Monopolar electrosurgical energy is the most commonly used energy source during laparotomic and laparoscopic surgery. The clinical application of monopolar energy is not without risk. Monopolar electrosurgical energy was introduced into surgical practice at the turn of the 20th century. Alternate site burns during laparotomic application were the most common complication for the first half century (i.e., ground point burns and dispersive electrode burns [1920–1970]). The aims of this article were to discuss historic design flaws associated with the most common alternate site burns, ground point burns, and dispersive electrode burns and the technological advancements introduced to mitigate these risks to the patient and to discuss current design flaws associated with stray energy burns during laparoscopy because of insulation failure and capacitive coupling and the technological advancements introduced to eliminate these risks to the patient. Today, insulation failure and capacitive coupling are the most common reasons for electrosurgical injury during laparocopic procedures. There is a need for advanced technology such as active electrode monitoring to address these invisible risks to the surgeon and their patients. In addition, the laparoscopic surgeon should be encouraged to study the basic biophysics involved in electrosurgery.
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Historic Technology Design Flaws: Alternate Site Burns
Since the inception of monopolar electrosurgery in the early 1900s and before laparoscopic surgical access was used, there were 3 sites where the patient could be burned: 1 intended and 2 unintended alternate sites. The intended site is the site whereby the surgeon introduces electrosurgical current to control bleeding (fulgurate and desiccate) and to cut (vaporize) tissue [1]. The active electrode's design requires a high-power density in order to heat the target tissue rapidly. Unintended
Design Change to Address Ground Point Burns: Isolated Electrosurgical Output Stage
The technological advancement of “isolated” ESUs was introduced in the late 1960s to protect the patient from ground point burns. Isolating the output stage, the ESU creates a circuit such that the therapeutic current the surgeon introduces has only 1 pathway back to the ESU: the dispersive electrode or neutral electrode. Since their introduction, isolated output ESUs have essentially eliminated ground point burns [2]. Precautions still need to be taken to not allow the patient to come in
Contact quality monitoring (CQM) circuits were incorporated into the ESU's design in the early 1980s to prevent dispersive electrode skin burns. The CQM circuitry within the ESU requires a dual-section dispersive electrode, which is continually monitoring the total impedance of the dispersive electrode to the patient during surgery whether the ESU is activated or not (Fig. 3) [4]. If during the procedure the dispersive electrode becomes compromised or partially detached, the CQM circuit detects
Laparoscopic Surgical Access: Multiport and Stray Energy Burns
The adoption of multiport and single-port laparoscopic surgery in the early 1970s introduced a new and different class of alternate site burn risks to the patient—stray energy burns, which emanate from the laparoscopic instrument. This new class of burns to intraabdominal tissues and organs during laparoscopic procedures has resulted in a significant increase in patient morbidity and mortality [6]. Before laparoscopy, alternate site burns involved patient morbidity.
In a survey of members of the
Medicolegal Implications from SILS Electrosurgery Injury
Unfortunately, a patient died after an electrosurgical injury during an SILS procedure that involved the use of an operative laparoscope. In judicial proceedings in April 2012 in Nevada [23], a unanimous jury verdict acquitted the gynecologist based on evidence presented that the root cause of the patient's injury was because of technology (design flaw) and not surgical technique. This was a preventable death and with the rise in interest of SILS in gynecologic surgery, general surgery,
Design Change to Address Stray Energy Burns: Active Electrode Monitoring
Active electrode monitoring (AEM) was introduced in the mid-1990s (Encision Inc., Boulder, CO) and is designed to protect the patient against stray energy caused by instrument insulation failure and excessive capacitive coupling in zones 2 and 3 (Fig. 4) 22, 36. The AEM system consists of instruments with an integrated coaxial conductive shield (Fig. 11), which encapsulates the primary active insulation in zones 2 and 3. A circuit is then created between the shielded instrument, the AEM
Advancements in the Design of ESUs and Laparoscopic Instruments
Advancements in the design of ESUs and laparoscopic instruments include the following: (1) isolated generators (1970s), (2) the CQM system (1980s), and (3) the AEM system (1990s). Isolated ESU, CQM, and AEM technological advancements in design are warranted from the original manufacturers to protect the patient from ground point burns, dispersive electrode burns, and stray energy burns in zones 2 and 3, respectively (Fig. 4). Each of these advancements does not require a change in surgical
Summary: Technological Advancements
Surgical misadventures associated with the use of monopolar electrosurgical energy may be attributed to surgeon technique or technology. This article has discussed in detail the technology issues specific to the historic, early design flaws, and the design advancements incorporated to address ground point burns and dispersive electrode burns with the introductions of isolated ESU (radiofrequency) output stages and CQM, respectively. Current design flaws associated with conventional laparoscopic
Over the past five decades, many technological advances in electrosurgery have been implemented; all directed toward patient safety by reducing surgical complications. However, electrosurgical complications may also be linked to surgical techniques and ESU design flaws [10]. In order to produce minimal risk, the ESU should undergo checks prior to marketing [11], calibrated before being put into clinical use [12], along its working life also.
This paper presents an approach to systematic error correction for improving the accuracy of the electrosurgical unit (ESU), through a method that enables safer operation for both surgeons and patients. The equations for systematic errors encountered during the calibration of the eight ESUs were obtained using regression analysis. The ESU calibration was performed using a power analyzer and the reference power value was selected on the ESU panel; the power value indicated by the ESU was noted from the power analyzer and recorded. The fitted regression models were suitable for predicting systematic errors associated with ESU output power values, as a reduction of about 84 % was noted in cutting power (CuP) and about 74 % for coagulation power (CoP). After correction, systematic error values remained below 1.9 W and 0.4 W in cutting and coagulation power, respectively. The maximum error values obtained were less than those specified for the IEC 60601-2-2 standard for all evaluated ESUs.
The use of monopolar energy in other studies can explain the absence of management of severe defects by operative hysteroscopy. Bipolar energy presents a lower risk of tissue damage nearby, mainly in severe defects, whereas the effect's distance is greater with monopolar energy [24,25]. Regarding the rates of pregnancy in women who were infertile after hysteroscopic management, we report rates of 62.5% and 66.7%, respectively, in the nonsevere group and in the severe defect group.
To compare the outcomes of hysteroscopic management in women with a severe or nonsevere symptomatic cesarean scar defect (residual myometrium ≤3-mm vs >3-mm, respectively).
Retrospective cohort study.
Gynecology department of a teaching hospital.
Seventy-one women with an operative hysteroscopy for a symptomatic defect (49 with severe defects and 22 with nonsevere ones).
Operative hysteroscopy for cesarean scar defect in women with a severe defect (residual myometrium ≤3-mm) and with nonsevere defect (residual myometrium >3-mm).
The main objective was to compare success rates between the 2 groups. The secondary objectives were the comparisons of (1) the number of women who required more than 1 procedure, (2) the rate of complications, (3) the number of subsequent pregnancies, and (4) the evolution of residual myometrium thickness between the groups.
The success rates were not significantly different between the groups (73.5% in the severe group and 63.6% in the nonsevere group [p = .40]). The number of women requiring more than 1 procedure was also similar, as were the rate of complications and the mean increase of myometrium thickness. The rate of subsequent pregnancies in women who were infertile was significantly higher in women with a severe defect (p = .04).
The hysteroscopic approach seems to be a good way to manage cesarean scar defects even when the residual myometrium is thin. A prospective study is, however, necessary to confirm these findings.
It is currently estimated that around 500 to 600 surgical fires occur annually in the United States [13]. Adverse events are mainly given by thermal injuries [6,7,14–18], which are more often related to an improper application of the neutral electrode and less frequently to unintentional contact of the active electrode with the tissue to dispersion phenomena during the use or to “insulation failure”, “direct coupling” and “capacitive coupling” [19–23]. Cases of electromagnetic interference are also described in patients with pacemakers [7,24–27] or sacral nerve stimulator and spinal stimulators [28] as well as cases of fire of the endotracheal tube in the course of tracheostomy [7,29–32] for the use of the electrosurgical unit in an environment with a high concentration of oxygen or anesthetic gases [33,34].
The use of the electrosurgical unit (ESU) is well-established in the surgical practice. The Authors, to better understand the genesis of injuries connected to the use of electrosurgical instruments, conducted an in-depth literature review pertaining to this topic.
Using the most important medical databases, a research of experimental studies in the last 20 years was conducted.
The analysis of the mechanisms responsible for the lesions showed that high energy devices remain as the most common cause of injury. Adverse events are mainly given by thermal injuries; cases of electromagnetic interference are also described in patients with pacemakers or sacral nerve stimulator and spinal stimulators as well as cases of fire of the endotracheal tube in the course of tracheostomy for the use of the electrosurgical unit in an environment with a high concentration of oxygen or anesthetic gases. Also reported in the literature are individual cases of fires caused by sparks from the electrosurgical handpiece also for the use of disinfectants and/or in relation to surgical drapes.
In order to clearly define the medical-legal aspects, focusing on the professional responsibility of the surgical and nursing staff, the authors’ attention was brought to the need for an effective prevention plan that highlights not only the importance of an accurate procedural knowledge in order to safety use the electrosurgical instruments, but also the need for a system that monitors any complications or adverse events resulting from the use of such instruments.
In the present study, we employed monopolar electrosurgery for I-EVL and C-EVL mice; the tip of the electric apparatus was placed at the oval window and the reference ground pad was placed underneath the body of the mouse. Although this system has an impedance monitor mechanism, to regulate the current output, high-current density can occur especially at the ground points and can cause burns (Odell, 2013). Accordingly, it is suggested that this may be an explanation for the abscess found in I-EVL mice.
The vestibular lesion (VL) is required to examine the physiological function of the vestibular system in animals. Toxic chemicals or electrical apparatus have been used for the VL, however, they are not ideal as they have low specificity, and can result in unintended damage, and systemic toxic effect.
Localized vibration-induced VL, using an ultrasonicator, is expected to overcome the problems associated with chemical and electrical lesions. Thus, we examined the effect of the ultrasonication on the VL from the aspects of both the physiological function and histology in the present study.
and Comparison with Existing Method(s) Complete VL, which was evaluated by deterioration of swimming skills, righting reflex, and body stability, was induced using an ultrasonicator or electrical apparatus. Histological evaluation shows that hair cell layers in the saccule and utricle were completely destroyed in both methods Furthermore, significant drop in body mass was observed in VL. However, abscess at the cranial base was observed in VL induced by the electrical apparatus in ICR mice. Complete chemically-induced VL was observed in C57BL/6J but not ICR mice, and systemic leakage of the toxic chemicals (arsenic) was not detectable even 1 day after surgery.
Compared to the electrical apparatus, the ultrasonicator is useful for inducing VL in ICR and C57BL/6J mice, as it results in less non-specific damage. Toxic chemicals can be used for inducing VL in C57BL/6J mice; however, this method does not ensure complete disruption of the hair cells in the saccule and utricle.
There are 2 main types of electrocautery devices that are used in electrosurgery: monopolar and bipolar devices. With monopolar electrosurgery, energy flows from the generator to the active electrode, and then the energy passes through the patient to the dispersive cautery pad, thus completing the electrical circuit.9 There are 3 main monopolar modes used to produce the different tissue effect: (1) cut, (2) coag, and (3) blend.10
To compare the effectiveness and safety of a flexible carbon dioxide (CO2) laser fiber to the ultrasonic scalpel when employed through a robotic surgical system.
Retrospective cohort study.
Level II-2 evidence.
Reproductive surgery practice at an academic hospital.
Two hundred thirty-six women who had undergone robot-assisted laparoscopic myomectomy with either CO2 laser (n = 85) or the ultrasonic scalpel (n = 151).
Robot-assisted laparoscopic myomectomy employing either a flexible CO2 laser fiber or a robotic ultrasonic scalpel as the primary energy tool.
Perioperative outcomes (estimated blood loss, operative time, length of hospital stay) of patients undergoing robot-assisted myomectomy with a flexible laser fiber or ultrasonic scalpel. Estimated blood loss and operative time were comparable (p = .95 and p = .55, respectively) between the 2 groups after adjusting for all confounders, whereas length of hospital stay remained significantly different (p = .004). Odds ratio for complications was 0.35 (95% confidence interval 0.08–1.56; p = .17), which denotes no difference in the risk for complications between the 2 groups.
Robot-assisted laparoscopic myomectomy with a flexible CO2 laser fiber is safe and has comparable operative outcomes to the ultrasonic scalpel. The small size and flexibility of this device allows robotic surgeons to employ safe focal energy without sacrificing operative ergonomics.
