Don't Get Burned by Electrosurgery

A little knowledge is a dangerous thing. Surgeons clearly don’t intend to cause stray energy burns when they cut and coagulate tissue with energy-based surgical instruments — they simply might not know any better. “There’s evidence that electrosurgery is poorly understood by many surgeons, and this lack of understanding can lead to adverse outcomes,” says Mohsen El-Sayed, MD, FRCOG, a gynecologic surgeon at Darent Hospital in Kent, England. “Surgeons — as well as surgical staffs — should have a basic knowledge of how energy devices work, the mechanisms of their potential complications and how to avoid them.”

Sharon Bachman, MD, agrees. “Having a grasp of the physics of the energy is helpful for physicians who use the devices with a level of mastery,” says Dr. Bachman, a general surgeon at Inova Fairfax Medical Group in Falls Church, Va. “They need to know how to achieve desired tissue effect with the least amount of energy. I’m not sure that’s how a lot of surgeons think. Some have an energy level they always use and simply stick with it. Changing how they practice requires some encouragement.”

Dr. El-Sayed says safety-minded surgeons should be constantly aware of these potential electrosurgery complications and take steps to prevent them from happening: 

• Direct application. Lateral thermal spread that occurs near the tips of instruments when the devices are activated can injure non-targeted anatomy. This is the most common type of electrosurgery injury that often results in thermal burns to tissue, critical structures and blood vessels. Surgeons should keep the tips of devices away from vital structures and use short bursts of energy to achieve the desired tissue effect.

• Inadvertent activation. The accidental activation of electrosurgery devices can cause unintentional patient burns. When devices are not in use, surgeons should remove them from the surgical field and store them in a rigid plastic holder. Devices with audible activation tones alert surgeons and members of the surgical team when devices are activated — purposefully or inadvertently.

• Residual heat. The tips of energy devices remain hot for periods of time after deactivation, depending on the type and make of the instrument. Surgeons should therefore avoid touching tissue and critical structures immediately after using devices.

• Insulation failure. This mishap involves the breakdown of the insulation that surrounds active electrodes. Small imperfections are nearly impossible to notice with the naked eye, so some instruments feature double layers of different colored insulation, which make defects in the outer layer easier to notice. Shielded laparoscopic instruments and active electrode monitoring, which constantly monitor shields for insulation failure and capacitive coupling, both help to prevent stray energy burns.

• Direct coupling. When active electrodes touch nearby metal instruments, often as a result of surgeon error, current that flows to the instruments can burn tissue it touches. To prevent this from happening, surgeons should maintain constant visual contact with the tip of instruments and be the only ones to activate the devices.

• Capacitive coupling. This can occur when current is transferred from the active electrode through intact insulation to adjacent conductive material. The transfer of energy can cause unintended burns to nearby tissue and structures. Surgeons should use lower power settings and short activation bursts, and avoid maneuvering instruments close to metal objects in the surgical field.

Dr. El-Sayed says monopolar devices present the risk of lateral thermal spread, direct coupling, insulation failure and capacitive coupling. He also points out that bipolar devices are associated with less risk of lateral thermal spread and eliminate risks of direct coupling and capacitive coupling. Bipolar instruments can still cause complications resulting from insulation failure and inadvertent activation, however.

When using monopolar instruments, says Dr. El-Sayed, surgeons should use the lowest possible power setting. The smaller the electrode, the higher the concentration of current. He says surgeons can employ this principle by reducing the contact area of the active electrode, which increases current density at targeted tissue, in order to achieve the desired effect without increasing the amount of energy used. 

Dr. El-Sayed points out bipolar devices, on which current flows between tissue grasped in two active electrodes at the tip of the instrument, use less energy than monopolar devices to dissect and coagulate, and are therefore considered a safer option. Increasingly complex laparoscopic surgery led to the advent of advanced bipolar devices, which he says seal vessels up to 7 mm in diameter. These instruments sense the resistance of the tissue being grasped and automatically adjust the amount of energy delivered to the active electrode to optimize tissue effect with limited thermal spread.

Dr. El-Sayed says keeping the jaws of bipolar instruments clean throughout surgery will ensure they interact with tissue as intended. Importantly, bipolar devices shouldn’t be used in patients with liver cirrhosis, prolonged steroid use, atherosclerosis, diabetes, malnutrition and collagen diseases — comorbidities that affect blood flow and could preclude them from safe electrosurgical hemostasis.

Advanced technologies such as isolated electrosurgical generators, return electrode monitoring and active electrode monitoring have contributed to the safe use of electrosurgery devices, notes Dr. El-Sayed. “Advanced bipolar devices add another layer of safety,” he says. “Such technologies complement the surgeon’s understanding of how devices work as well as the mechanisms of their potential complications.”

He strongly suggests that surgeons and surgical team members involved in electrosurgery cases complete training programs that cover the safe use of energy-based devices. FUSE (Fundamental Use of Surgical Energy), offered by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), is a widely known educational option. “Comprehensive knowledge about surgical energy and developing technology ultimately contribute to increased electrosurgical safety,” says Dr. El-Sayed. OSM