Essential principles of electrosurgery in operative laparoscopy

Factors affecting insulation failure in reusable surgical devices

The purpose of this study was to investigate the associated factors of insulation failure (IF) in reusable endoscopic instruments. The insulation coating of reusable endoscopic instruments underwent routine visual checks, hand washing to remove visible stains, and mechanized sterilization. We recorded the cleaning number and usage period of all instruments. The instruments were tested for IF using a detector. IF was found in eight of 69 devices (11.6%). Examining by clinical specialty, we found IF in 4 of 28 gastrointestinal (14.3%), 3 of 20 gynecological (15.0%), 1 of 12 urological (8.3%), and none of the nine thoracic devices. The median distance from the tip to the damaged part was 5 cm (3-5 cm). In the IF and the intact groups, the period of use [7 years (6-8) versus 7 years (4-8), P = 0.90] and the number of cleanings [281 (261-323) versus 261 (179-320), P = 0.27] were not significantly different. The IF group included products of three different companies; however, six of the eight (75.0%) were from the same company. Cleaning methods and usage period have a lower impact on IF. The use of reusable forceps as a monopolar device was found to pose a higher risk, requiring regular assessments.

The packaging and clean method contribute to insulation failure of electrosurgical instruments

With the rapid development of medical technology, the use of electrosurgical instruments is dramatically increased in various types of surgery. However, the damage of the insulation layer of the reusable electrosurgical instrument often causes surgical accidents. The procedures of packaging and cleaning contribute to many damages to insulating layer of reusable electrosurgical instruments.Various types of reusable electrosurgical instruments were detected for insulation failures, conduction failures, short-circuit by using a high-voltage detector, DIATEG (Morgate company). In addition, reusable electrosurgical instruments were detected for insulation failures after packaging and cleaning by different procedures.13.1% (129/740) electrosurgical instruments had an insulation test failure; 6.2% (9/146) monopolar wires were with conduction failure; and 7.7% (16/207) bipolar wires were with short-circuit. Different packaging and cleaning procedures contribute to various degrees of damages to insulating property of reusable electrosurgical instruments.Insulation failure was a wide problem of reusable electrosurgical instruments, while fixed packaging method and mild cleaning procedures result in fewer damages to insulating property of reusable electrosurgical instruments.

Indirect electrical injuries from capacitive coupling: a rarely mentioned electrosurgical complication in monopolar laparoscopy

Electrothermal injuries in monopolar laparoscopy may derive indirectly, but rarely, from capacitive coupling releasing stray currents into neighboring non-targeted tissues, with intact instrument insulation. Since 2007, seven episodes of indirect electrosurgical damage to non-targeted tissues have been observed in our gynecological practice, including incidental coagulative necrosis of appendix, Fallopian tube, cystic pedicle, and broad ligament stump. Such an electrical response becomes greater where there is increased contact with the cystic wall (cysts <3 cm in diameter). Appropriate measures are available for minimizing capacitive coupling specifically caused by monopolar electrocautery. Thorough staff training, regular safety inspections, and strict procedure performance should exist to minimize such risks and injuries.

The effects of ultrasonic and electrosurgery devices on nerve physiology

BACKGROUND

While the risks associated with the use of electrosurgery near nerves are well known, few studies have examined the neurophysiologic effects of application of the Harmonic Blade, an ultrasonic scalpel, in the vicinity of nerve fibres. This study sought to compare the sub-acute neurophysiologic effects of the Harmonic Blade and electrosurgery after incisions close to the sciatic nerve.

METHODS

Incisions were made in rats with the Harmonic Blade and electrosurgery at distances of 1, 2, 3 and 4 mm from the sciatic nerve. Sham surgery was also performed. The compound action potential, conduction velocity and calibrated nylon filament (von Frey hair, VFH) stimulating force were monitored for up to 3 hours after surgery. The sciatic nerve was assessed for inflammation via H&E staining and impaired axonal transport by β-APP immunohistochemistry.

RESULTS

Electrosurgery incisions produced a significantly greater decrease in compound action potential and conduction velocity, and increase in the VFH force than the Harmonic Blade over all time points and distances from the sciatic nerve. The Harmonic Blade was similar to sham surgery for the compound action potential and VFH force. Electrosurgery yielded significantly greater leukocyte infiltration than the Harmonic Blade and produced the highest levels of β-APP immunoreactive swellings.

CONCLUSIONS

Incisions with electrosurgery in the range of 1-4 mm of the sciatic nerve caused substantial changes in neurophysiologic functioning and inflammation. In contrast, the Harmonic Blade was similar to sham surgery in the vicinity of the nerve, producing little observable acute trauma.

Diathermocoagulation in cutting mode and large flap dissection

BACKGROUND

The aim of this study was to determine the overall complication rate associated with the use of diathermocoagulation in cutting mode for flap dissection.

METHODS

Because of the high rate of complications generally associated with abdominoplasty, a large flap, abdominoplasty, or abdominal dermolipectomy model was chosen. A retrospective review was conducted regarding 647 abdominoplasty procedures, 320 of which were performed with the monopolar diathermocoagulation in the cutting mode and 327 of which were performed with a steel scalpel. The two groups were similar regarding morphologic characteristics, prescriptions, and procedures. In both cases, hemostasis was performed with punctual monopolar coagulation current. Analysis was performed regarding the frequency of major general complications (e.g., deep vein thrombosis and pulmonary embolism), major surgical complications (e.g., acute hemorrhage), and "minor" complications (e.g., postoperative secondary collections or delayed wound healing).

RESULTS

In the electrosurgery group, the incidence of noninfectious collections was significantly higher, as was the production of the drains. No difference was seen in terms of reintervention for acute hematoma, postoperative infectious collections, blood loss, hospital stay, or thromboembolic complications. Operations took significantly longer with the steel scalpel. The follow-up was significantly longer in the diathermocoagulation group.

CONCLUSIONS

Monopolar diathermocoagulation has already proven its place in the general work of every surgeon. Moreover, this technique remains superior in terms of the rapidity with which surgery can be performed when dissecting large areas. Nevertheless, the higher rate of surgical complications leads to a longer follow-up period that, in part, runs counter to this advantage.

Bipolar electrosurgery: convention and innovation

Bipolar electrosurgery is part of the customary gynecologic surgical armamentarium providing isolated thermal effects and blood vessel occlusion. However, end points are not always predictable as hemostasis may require contiguous applications and thermal damage can significantly expand beyond the target zone. Unintentional transection of a patent vessel cannot be entirely reduced. Recent advances in bipolar technology provide more predictable vessel occlusion with less thermal damage. To date, there are 3 novel bipolar platforms, using either impedance feedback from the operative site to moderate output as pulsed current with lower voltage or by local regulation using nanotechnology within the jaws.

Chemically assisted dissection of tissues: an interesting support in abdominal myomectomy

BACKGROUND

The aim of this study was to verify the efficacy of sodium-2-mercaptoethanesulfonate (mesna) in the chemical separation of tissues in abdominal myomectomies when used with the traditional mechanical separation techniques.

STUDY DESIGN

In a prospective, randomized study, 58 women underwent abdominal myomectomy. In 29 of these, we used mesna for highlighting and separating tissues, and in the other 29 we used saline solution for the same purposes. The variables evaluated included the number of myomas removed, the volume of the biggest myoma, and the total volume of the myomas removed in every intervention. We also recorded operating time, the length of hospital stay, the degree of procedure difficulty, perioperative blood loss, operative complications, and cost.

RESULTS

The operation was significantly shorter in the mesna group (p < 0.05) even though the volume and the number of myomas were larger. The degree of difficulty evaluated by the surgeon at the end of every operation was not significantly different in the two groups. The reduction in hemoglobin 24 hours after operation was significantly less in the patients treated with mesna (p = 0.006), but this difference was probably altered by the increase in hematocrit levels.

CONCLUSIONS

Because of its ability as a chemical dissector, mesna may be a useful aid in this type of benign gynecologic operation. Larger studies to confirm this are needed.

Histologic characteristics of laparoscopic argon beam coagulation

STUDY OBJECTIVES

To describe histologic effects of laparoscopic argon beam coagulation and determine the extent of tissue necrosis at various power settings and exposure times.

DESIGN

Prospective experimental analysis (Canadian Task Force classification II-1).

SETTING

University animal laboratory. Subjects. Adult female domestic pigs.

INTERVENTIONS

Various power settings (40, 60, 80 W) at increasing exposure times (1, 3, 5 sec) were used during laparoscopic application of argon beam coagulation to different tissues (uterine horn, bladder, ureter, kidney, bowel, liver). Animals were sacrificed within 1 hour of coagulation for histologic tissue preparation.

MEASUREMENTS AND MAIN RESULTS

Histologic measurements of both depth and lateral extent of electrosurgical tissue effects (mm +/- SD) were ascertained and evaluated statistically by one-way repeated measures analysis of variance. Depth of tissue necrosis was confined to 1 mm or less in uterine horn, bladder, and ureter. Even at highest power settings, bowel had tissue necrosis no greater than 2 mm. Both liver and kidney showed a deeper histologic effect (4-5 mm). The lateral extent of tissue necrosis ranged from 2 mm (ureter) to 15 mm (liver).

CONCLUSION

Laparoscopic argon beam coagulation results in tissue effects that are dependent on both low power setting and duration of application, as well as on electrical and physical characteristics of target tissue. Thermal tissue penetration can be expected to be less than 2 mm in bowel, bladder, and ureter, and less than 5 mm in kidney and liver, even at 5 seconds of exposure time and at a power setting as high as 80 W. As with all thermal modalities used for hemostasis and tissue coagulation, laparoscopic argon beam coagulation can be performed safely as long as the potential for inadvertent thermal injury is understood.

William T. Bovie and electrosurgery

For thousands of years human beings have used heat in the form of cautery to treat trauma and disease. By the late nineteenth century, as technology advanced, heat could be produced by electric current. In 1920 William T. Bovie, an eccentric inventor with a doctorate in plant physiology, developed an innovative electrosurgical unit that Harvey Cushing, the founder of modern neurosurgery, introduced to clinical practice. The Bovine unit passes high frequency alternating current into the body allowing the current to cut or coagulate. After 75 years this basic device remains a fundamental tool in the practice of surgery.

Laparoscopic electrosurgical complications and their prevention

Insulation failures, direct coupling, and capacitive coupling around active electrodes may cause serious burns and tissue damage to patients undergoing laparoscopic procedures. A coordinated team effort between perioperative nurses and surgeons can prevent life-threatening complications from laparoscopic electrosurgical procedures. Knowledge of the biophysics of electrosurgery, the mechanisms of electrosurgery complications, and prevention of patient injuries will empower surgical team members to provide quality outcomes for patients undergoing laparoscopic procedures.