ABCs of Electrosurgery

Patient Safety

By: John Pfenninger

Published: 10/10/2007

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Radiosurgical instruments don't require tactile pressure to cut tissue, yet they perform like the sharpest of scalpels.


Nowadays, the term electrosurgery is something of a misnomer. Today's surgeons perform radiosurgery, because the generators operate at radio frequency. This is an important distinction: The higher the frequency, the lower the voltage you need to use (although you sometimes must turn up the voltage to do deep cuts). This minimizes the risk of unwanted tissue damage, especially if you use pure cutting mode and bipolar current whenever possible. There are three key challenges when I teach radiosurgery to students: technique, safety and equipment familiarity.

The same basic components
Several radiosurgery units are on the market, each with different characteristics, waveforms and power outputs (see "What's New in Electrosurgery Generators" on page 48). Their basic components, however, are the usually the same:

  • The generator. This converts the main voltage to radio-frequency current. The generator lets the surgeon select different monopolar and/or bipolar waveforms for cutting and coagulation.
  • A return electrode and ground plate or dispersive electrode. This is used in monopolar mode. The return electrode is placed as close as possible to the surgical site. The ground plate is sometimes a small plastic-covered plate, placed in close proximity to the patient.
  • An active electrode with a handle connected to the generator by a flexible wire. Different-shaped electrodes are inserted into this handle and clamped in position. Depending on the procedure and surgeon preference, the active electrode may be a single wire for incision or fulguration, a loop electrode for cutting, a ball-ended piece for hemostasis or a bipolar forceps.
  • Surgeon controls. This can be a foot switch or finger-operated hand switch on the electrode handle. It's used to switch from one mode to another, such as going from bipolar over to monopolar cutting.
  • Smoke evacuator. Lastly, a smoke evacuator may be employed. This is essential where excessive smoke can obscure surgeon vision, such as wire loop excision of the cervix (LEEP) in GYN surgery.

Technique and safety
In terms of technique, surgeons have to adjust to the fact that radiosurgical instruments don't require tactile pressure to cut tissue, yet they perform like the sharpest of scalpels. No pressure should be used during radiosurgery.

Developing safe practice is a matter of being aware of the risks associated with electrosurgery (such as direct coupling caused by pilot error and capacitive coupling during laparoscopy), using the lowest-possible power setting and appropriate waveform for the procedure and using safety technologies, as needed. For example, while you may not need return-electrode grounding pads for external dermatology procedures done in monopolar mode, they should always be used in conjunction with laparoscopy and any time the patient is under general anesthesia.

Inside HALT, an Outpatient Hysterectomy Procedure

Radiofrequency ablation of uterine fibroids has emerged as a promising outpatient alternative to hysterectomy, says Bruce Lee, MD, of the Monterey Peninsula Surgery Center in Monterey, Calif., who has performed more than 100 HALT (Hysterectomy Alternative) procedures.

HALT is a variation of electrosurgery under laparoscopic visualization. Your surgeon will need to use a specially designed radiofrequency generator, with compatible needle electrodes. The equipment, manufactured by Rita Medical Systems of Mountain View, Calif., costs $37,500. You'll also need high-quality ultrasound equipment ($75,000 to $115,000) and standard laparoscopic equipment (such as monitors, insufflators and a printer), which costs about $30,000.

HALT is performed under general anesthesia. Monterey Peninsula estimates the total supply costs per case to be $1,833. This includes the disposable probe and pads for the Rita generator (about $1,300 to $1,450 per case) and a $496 disposable trocar.

Case times vary widely depending on the severity and complexity of the fibroids being treated. Monterey Peninsula's average case time is about four hours, but actual times range from two to six hours. Likewise, PACU times vary widely, ranging from one to five hours.

Discharge medication typically consists of a prescription for a mild oral narcotic. Prophylactic antibiotics may be used if hysteroscopy had been planned before opting for HALT. Dr. Lee reports that 98 percent of patients return to normal activity within three-to-10 days of the surgery.

Monterey Peninsula describes the reimbursement climate for HALT as "moderate." It is not a Medicare-reimbursed procedure, nor can it be treated as a workers' comp case. The facility generates about 34 percent of its volume from Blue Cross/Blue Shield (for about a $5,500 reimbursement) and 23 percent from commercial carriers (reimbursements average around $7,500). The procedure can be billed as an unlisted laparoscopy (CPT 58578). About 20 percent of the facility's payers will approve it on this basis. Other suggested CPT codes: 49320 (Diagnostic laparoscopy), 49200 (Excision or destruction, tumors or cyst) and 76490 (Ultrasound guidance).

One way to convince reluctant payers is to compare the cost of the average two- or three-day inpatient stay for hysterectomy to the outpatient HALT procedure. According to Monterey Peninsula's data, the average cost of a three-day hysterectomy admission is $26,500. Dr. Lee says he hasn't had any HALT patients admitted for overnight observation.

- Bill Meltzer

What"s New in Electrosurgery Generators

As surgeons in GYN, urology, general surgery and dermatology rely more heavily on electrosurgical generators, the market has grown, spawning digital generators, procedure- and tissue-specific waveform options, fluid management and im-pedance-reduction technologies. Here's the latest from the major manufacturers.


Aaron/Bovie Medical IDS-300
(800) 537-2790
www.boviemedical.com
www.aaronmed.com
List price: not provided

The IDS-300 is an all-digital, plug-and-play monopolar and bipolar generator that offers real-time measurement of tissue impedance (5,000 times per second). As the impedance varies, the power adjusts automatically to deliver a consistent clinical effect. The unit offers digitally controlled cutting, blended current and coagulation settings, designed to maximize reproducibility and surgeon control. Some of the key system safety features include NEM (Neutral Electrode Monitoring), which is digitally implemented monitoring of electrode integrity; an output safety technology dubbed First Come First Served, which lets only one output device to be activated at any given time; and a digital error-detection mode that instantly disables output and displays an explanatory error-code message to the operator at the first sign of a problem.


Codman Malis CMC-III Bipolar
(800) 225-0460
www.codman.com

List Price: $15,348The Malis CMC-III bipolar generator offers cutting capabilities similar to a monopolar waveform without the thermal and current spread of monopolar surgery, according to the company. The waveform also promotes efficient tissue coagulation, whether bathed in bodily fluids or irrigation, and the system provides flow-controlled fluid delivery. New from Codman: IsoCool bipolar forceps, which can be used in conjunction with the CMC-III and other bipolar mode generators. The forceps incorporate a proprietary technology called active heat transfer that draws heat away from the forceps tips and maintains tip temperatures below 80'C. This prevents overheating and tissue sticking, according to company, virtually eliminating the need for neurosurgeons to interrupt procedures to avoid forceps overheating or passing the instrument to the scrub nurse for cleaning.


Conmed System 5000
(800) 448-6506
www.conmed.com
List Price: not provided

The System 5000 features user-friendly modules with programmable memory settings for a variety of functions, including general monopolar mode, fluids mode, laparoscopic mode, pulse-cutting and coagulation modes, and multiple bipolar waveforms. The fluids mode provides instantaneous energy for irrigated surgical fields and laparoscopic mode automatically monitors and limits output voltage. This minimizes the risk of capacitive coupling (energy transfer through intact insulation), according to the company. The generator incorporates the company's proprietary energy synchronous processing technology, which synchronizes and adjusts the current and the voltage in all operational modes, sampling current and voltage over 450,000 times per second. The company says that the technology promotes a more consistent tissue effect.


Ellman Surgitron Dual Frequency
(800) 835-5355
www.ellman.com
List price: $14,995

The Surgitron is a dual radiofrequency generator offering five distinct waveforms, providing procedure- and tissue-specific treatment options to the surgeon: a fully filtered monopolar-cutting waveform, a fully rectified monopolar waveform, a partially rectified coagulation waveform, a fulgurating waveform for maximum tissue penetration, spark-gap tissue destruction, and hemostasis and bipolar coagulation.


Elmed BC 50 M/M
(630) 543-2792
www.elmed.com
List price: $1,285

The ELMED BC 50 M/M is an all purpose radiofrequency bipolar coagulation generator with macro and micro modes. In the macro mode, the system may be used for bipolar coagulation in laparoscopy and other procedures in which the surgeon uses large forceps. According to company literature, ligation of vessels, even large ones, is reliably performed without trauma to adjacent tissue. Micro mode is intended for wet-field coagulation in ophthalmology, neurosurgery, hand surgery and other microsurgies. The current intensity may be regulated within the full range of the dial setting, whether in micro or macro mode. Modes may be switched either by surgeon footswitch or handswitch controls.


Erbe VIO 300 D
(800) 778-3723
www.erbe-usa.com
List price: $13,800

The VIO 300 D is Erbe's new fully programmable, modular, upgradable electrosurgery platform. The company says the system offers automatic dosing of power, to provide as much energy as you need, but as little as necessary. It can be programmed to a specific procedure, anatomy or physician preference. The VIO offers new cutting and coag modes, such as Swift Coag for effective coagulation suitable for dissection with a high degree of hemostatis, Dry Cut for slower cutting speeds and good hemostatis and Twin Coag for simultaneous cutting and coagulation. In total, VIO offers five cutting modes, five monopolar and three bipolar coag modes. All modes offer multiple effects for desired tissue effects.


Gyrus PK Tissue Management System
(763) 416-3034
www.gyrusmed.com
List Price: $16,000 (standard PK generator)

The PK (Plasma Kinetic) Tissue Man-agement System has the PK Generator, which cuts, coagulates or vaporizes tissue with bipolar energy. The generator works with over 20 laparoscopic and open-surgery instruments. Bipolar vapor pulsed coagulation (VPC) controls hemostasis and coagulates the contacted tissue evenly, with minimal lateral thermal spread or tissue sticking due to reduced eschar formation. The impedance monitor measures tissue response and tailors energy delivery to tissue type. The generator automatically changes the power setting when the surgeon changes PK instruments.


Olympus UES-40
(800) 548-5515
www.olympusamerica.com
List price: $10,000

The UES-40 generator, scheduled for release this spring, will (like its predecessor, the UES-30) be the first generator to incorporate an automatic smoke evacuation feature, says Olympus. The model is also the first universal monopolar/bipolar generator with the ability to switch over to a dedicated bipolar mode indicated for urological resection procedures. The UES-40 incorporates several widely used safety technologies, including ultra-high radio frequency and low tissue impedance waveforms. The generator is compatible with a variety of active electrodes and functions in conjunction with all laparoscopic instruments, says Olympus.


Valleylab Force FX
(800) 255-8522
www.valleylab.com
List price: not provided

The Force FX incorporates Valleylab's proprietary Instant Response technology, which the company says ensures consistent clinical performance using less power. Computer-controlled output for automatic response to changes in tissue impedance reduce the need for the surgeon to adjust power settings based on tissue type. Lower voltages reduce sparking, thermal spread, neuro-muscular stimulation and radiofrequency interference. The generator offers three cutting (low for laparoscopy, pure cut and blended current) and coagulation modes, as well as three bipolar modes. The Force FX also incorporates the company's REM (return-electrode monitoring) contact quality-monitoring system, which has been used in more than 100 million monopolar electrosurgical procedures worldwide to minimize the risk of patient burns at the return electrode site.


Richard Wolf Bipolar Generator
(800) 323-WOLF
www.richardwolfusa.com
List price: not provided

This digital bipolar generator is designed for use with the Kleppinger forceps, automatically compensating as tissue impedance develops. The company says the Kleppinger forceps differ from other bipolar forceps in that is designed to not squeeze or crush the tube during application. Variable acoustic and visual signals aid the surgeon in determining a coagulation endpoint. A cutting waveform ensures rapid, precise coagulation of tissue with minimal tissue adherence to forceps, according to the firm. The user may test the generator, cable and instrument by simply closing the jaws of the forceps and activating the footswitch without contaminating the instrument.

- Bill Meltzer

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