The Use of Diathermy Scissors in Parotid Gland Surgery

The Use of Diathermy Scissors
in Parotid Gland Surgery
Juergen O. Ussmueller, MD; Michael Jaehne, MD; Bjoern-Georg Neumann, MD
Objective: To evaluate the benefits, as well as the possible
complications, of the use of diathermy scissors in
parotid gland surgery.
Design: Prospective study of the surgical procedures of
the diathermy scissors and a retrospective comparison
with a conventionally treated control group concerning
cut-closure time.
Setting: Tertiary care referral academic center.
Patients: Prospective examination of 30 unselected patients
undergoing superficial (n=23) or subtotal/total
(n=10) parotidectomies performed with diathermy scissors.
Indications were benign tumors (n=18), malignant
tumors (n=12), and cystic lesions (n=3). In a control
group (n=50), 36 superficial and 21 subtotal/total
parotidectomies were performed.
Results: The use of diathermy scissors reduces the need
to frequently change dissecting and coagulating surgical
instruments. The scissors reduce intraoperative bleeding
and therefore improve visualization and orientation
From the Department of
Otorhinolaryngology–Head and
Neck Surgery, University
Hospital Eppendorf, Hamburg,
Germany. The authors have no
relevant financial interest in
this article.
ORIGINAL ARTICLE
THE BASIC GOAL OF PAROTID
gland surgery is the continuous
preparation and
strict preservation of the facial
nerve during en bloc resection
of a tumor along with surrounding
tissue; therefore, the tissue lying
superficial to the facial nerve is dissected
microscopically. Microscopic dissection,
however, may lead to multilocular minor
bleedings, which in turn may obscure visualization
of the course of the nerve and
require frequent replacement of the operating
tools for dissection and coagulation,
leading to prolonged surgery.
In a prospective study, we examined
the benefits of, as well as the complications
that can result from, the use of diathermy
scissors to determine whether
they are a suitable tool for parotid gland
surgery.
in the surgical field. Postoperative bleeding or seroma and
Frey syndrome were not observed. In 1 case, a salivary
fistula was present for 3 weeks. Three cases of transient
facial weakness occurred, all of which completely resolved
by 6 months after surgery. In the control group,
the cut-closure time ranged from 50 to 120 minutes (average,
87.6 minutes) during superficial parotidectomy;
it ranged from 80 to 160 minutes (average, 130.0 minutes)
during subtotal and total parotidectomy. In comparison,
in the study group, the average time gain was
16 minutes during superficial parotidectomy when diathermy
scissors were used, a statiscally significant difference
(P=.03). During subtotal and total parotidectomy
with diathermy scissors, the average time gain was
19.3 minutes and was statistically not significant (P=.23).
Conclusions: The results of the present study show that
diathermy scissors are very well suited for most of the
surgical steps in parotid gland surgery. They provide an
elegant, safe, and fast surgical procedure, especially in
the hands of an experienced surgeon.
Arch Otolaryngol Head Neck Surg. 2004;130:187-189
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METHODS
In a prospective study involving 30 patients,
23 superficial parotidectomies, 9 subtotal parotidectomies,
and 1 total parotidectomy were
performed with diathermy scissors. The main
indications for surgery included benign and
malignant tumors (pleomorphic adenoma,
Warthin tumor, oncocytoma, acinic cell carcinoma,
mucoepidermoid carcinoma, carcinosarcoma,
malignant lymphoma, and metastasis)
as well as cystic lesions (cystic lymphoid
hyperplasia in AIDS and salivary duct cyst). In
4 cases, exposure of the facial nerve was required
during excision of cutaneous malignancies
(malignant melanoma and Merkel cell
carcinoma). Diathermy scissors were used to
perform a total of 37 operations, 4 of which
were surgical revisions.
The standard procedure consisted of microscopic
identification of the facial nerve stem
in the stylomastoid fossa, followed by anterograde
preparation of the facial nerve fan. The

Figure 1. Superficial parotidectomy performed with diathermy scissors,
intraoperative view. Simultaneous dissection of the parotid gland
parenchyma lying superficial to the facial nerve (arrow indicates bifurcation
of the facial nerve trunk).
Figure 2. Superficial parotidectomy performed with diathermy scissors,
intraoperative view. Dissected parenchyma of the superficial parotid lobe
showing no bleeding.
use of the microscope made identification and preparation of
the nerve branches safer and easier. After the nerve stem was
definitively identified, the diathermy scissors were used almost
continuously, for preparation, conventional cutting, conventional
bipolar coagulation, and simultaneous cutting and
bipolar coagulation. The bipolar intensity setting was 50 W.
Additional intraoperative facial nerve monitoring was conducted
in cases involving revision surgery and resection of malignant
skin tumors of the cheek.
After surgery, the entire range of complications, especially
hemorrhage, hematoma, seroma, salivary fistula, Frey syndrome,
and facial nerve paralysis, was examined. Postoperative
follow-up lasted for 12 months. Assessment of concomitant nerve
impulses (caused by the scissors) and the possible adverse impact
of facial nerve monitoring were of special interest. Required
time for surgical preparation was examined retrospectively by comparison
of the average cut-closure time in the study group with
that in a control group of 50 patients who were conventionally
treated. The control group underwent 36 superficial and 21 subtotal/total
parotidectomies in the same surgical manner but without
the use of the diathermy scissors. Cases involving revision
surgery and preparation of the facial nerve in skin malignancies
were excluded. The indications for surgery were almost the same
in both groups. The follow-up time was the same (12 months).
All operations were performed by the same surgeon, with
the patients under general anesthesia and normal conditions
of blood pressure (110-130 mm Hg systolic). The statistical significance
of cut-closure time differences was calculated by normality
(Kolmogorov-Smirnov) and t tests.
No. of Operations
12
10
8
6
4
2
0
Superficial Parotidectomy
40 60 80 100 120 140 160
Cut-Closure Time, min
RESULTS
Diathermy scissors are very well suited for most of the
surgical steps in parotid gland surgery. However, some
practice is needed for proper use of this tool. Both arterial
and venous bleeders are safely coagulated, resulting
in a major reduction of intraoperative bleeding. Coagulation
of arterial and venous vessels with a diameter of 2
to 3 mm can ideally be performed before cutting, with
the tips of the scissors slightly open. This step, in turn,
reduces the frequency with which instruments need to
be changed. Simultaneous cutting and coagulation also
reduces intraoperative bleeding. Therefore, the use of the
diathermy scissors improves the view in the surgical field,
especially visualization of the facial nerve branches
(Figure 1 and Figure 2).
COMPLICATIONS
There was no evidence of postoperative bleeding, hemorrhage,
or seroma. In 1 case, after superficial parotidectomy
for pleomorphic adenoma, a salivary fistula was present
for 3 weeks. Within the 12-month follow-up period,
we did not observe any cases of Frey syndrome. Transient
facial nerve paralysis occurred in 3 of 37 cases: 2
cases with isolated inferior trunk weakness and 1 case
with a complete peripheral facial paresis. All 3 cases completely
resolved by 6 months after surgery. The quality
of facial nerve monitoring was not impaired by diathermy
scissors. Muscle contractions were sometimes observed
with the use of the diathermy scissors, similar to
electrocautery.
CUT-CLOSURE TIME
Diathermy
Scissors Group
Control Group
Figure 3. Cut-closure time of superficial parotidectomy performed with and
without diathermy scissors.
During superficial parotidectomy procedures (n=23), the
cut-closure time ranged from 50 to 120 minutes, with
an average of 87.6 minutes (Figure 3). During subtotal
and total parotidectomy procedures (n=10), it ranged
from 80 to 160 minutes, with an average of 130.0 minutes
(Figure 4). In comparison, in the control group
these figures were 60 to 140 minutes (average, 103.6 minutes)
for superficial parotidectomy and 80 to 230 min-
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utes (average, 149.3 minutes) for subtotal and total parotidectomy
(Figures 3 and 4). Therefore, with the use
of diathermy scissors, we saw a statistically significant
average time gain of 16.0 minutes (15.4%) (P=.03) during
superficial parotidectomy procedures. During subtotal
and total parotidectomy procedures, the average time
gain was 19.3 minutes (12.9%); it was not statistically
significant, however, because of the small number of
operations.
COMMENT
With the development of and advances in new and alternative
surgical dissection techniques (eg, lasercutting
technologies, ultrasound scalpel, water-jet dissection,
and others), a decision has to be made as to which
one of these tools is best used for the large spectrum of
surgical procedures. 1 Additional technical support and
the acquisition of new practical skills to properly use these
tools are also frequently required.
In contrast, the diathermy scissors represent a simple
extension of the application of dissection scissors but with
additional hemostatic capability. There are numerous publications
concerning the application of diathermy and
bipolar scissors in different surgical procedures (eg, colectomy,
circumcision, laparoscopic cholecystectomy,
vaginal and abdominal hysterectomy, and elevation of the
radial forearm fasciocutaneous free flap). Baggish and
Tucker 2 conclude that bipolar scissors provide significant
safety advantages and performance that is equal to
or better than monopolar scissors when used for laparascopic
surgery. In head and neck surgery, bipolar scissors
have already been used for (pediatric) adenoidectomy,
tonsillectomy, punctate diathermy of the soft palate
in the surgical treatment of snoring, reduction of the nasal
turbinates, and excision of thyroid cancer 3 ; they have
also proved useful in facial plastic surgery. 4 Wax et al 5
compared scalpel and bipolar scissors in the elevation of
radial forearm fasciocutaneous free flaps. They found that
the total mean time of flap elevation and blood loss were
reduced significantly in the bipolar scissors group, whereas
the complications were equivalent. 5 To our knowledge,
the present study is the first one to evaluate the use of
diathermy scissors in parotid gland surgery.
The facial nerve is more likely to be injured during
parotidectomy than during any other procedure in head
and neck surgery, with far-reaching functional and cosmetic
consequences. It is the complex topography of parotid
gland disease, with tumors often neighboring the
facial nerve, as well as the anatomy of the nerve itself,
with its sometimes extremely thin branches, that contributes
to the risk of injury during surgery. At the same
time, the well-perfused gland parenchyma makes surgical
dissection difficult. Depending on these factors, and
on the surgeon’s experience, significant differences may
occur in regard to the required surgical time as well as
to postoperative complications. Judging from our expe-
No. of Operations
5
4
3
2
1
Subtotal/Total Parotidectomy
0 60 80 100 120 140 160 180 200 220 240
Cut-Closure Time, min
rience, the diathermy scissors offer substantial support
for the surgeon in parotid gland surgery.
CONCLUSIONS
The use of diathermy scissors in parotid gland surgery
not only will reduce the previously frequent need to
change dissecting and coagulating instruments, it also will
result in a very elegant, safe, and fast surgical procedure,
especially in the hands of an experienced surgeon.
With proper application, the scissors can facilitate dissection,
reduce intraoperative bleeding, and therefore improve
visualization of the surgical field.
Submitted for publication January 8, 2003; final revision
received May 7, 2003; accepted June 25, 2003.
This study was presented in part at the First International
Congress on Salivary Gland Diseases; January 27,
2002; Geneva, Switzerland.
Corresponding author and reprints: Jürgen Ußmüller,
MD, Klinik und Poliklinik für Hals-Nasen-Ohren–
Heilkunde, Universitätsklinikum Hamburg-Eppendorf, Martinistraße
52, D-20246 Hamburg, Germany (e-mail:
ussmueller@uke.uni-hamburg.de).
REFERENCES
Diathermy
Scissors Group
Control Group
Figure 4. Cut-closure time of subtotal/total parotidectomy performed with
and without diathermy scissors.
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free flaps. Laryngoscope. 2001;111:568-571.
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