mean pain score of 0, indicating complete resolution of pain. The mean day of return to routine activities for the ligation group was 6.91 days (SD = 0.74), while for the bipolar cautery group, it was 7.63 days (SD = 0.94). This difference was statistically significant (p = 0.001), indicating that patients in the ligation group returned to routine activities significantly sooner than those in the bipolar cautery group. CONCLUSION : The results of this study suggest that ligation and bipolar cautery techniques are both effective methods of achieving haemostasis for tonsillectomy procedures, with comparable intraoperative blood loss. However, ligation may offer advantages in terms of reduced postoperative pain. And the recovery for ligation is lower as compared to bipolar group. Both the methods shows negligible risk towards development of post operative haemorrhage.