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Electrosurgery

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Electrosurgery(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time.

Steps for Successful Course Completion

To earn continuing education credit, the participant must complete the following steps:1. Read the overview and objectives to ensure consistency with your own learning

needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective.

2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

© 2016All rights reserved

Pfiedler Enterprises, 2170 South Parker Road, Suite 125, Denver, CO 80231www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196

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OvERvIEW Electrosurgery may be hazardous. It is important that clinicians understand how electricity behaves and relates to electrosurgical function and applications can contribute to its safe use. Knowledge of the intraoperative, intraoperative and postoperative medical and nursing considerations and interventions can impact positive patient outcomes.

OBjECTIvESAfter completing this continuing education activity, the participant should be able to:

1. Relate the properties of electricity to the clinical applications of electrosurgery.2. Discuss four variables the surgeon controls that impact surgical effect.3. Identify potential patient injuries related to electrosurgery and the technological

advances designed to eliminate these problems.4. Discuss the tissue effect of tissue fusion technology.5. Describe best practices to achieve favorable patient outcomes related to

electrosurgery.

INTENDED AUDIENCE This continuing education activity is intended for perioperative registered nurses and other health care team members who provide patient care during surgery or other invasive procedures.

CREDIT/CREDIT INFORMATIONState Board Approval for NursesPfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hour(s).

Obtaining full credit for this offering depends upon completion, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

RELEASE AND EXPIRATION DATEThis continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in August 2016 and can no longer be used after August 2018 without being updated; therefore, this continuing education activity expires August 2018.

DISCLAIMERPfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity.

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SUPPORTFunds for the development of this activity were provided by Medtronic.

AUTHORS/PLANNING COMMITTEE/REvIEWERjulia A. Kneedler, RN, MS, EdD Denver, COProgram Manager/ReviewerPfiedler Enterprises

Judith I. Pfister, RN, BSN, MBA Denver, COProgram Manager/PlannerPfiedler Enterprises

Donna S. Watson, MSN, RN, CNOR, FNP Boulder, CODirector of Professional Societies & Patient Advocacy/AuthorMedtronic

Melinda T. Whalen, BSN, RN, CEN Denver, COProgram Manager/ReviewerPfiedler Enterprises

DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO CONTROL CONTENT FOR THIS ACTIvITYPfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information below is provided to the learner, so that a determination can be made if identified external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/disclosure

Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Planning Committee/Authors/Reviewers:

julia A. Kneedler, EdD, RN No conflict of interest

Judith I. Pfister, MBA, RN No conflict of interest

Donna S. Watson, MSN, RN, CNOR, FNP Employee of grant provider

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Melinda T. Whalen, BSN, RN, CEN No conflict of interest

PRIvACY AND CONFIDENTIALITY POLICYPfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding continuing education. The information we collect is never shared for commercial purposes with any other organization. Our privacy and confidentiality policy is covered at our website, www.pfiedlerenterprises.com, and is effective on March 27, 2008.

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INTRODUCTIONModern surgery, as cited by Sullivan, is defined as a “branch of medicine concerned with treatment of injuries or disorders of the body by incision, manipulation or alteration of organs, etc., with the hands or with instruments.”1 Throughout the history of surgery, the use of instruments and tools to assist in the control of disease and minimize bleeding has been developed and utilized as a therapeutic treatment. Innovations of the past proved to provide practical solutions for maintaining and controlling hemostasis to facilitate a successful surgical outcome. It is this ongoing innovation that has spurred the evolution of the advanced innovative instruments of today’s surgery.

HISTORICAL DEvELOPMENT OF AN ESSENTIAL TOOLDr. Morstede in 1446, as cited in Kirkup p. xi, stated that “Instruments of iron; some are used to cut as scissors, scalpels….some are used to burn with as cautery. Some are used to determine the depth of sores, and some are used to sew as needles and pipes.”2

The Egyptians are considered to be among the first to use cautery to treat patient conditions. Cautery is mentioned as a treatment to control hemorrhage in the Ebers Papyrus, believed to be written around 1500 BC.3 Continued use and application of cautery by ancient Egyptian physicians around 1700 BC is described in the Edwin Smith Papyrus, considered to be the oldest medical text discovered (see Figure 1). The Edwin Smith Papyrus was written by one of the earliest practicing physicians, Imhotep, and describes the examination, diagnosis, prognosis and treatment of 48 neurosurgical-type cases.4 The Papyrus provides a view of the challenges of the time, detailing anatomical correlations with clinical symptoms, the use of hemostasis with cautery, tape, sutures and the use of copper salts for antisepsis.5 The Papyrus discusses the use of a fire drill, considered to be a form of the cautery used.

Figure 1. Edwin Smith Papyrus. Courtesy of the New York Academy of Medicine Library

Hippocrates (460-377 B.C.) considered the “Father of Medicine,” described the application of “red-hot” iron instruments to cauterize and suppress hemorrhoids.6 Thales, the “Father of Science,” described the attraction of certain material to amber when rubbed. Elecktron, the Greek word for amber, is considered the root of electricity.7

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The use of cautery during the 16th century declined due to another preferred modality utilized to control bleeding. Ambroise Paré (1510-1590), a French surgeon, used ligature to control bleeding instead of hot irons for battlefield amputations. Paré observed improved wound healing and less pain with the use of ligature and used this methodology exclusively. It was presumed that the use of suture required a higher skill level than the application of cautery, resulting in improved patient outcomes with less tissue damage.8

William Gilbert (1540-1603), provided early contributions to the foundation of the modern day electrosurgery generators. Gilbert, a practicing court physician to Queen Elizabeth, was interested in magnetism. He was the first to use the term, “electricity.”9 “De Magnete” a book written by Gilbert (1600) details his research with electricity that included amber’s frictional properties. Through this work, he is recognized as the “Father of Electrotherapy.”7

Throughout the 17th Century, interest continued to build around electricity and electrotherapy research. Each discovery and advance contributed to the building of knowledge in the natural sciences. The progression in the field of electrotherapeutics occurred during three distinct eras.10, 11 The first era occurred prior to 1786 with the focus on static electricity; the second era between 1786-1831 with galvanization and muscle spasm; and the third era began in 1831 and continues through the present.

The first era began with the search for an explanation on the phenomenon of static electricity. Static electricity starts as a charge accumulation on an object. The charge does not allow for current to flow; however, the charge can jump from one object to another. Many researchers of the time started to experiment with static electricity. The most famous researcher to study static electricity was Benjamin Franklin (1706-1790). Franklin studied the similarities of static electric sparks and lightning. It was these similarities that evolved to his renowned kite experiment. He was able to induce lightning to flow from a kite and collect into a Leyden jar, proving that static electricity and lightning have similar properties. Later, the work of Franklin resulted in the design of the lightning rod for building structures, to receive the charge from lightning to serve as a conduit to the ground in order to minimize structural damage and fires.12

The second era began with muscle spasm and galvanization research by Luigi Galvani (1737-1798). Galvani was able to reproduce muscle spasms with the direct application of an electrical charge to a frog leg. Continued work in this area resulted in the study of electrophysiology.13 The work of Alessandro Volta (1745-1827) contributed to the development of the first battery. The battery was composed of two types of different metals, cardboard, and an acidic solution. The result was a battery that could transmit an electrical current. Current wet cell batteries are designed to apply the same principles. Volt, the measurement of electrical energy, was named after Volta.14

In 1831, the third era for electrotherapeutics began with electromagnetism research led by Joseph Henry and Michael Faraday. Both discovered that an electrical current could be induced by moving a magnet. The discovery resulted in the ability to induce an electrical current through a wire with a range of applications (eg, electromedical devices, telegraph, telephone).10

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In the late 1800s, significant research began related to the therapeutic application of electricity. In 1881, William J. Morton discovered that the application of around 100 kHz of high frequency did not result in the pain or shock that was associated with current in the lower frequency range. In 1891, Jacques-Arsène d’Arsonval conducted similar research and made the significant discovery that alternating current greater than 100 kHz did not result in neuromuscular stimulation.15

Researchers in the 1900s discovered that variations of high frequency current could result in different waveforms, resulting in different tissue effects. The labels which indicate a specific tissue effect remain in use today. In 1907, Walter deKeating-Hart and Simon Pozze used the term “fulguration.” This is from the Latin word, “fulgur” which means lightning. Fulguration is used to describe the tissue effect of superficial tissue carbonization. In 1909, Doyen described the use of coagulation. Coagulation is from the Latin phrase indicating “to curdle.” Additionally, Doyen was the first to experiment with bipolar coagulation, using a second electrode. This innovation was referred to as an indifferent electrode and later became used as a patient return electrode.16 The term desiccate was introduced in 1914 by William Clark. Clark described tissue desiccation as the application of heat that resulted in tissue effect with ranges between hyperemia and carbonization, the end result of tissue destruction.17

One of the first clinical applications of electrosurgery is credited to the French surgeon, Joseph A. Rivière.9 He successfully treated hand ulcers of a musician with repeated applications of electrical sparks. The results of the new treatment were presented at the First International Congress of Medical Electrology and Radiology in 1900.9

In 1910, Dr. Edwin Beer published his treatment of bladder tumors with the application of high frequency current in the Journal of the American Medical Association. He outlined the treatment methods, equipment, tissue effect and clinical outcomes of the new high frequency treatment therapy.18 After reading Beer’s success, A. Raymond Stevens, M.D. reported two cases in 1913 involving the application of high frequent current for prostatic obstruction, stating the ease of use and efficiency as a contributing factor to his successful outcomes.19 In 1917, Dr. Bugbee published his results of treating urological obstructions in the Urological and Cutaneous Review.20

Early reports of the successful use of high frequency electrical current illustrate that technology has evolved over time because of the efforts of many scientists and clinicians. Likewise, during this period, many electrosurgery devices were developed. Lee DeForest filed the first patent for an electrosurgery generator on February 10, 1907. He described it as being specifically designed for use on patients during surgery.21

The historical development of electrosurgery tells us that many men have contributed to its advancement over a long period of time. Despite the efforts of so many, the technology is most closely associated with William T. Bovie and Harvey Cushing. The individual genius of each and the collective genius of the partnership greatly contributed to their success at promoting and facilitating the use of electrosurgery worldwide.

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William T. Bovie was born in Augusta, Michigan on September 11, 1882. He studied botany, and then went to Harvard to study for a doctorate in plant physiology. He stayed on to work at the Harvard Cancer Commission.22 It was there that he became interested in electrosurgery. His work included treating cancer patients with radium. He came to believe that the cautery effect achieved from radium emanation could also be achieved using high frequency current. It was for this use that his generators were first developed. His work with Harvey Cushing, however, resulted in a generator that was better suited for the operating room than some that preceded it. Bovie and Cushing also worked with Liebel-Flarsheim to manufacture a commercial unit. Sales of the electrosugery units were not profitable for many years because of low demand and constantly changing improvements. Whenever Bovie or Cushing developed improvements in the technology, the previous machines were reported scrapped. The Bovie originally sold for $2,000, but by 1932 the price had dropped to $1,250. Bovie never benefited financially from his invention. He sold his patent to Liebel-Flarsheim for $1.10.

Harvey Williams Cushing was born in Cleveland, Ohio on April 8, 1869. He entered Yale College in 1887, Harvard Medical School in 1891. In 1896 he began his residency with William Halsted at Johns Hopkins in Baltimore. He completed his residency there in 1900. He returned to Boston in 1901 to Peter Bent Brigham Hospital. It was in Boston that Cushing’s collaboration began with William T. Bovie.23

Blood control during surgery had always been a concern for Cushing. In a 1911 paper, “The Control of Bleeding in Operations for Brain Tumor,” Cushing gives an account of the methods he used to achieve hemostasis including wax, pledgets and silver clips.24 Despite the variety of methods to achieve hemostasis, there were still patients considered to be inoperable because of the fear of bleeding.

It is reported that Cushing first contemplated the use of electrosurgery during a medical conference in 1925. Two of Cushing’s residents were watching an electrosurgery demonstration when Cushing walked up to them. One suggested that Cushing use the machine on the brain. Cushing paused and looked thoughtfully at the demonstration in progress.25 He later visited Bovie at Harvard. Their collaboration began with Cushing making arrangements with Bovie to use his device in the operating room. The two men worked together over the next two years using the machine on patients, and making changes and refinements to the machine and its accessories. A 1928 paper reported on their success, which has stood the test of time.26

BIOPHYSICS OF ELECTROSURGERYALTERNATING CURRENTElectrosurgery is the application of high-frequency alternating electrical current (AC) delivered into biological tissue, resulting in a desired clinical tissue effect.27-29 High-frequency electrosurgery devices operate in the range of 200 kilohertz (kHz) to 3.3 megahertz (MHz) to minimize faradic effect or electrocution. The tissue effect is dependent upon the concentration of the energy, amount of time applied, and electrical properties of the tissue. When applied correctly, the clinical endpoint of desired tissue effect will result in controlled cutting, dissection or coagulation.

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DIRECT CURRENTAlthough used interchangeably, electrosurgery is not electrocautery. An electrocautery device delivers direct current (DC) through a heating element such as a probe or wire intended to cauterize tissue. The patient’s body is not part of the circuit. Electrocautery has a limited application and does not allow for cutting, dissection or the coagulation of large vessels. Unlike electrocautery, electrosurgery utilizes electromagnetic energy through tissue to produce heat resulting in the desired tissue effect.30 During electrosurgery, the patient’s body becomes part of the electrosurgical circuit.

FUNDAMENTALS OF ELECTRICITY

ELECTRICITYUnderstanding the fundamentals of the physics of electrosurgery is important for the end user. This knowledge increases awareness of the proper application techniques for electrosurgery. Implementation of appropriate electrosurgery techniques influence and promote positive patient outcomes.

Electricity is a phenomenon of nature that results from movement of electrons from one atom to another. Atoms are composed of negatively charged electrons, positively charged protons, and neutrally charged neutrons. Atoms containing an equal number of electrons and protons are considered charge neutral. When a force is introduced, here is a change to the charge due to movement of electrons from one atom base to another. The net charge results in some atoms becoming positively charged and others negatively charged, based on the number of electrons and protons present. Movement of electrons is predictable, unlike charges attract and like charges repel. It is the movement of electrons that is electricity.

BASIC PRINCIPLES OF ELECTROSURGERYBasic principles of electricity that impact patient care and outcomes of electrosurgery include:31, 32

• Electricity follows the path of least resistance, • Electricity will always seek to return back to an electron reservoir (eg,

electrosurgery unit or earth ground), and • A closed circuit must be established in order for electricity to flow.

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Electrosurgery and Radio Frequency CurrentWhy electrosurgery generators do not shock patients is a common question. The answer is because of the higher frequencies at which electrosurgery generators operate. Electrosurgery generators take 60 Hz current and ramp it up to the radiofrequency range. Radiofrequency current alternates so rapidly between the positive and negative poles that cells do not depolarize, or react to the current. Neuromuscular stimulation ceases at about 100,000 Hz. AM radio stations operate in the 550 to 1500 kilohertz (kHz) range. Electrosurgery generators typically operate in the 200 kHz to 3.3 megahertz (MHz) range (see Figure 2). That is well above the range where neuromuscular stimulation or electrocution could occur.33

Figure 2. Frequency Spectrum

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• Electricity will always seek to return back to an electron reservoir (e.g., electrosurgery unit or earth ground), and

• A closed circuit must be established in order for electricity to flow.

Electrosurgery and Radio Frequency Current

Why do electrosurgery generators not shock patients is a common question. The answer is because of the higher frequencies at which electrosurgery generators operate. Electrosurgery generators take 60 Hz current and

ramp it up to the radiofrequency range. Radiofrequency current alternates so rapidly between the positive and


negative poles that cells do not depolarize, or react to the current. Neuromuscular stimulation ceases at about 100,000 Hz. AM radio stations operate in the 550 to 1500 kilohertz (kHz) range. Electrosurgery generators typically operate in the 200 kHz to 3.3 megahertz (MHz) range (see Figure 2). That is well above the range where neuromuscular stimulation or electrocution could occur.33

Bipolar Electrosurgery

Bipolar electrosurgery is the use of alternating electrical current in which the circuit is confined within an instrument using two adjacent poles—one positive and one negative—located in close proximity to one another. Current flow is restricted between the two poles.27 A variety of bipolar instrument configurations are available including forceps, scissors or graspers.

Because the positive and negative poles are so close, lower voltages are used to achieve tissue effect. Most bipolar units use a low voltage waveform that achieves hemostasis without unnecessary charring. A patient return electrode is not needed when bipolar is used because current flow is confined to the tissue between the poles of the instrument (see Figure 3).

Bipolar is a very safe electrosurgery technology. There are newer bipolar generators that incorporate a “macro” or bipolar “cut” mode that has higher voltage and is designed for use with newer generations of bipolar cutting instruments. Bipolar is widely used in neurosurgery and gynecologic surgery. It is also safer to use when there is a question about the efficacy of using more powerful monopolar electrosurgical units (e.g., with pacemakers and implantable cardioverter/defibrillators).

ELECTROSURGERY 200 kHz – 3.3 MHz

550‐1550 kHz 54‐880MHz AM Radio Television

60 Hz 100kHz Household Muscle and Appliances nerve stimulation ceases

Figure 3. Bipolar Circuit

Bipolar ElectrosurgeryBipolar electrosurgery is the use of alternating electrical current in which the circuit is confined within an instrument using two adjacent poles – one positive and one negative – located in close proximity to one another. Current flow is restricted between the two poles.27 A variety of bipolar instrument configurations are available including forceps, scissors or graspers.



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• Electricity will always seek to return back to an electron reservoir (e.g., electrosurgery unit or earth ground), and

• A closed circuit must be established in order for electricity to flow.

Electrosurgery and Radio Frequency Current

Why do electrosurgery generators not shock patients is a common question. The answer is because of the higher frequencies at which electrosurgery generators operate. Electrosurgery generators take 60 Hz current and

ramp it up to the radiofrequency range. Radiofrequency current alternates so rapidly between the positive and


negative poles that cells do not depolarize, or react to the current. Neuromuscular stimulation ceases at about 100,000 Hz. AM radio stations operate in the 550 to 1500 kilohertz (kHz) range. Electrosurgery generators typically operate in the 200 kHz to 3.3 megahertz (MHz) range (see Figure 2). That is well above the range where neuromuscular stimulation or electrocution could occur.33

Bipolar Electrosurgery

Bipolar electrosurgery is the use of alternating electrical current in which the circuit is confined within an instrument using two adjacent poles—one positive and one negative—located in close proximity to one another. Current flow is restricted between the two poles.27 A variety of bipolar instrument configurations are available including forceps, scissors or graspers.


Bipolar is a very safe electrosurgery technology. There are newer bipolar generators that incorporate a “macro” or bipolar “cut” mode that has higher voltage and is designed for use with newer generations of bipolar cutting instruments. Bipolar is widely used in neurosurgery and gynecologic surgery. It is also safer to use when there is a question about the efficacy of using more powerful monopolar electrosurgical units (e.g., with pacemakers and implantable cardioverter/defibrillators).

ELECTROSURGERY 200 kHz – 3.3 MHz

550‐1550 kHz 54‐880MHz AM Radio Television

60 Hz 100kHz Household Muscle and Appliances nerve stimulation ceases


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Bipolar is a very safe electrosurgery technology. There are newer bipolar generators that incorporate a “macro” or bipolar “cut” mode that has higher voltage and is designed for use with newer generations of bipolar cutting instruments. Bipolar is widely used in neurosurgery and gynecologic surgery. It is also safer to use when there is a question about the efficacy of using more powerful monopolar electrosurgical units (eg, with pacemakers and implantable cardioverter/defibrillators).

Monopolar ElectrosurgeryThe most frequently used method of delivering electrosurgery is monopolar because it has a greater range of tissue effects and it is more powerful. When using monopolar electrosurgery the generator produces the current, which travels through an active electrode into patient tissue. The current then passes through the patient’s body to a patient return electrode that collects the current and carries it safely back to the generator (see Figure 4) as the intended pathway for the electrical current flow. The type of monopolar generator used, along with appropriate surgeon and perioperative nursing interventions, can help ensure that this is the path the current takes.

Figure 4. Monopolar Circuit

Current Concentration/DensityThe reason for using electrosurgery is to produce high-frequency electrical current that will create the desired clinical effect.27 Heat is produced when high-frequency current is concentrated. The amount of heat produced determines the extent of the tissue effect. Current concentration or density depends on the size of the area through which the current flows. A small area that concentrates the current produces more impedance/resistance and will require more force to push the current through the limited space. The combination of greater force through a smaller space produces more heat. A large area that spreads out the current has less impedance/resistance to the flow of the current, which reduces the amount of heat produced (see Figure 5).

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Figure 5. Current Concentration/Density

vARIABLES OF RADIOFREQUENCY ELECTROSURGERYAn electrical circuit is created when there is a conductive pathway that allows the free electrons to flow. An example of a closed or complete electrical circuit during surgery include an electrical current flowing from the electrosurgical generator unit, active electrode, patient tissue, and returned through a dispersive patient electrode back to the generator (see Figure 6).

Figure 6. Electrical Circuit

Current (I)An electrical current (I) is produced when continuous movement of free electrons occurs through a conductor within a circuit. During electrosurgery, a current is generated by the electrosurgical unit and delivered through tissue via an instrument electrode tip.

voltage (v) The force responsible for moving the generated electrical current through the active electrode is voltage (V). Voltage measured in amperes (A) or amps, is the electrical potential to move free electrons from one point to another point within a circuit. Voltage may range from 2,000 to 10,000 volts depending on the generator. During electrosurgery, the amount of voltage generated is based on tissue resistance. The greater the tissue

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resistance, the higher the voltage necessary to push the current and penetrate the tissue for the desired clinical effect.27 The higher the voltage, the greater the flow of electrons and potential for an untoward patient outcome.

Impedance/resistance (R)As free electrons move through tissue within a circuit, there is a degree of impedance/resistance that occurs. Although the terms are used interchangeably, impedance refers to the opposition to the flow of alternating current; the term resistance refers to the opposition to the flow of direct current. This results in friction due to the opposition of the flow of current, referred to as resistance. Resistance is measured in ohms (Ω). Different sources of resistance may include, but are not limited to: different tissue types, distance between electrodes (the greater the distance, the greater the resistance) and the distance between the active electrode and the intended tissue.

Power (P)Power is the heat energy that is produced by resistance during surgery. It is the heat that is produced at the surgery site that results in tissue effect. The desired power level is expressed as a numerical setting selected by the surgeon, displayed as watts on the light emitting diode (LED) screen of an electrosurgical unit. Generally, the maximum coagulation output on a generator is 120 watts, and 300 watts in cut output.

Ohm’s LawOhm’s Law describes the relationship of these variables of electricity involving a complete circuit with flowing electrons.27, 29, 34

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Current (I)

An electrical current (I) is produced when continuous movement of free electrons occurs through a conductor within a circuit. During electrosurgery, a current is generated by the electrosurgical unit and delivered through tissue via an instrument electrode tip. Voltage (V)

The force responsible for moving the generated electrical current through the active electrode is voltage (V). Voltage measured in amperes (A) or amps, is the electrical potential to move free electrons from one point to another point within a circuit. Voltage may range from 2,000 to 10,000 volts depending on the generator. During electrosurgery, the amount of voltage generated is based on tissue resistance. The greater the tissue resistance, the higher the voltage necessary to push the current and penetrate the tissue for the desired clinical effect.27 The higher the voltage, the greater the flow of electrons and potential for an untoward patient outcome. Impedance/resistance (R)

As free electrons move through tissue within a circuit, there is a degree of impedance/resistance that occurs. Although the terms are used interchangeably, impedance refers to the opposition to the flow of alternating current; the term resistance refers to the opposition to the flow of direct current. This results in friction due to the opposition of the flow of current, referred to as resistance. Resistance is measured in ohms (Ω). Different sources of resistance may include, but are not limited to: different tissue types, distance between electrodes (the greater the distance, the greater the resistance) and the distance between the active electrode and the intended tissue. Power (P)

Power is the heat energy that is produced by resistance during surgery. It is the heat that is produced at the surgery site that results in tissue effect. The desired power level is expressed as a numerical setting selected by the surgeon, displayed as watts on the light emitting diode (LED) screen of an electrosurgical unit. Generally, the maximum coagulation output on a generator is 120 watts, and 300 watts in cut output. Ohm’s Law

Ohm’s Law describes the relationship of these variables of electricity involving a complete circuit with flowing electrons.27, 29, 34

Ohm’s Law

Voltage (V) = Current (I) x Resistance (R) As the electrical current flows through patient tissue and back to the generator, the current passes through different tissue types with various levels of resistance. It is the resistance that drives voltage to push the flow of electrons. The greater the tissue resistance, the higher the output voltage or force needed, if the current is to remain constant. Applying Ohm’s Law, the current is inversely proportional to the resistance/impedance: W = I2 x R and W = V2/R.34

CLINICAL APPLICATION

When current is passed through adipose tissue which has a high resistance, the voltage output will be higher to achieve the desired tissue effect.34

Buildup of eschar (carbonized blood and tissue) at the end of an electrode will result in increased resistance. This will require an increased voltage to deliver the current and desired clinical tissue effect.27

As the electrical current flows through patient tissue and back to the generator, the current passes through different tissue types with various levels of resistance. It is the resistance that drives voltage to push the flow of electrons. The greater the tissue resistance, the higher the output voltage or force needed, if the current is to remain constant. Applying Ohm’s Law, the current is inversely proportional to the resistance/impedance: W = I2 x R and W = V2/R.34

CLINICAL APPLICATION • When current is passed through adipose tissue which has a high resistance, the

voltage output will be higher to achieve the desired tissue effect.34

• Buildup of eschar (carbonized blood and tissue) at the end of an electrode will result in increased resistance. This will require an increased voltage to deliver the current and desired clinical tissue effect.27

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Current Output WaveformsElectrosurgical generators allow for current output to be modulated, resulting in different waveforms. Four different waveform options include cut, blend, coagulation, and hemostasis with dissection. The resulting clinical effect on the tissue is determined by the application of the specific waveform.

The cut output mode is a low voltage continuous, non-modulated, sinusoidal waveform (see Figure 7). The current is delivered from the generator continuously. The lower voltage allows for tissue vaporization to occur with minimal amount of coagulation tissue effect.

The non-touch technique is applied with the active electrode tip, held slightly away from the intended tissue. This technique creates a spark gap or a steam envelope.32 The electrical sparks cause higher tissue temperatures that may quickly exceed 100°C resulting in vaporization of the intracellular fluids.27 This mode offers clean tissue division with minimal thermal spread. The cut mode may also be used to cauterize bleeders by applying the active electrode directly to tissue.

Figure 7. Cut Waveform

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Current Output Waveforms

Electrosurgical generators allow for current output to be modulated, resulting in different waveforms. Four different waveform options include cut, blend, coagulation, and hemostasis with dissection. The resulting clinical effect on the tissue is determined by the application of the specific waveform.




A blend mode modifies the cut continuous waveform into an interrupted blend waveform.35 The blend mode results in varying degrees of current delivery by modifying the duty (on/off) cycle (see Figure 8 “new”).

Figure 8. Blended Waveforms

The current is interrupted and the voltage is increased dependent upon the selected setting.

The waveform is no longer continuous. Varying degrees of cutting and hemostasis are achieved by the type of blend waveform selected: Blend 1 (50% on/50% off); Blend 2 (40% on/60% off); and Blend 3 (25% on/75% off). The higher the blend setting, the greater the hemostasis tissue effect.

CLINICAL APPLICATION CUT MODE

Apply the non‐contact CUT technique by placing the active electrode above the tissue with continuous movement. This allows for the low voltage current to cut tissue with minimal hemostatic effect. Apply contact CUT technique directly to tissue for immediate hemostatic effect. The contact technique is referred to as desiccation.

CLINICAL APPLICATIONCUT MODE

• Apply the non-contact CUT technique by placing the active electrode above the tissue with continuous movement. This allows for the low voltage current to cut tissue with minimal hemostatic effect.

• Apply contact CUT technique directly to tissue for immediate hemostatic effect. The contact technique is referred to as desiccation.


16


14

Current Output Waveforms

Electrosurgical generators allow for current output to be modulated, resulting in different waveforms. Four different waveform options include cut, blend, coagulation, and hemostasis with dissection. The resulting clinical effect on the tissue is determined by the application of the specific waveform.








CLINICAL APPLICATION CUT MODE

Apply the non‐contact CUT technique by placing the active electrode above the tissue with continuous movement. This allows for the low voltage current to cut tissue with minimal hemostatic effect. Apply contact CUT technique directly to tissue for immediate hemostatic effect. The contact technique is referred to as desiccation.



CLINICAL APPLICATIONBLEND MODE

• Select blend mode when hemostasis is desired with cutting.35

• Blend mode can be utilized when low voltage coagulation (desiccation) is desired such as during a laparoscopy.35

• Blend mode is activated by using the cut side of the electrosurgery unit.

Cogulation mode delivers a higher voltage modulated waveform with an intermittent duty cycle that is on about 6% of the time (see Figure 9). Because energy is delivered only about 6% of the time, the tissue is heated with intermittent spikes of high voltage. Depending upon the electrosurgical unit and the tissue, the voltage delivered may reach up to 9,000–10,000 volts. During the 94% rest phase of the duty cycle, the cells react by cooling down and form a coagulum.

A use of the coagulation mode is with a non-contact technique referred to as fulguration (ie, superficial coagulation or spray coagulation). The active electrode tip is held slightly above the tissue, creating a spark gap that results in desired tissue effect.

The sparks occur in a random pattern. For superficial oozing vessels and capillaries the spray coagulation mode may be selected.

17

Figure 9. Coagulation Waveform 6% on 94% off

15

Coagulation mode delivers a higher voltage modulated waveform with an intermittent duty cycle that is on about 6% of the time (see Figure 9). Because energy is delivered only about 6% of the time, the tissue is heated with intermittent spikes of high voltage. Depending upon the electrosurgical unit and the tissue, the voltage delivered may reach up to 9,000–10,000 volts. During the 94% rest phase of the duty cycle, the cells react by cooling down and form a coagulum.

A use of the coagulation mode is with a non-contact technique referred to as fulguration (i.e., superficial coagulation or spray coagulation). The active electrode tip is held slightly above the tissue, creating a spark gap that results in desired tissue effect.The sparks occur in a random pattern. For superficial oozing vessels and capillaries the spray coagulation mode may be selected.


Desiccation can be used with the coagulation waveform by applying the active electrode directly on desired tissue. The end result of desiccation is drying out of the tissue. Cutting in the coagulation mode will not deliver a clean tissue cut as will the cut mode.35

The newest monopolar mode allows for controlled dissection and hemostasis. This option is different from the traditional blend mode. It is a coagulation mode driven waveform, compared to blend which is a cut-driven waveform (see Figure 10). The mode is an interrupted 25% sinusoidal waveform. This allows for a unique combination of dissection with hemostasis while applying a lower power setting to achieve desired clinical results.

Figure 10. Dissection with hemostasis waveform

CLINICAL APPLICATION BLEND MODE

Select blend mode when hemostasis is desired with cutting. 35

Blend mode can be utilized when low voltage coagulation (desiccation) is desired such as during a laparoscopy.35

Blend mode is activated by using the cut side of the electrosurgery unit.

CLINICAL APPLICATION COAGULATION MODE

Apply the spray coagulation mode for oozing tissue sites and on larger superficial surfaces.35

During laparoscopic procedures the use of low voltage coagulation reduces the potential for insulation failure and capacitive coupling.35

CLINICAL APPLICATIONCOAGULATION MODE

• Apply the spray coagulation mode for oozing tissue sites and on larger superficial surfaces.35

• During laparoscopic procedures the use of low voltage coagulation reduces the potential for insulation failure and capacitive coupling.35




15

Coagulation mode delivers a higher voltage modulated waveform with an intermittent duty cycle that is on about 6% of the time (see Figure 9). Because energy is delivered only about 6% of the time, the tissue is heated with intermittent spikes of high voltage. Depending upon the electrosurgical unit and the tissue, the voltage delivered may reach up to 9,000–10,000 volts. During the 94% rest phase of the duty cycle, the cells react by cooling down and form a coagulum.

A use of the coagulation mode is with a non-contact technique referred to as fulguration (i.e., superficial coagulation or spray coagulation). The active electrode tip is held slightly above the tissue, creating a spark gap that results in desired tissue effect.The sparks occur in a random pattern. For superficial oozing vessels and capillaries the spray coagulation mode may be selected.





CLINICAL APPLICATION BLEND MODE

Select blend mode when hemostasis is desired with cutting. 35

Blend mode can be utilized when low voltage coagulation (desiccation) is desired such as during a laparoscopy.35

Blend mode is activated by using the cut side of the electrosurgery unit.

CLINICAL APPLICATION COAGULATION MODE

Apply the spray coagulation mode for oozing tissue sites and on larger superficial surfaces.35

During laparoscopic procedures the use of low voltage coagulation reduces the potential for insulation failure and capacitive coupling.35

18

CLINICAL APPLICATIONDISSECTION WITH HEMOSTASIS MODE

• Application results in lower voltage which reduces the potential for insulation failure and capacitive coupling.

• Fast movement results in enhances tissue division, slow movement results in enhanced coagulation effect.

INFLUENCING vARIABLES ON TISSUE EFFECTThere are many cognitive decisions indicated to achieve the desired clinical outcomes with minimal risk to the patient. The variables include, but are not limited to:

• Current output waveforms • Power setting• Time of application• Active electrode geometry and current density• Patient return electrode and current density• Tissue conductivity• Surgical technique

Power SettingWhen determining the appropriate power setting one should consider the electrosurgery unit and follow instructions for use. Always select the lowest power setting to achieve the desired tissue effect. Power setting should be determined by individual patient characteristics. Muscular patients who are of appropriate height and weight will require lower power settings than an obese or emaciated patient.

Placement of the patient return electrode should also be considered. The patient return electrode should be placed as close to the surgery site as possible. Consider the distance the current must travel from the surgery site to the patient return electrode. The greater the distance, the more impedance/resistance that will be encountered, requiring a higher power setting to achieve the desired tissue effect. To minimize impedance/resistance place the patient return electrode on a large vascular muscle, located as close to the surgery site as possible.

Time of ApplicationDwell time is the length of time the active electrode is in contact with the tissue (see Figure 11). Selection of the appropriate power setting, observation of the tissue effect, and appropriate dwell time application is essential in achieving the desired tissue effect. The ideal application is to apply the lowest power setting to achieve the desired clinical tissue effects. Long activation time will increase the risk for unintended thermal injury and too short of activation time may result in the absence of clinical tissue effect.32

19

Figure 11. The longer the electrosurgery current is applied the greater potential for thermal spread.

16

INFLUENCING VARIABLES ON TISSUE EFFECT

There are many cognitive decisions indicated to achieve the desired clinical outcomes with minimal risk to the patient. The variables include, but are not limited to:

• Current output waveforms • Power setting • Time of application • Active electrode geometry and current density • Patient return electrode and current density • Tissue conductivity • Surgical technique

Power Setting

When determining the appropriate power setting one should consider the electrosurgery unit and follow instructions for use. Always select the lowest power setting to achieve the desired tissue effect. Power setting should be determined by individual patient characteristics. Muscular patients who are of appropriate height and weight will require lower power settings than an obese or emaciated patient.

Placement of the patient return electrode should also be considered. The patient return electrode should be placed as close to the surgery site as possible. Consider the distance the current must travel from the surgery site to the patient return electrode. The greater the distance, the more impedance/resistance that will be encountered, requiring a higher power setting to achieve the desired tissue effect. To minimize impedance/resistance place the patient return electrode on a large vascular muscle, located as close to the surgery site as possible.

Time of Application

Dwell time is the length of time the active electrode is in contact with the tissue (see Figure 11). Selection of the appropriate power setting, observation of the tissue effect, and appropriate dwell time application is essential in

achieving the desired tissue effect. The ideal application is to apply the lowest power setting to achieve the desired clinical tissue effects. Long activation time will increase the risk for unintended thermal injury and too short of activation time may result in the absence of clinical tissue effect.32

Figure 11. The longer the electrosurgery current is applied the greater potential for thermal spread.

CLINICAL APPLICATION DISSECTION WITH HEMOSTASIS MODE

Application results in lower voltage which reduces the potential for insulation failure and capacitive coupling.

Fast movement results in enhances tissue division, slow movement results in enhanced coagulation effect.

Active Electrode Geometry and Current DensityThe selection of an appropriate size active electrode is as important as determining the current output waveform. Active electrode geometry correlates to the current density. It is the current density that relates to heat production and tissue effect. Current density is dependent upon surface contact area and geometry of the active electrode.33 Wu and colleagues state, “contact area is decreased by a factor of 10 (eg, 2.5 cm2 to 0.25 cm2), the current density increases by a factor of 100 (eg, 0.01 amp/cm2 to 1 amp/cm2), and the final temperatures increases from 37° C to 77° C” (p. 69).33 Thus, a large active electrode (eg, ball electrode) will require a higher power setting when compared to a small active electrode (eg, needle tip) to achieve the same desired tissue effect (see Figure 12).

Figure 12. Geometry Size and Effect on Power Settings

17

Active Electrode Geometry and Current Density

The selection of an appropriate size active electrode is as important as determining the current output waveform. Active electrode geometry correlates to the current density. It is the current density that relates to heat production and tissue effect. Current density is dependent upon surface contact area and geometry of the active electrode.33 Wu and colleagues state, “contact area is decreased by a factor of 10 (e.g., 2.5 cm2 to 0.25 cm2), the current density increases by a factor of 100 (e.g., 0.01 amp/cm2 to 1 amp/cm2), and the final temperatures increases from 37° C to 77° C” (p. 69).33 Thus, a large active electrode (e.g., ball electrode) will require a higher power setting when compared to a small active electrode (e.g., needle tip) to achieve the same desired tissue effect (see Figure 12).

Power setting requirement decreases

Power High current setting concentration requirement (density) decreases


ReRrr

Patient Return Electrode and Current Density

The patient return electrode size is designed to safely return the high-frequency current back to the electrosurgical unit, by dispersing the current over a large surface area. This results in low current concentration at the patient return electrode site. Should the current inadvertently become concentrated on a patient return electrode, the chance of thermal injury is significantly increased due to the high current concentration (See Figure 5).

Tissue Conductivity

Patient tissue type, muscle and fat result in various resistance/impedance to the flow of electricity. This is attributed to the inherent properties of the tissue type, muscle and fat (see Figure 13). The patient’s physical characteristics also provide impedance to the current flow as current completes the circuit through the patient return electrode and back to the electrosurgical generator. A patient who is muscular with minimal adipose tissue will conduct the current flow better than an obese or emaciated patient. Because each patient has different impedance levels, electrosurgery power settings should be determined on an individual basis.

0 500 1000 1500 2000 2500 3000 3500 4000 4500 OHMS

Figure 13. Tissue Impedance/Resistance Ranges

Power setting requirement increases

Buzz hemostasis Desiccate – stop bleeding

Prostate in nonconductive solution muscle, eye, skin, kidney pancreas

Oral cavity, liver

Gall Bladder

Bowel, brain grey matter, adipose, spleen

Mesentery, brain white matter, omentum

Lung, scar adhesions

Patient Return Electrode and Current DensityThe patient return electrode size is designed to safely return the high-frequency current back to the electrosurgical unit, by dispersing the current over a large surface area. This results in low current concentration at the patient return electrode site. Should the current

20

inadvertently become concentrated on a patient return electrode, the chance of thermal injury is significantly increased due to the high current concentration (See Figure 5).

Tissue ConductivityPatient tissue type, muscle and fat result in various resistance/impedance to the flow of electricity. This is attributed to the inherent properties of the tissue type, muscle and fat (see Figure 13). The patient’s physical characteristics also provide impedance to the current flow as current completes the circuit through the patient return electrode and back to the electrosurgical generator. A patient who is muscular with minimal adipose tissue will conduct the current flow better than an obese or emaciated patient. Because each patient has different impedance levels, electrosurgery power settings should be determined on an individual basis.


17

Active Electrode Geometry and Current Density

The selection of an appropriate size active electrode is as important as determining the current output waveform. Active electrode geometry correlates to the current density. It is the current density that relates to heat production and tissue effect. Current density is dependent upon surface contact area and geometry of the active electrode.33 Wu and colleagues state, “contact area is decreased by a factor of 10 (e.g., 2.5 cm2 to 0.25 cm2), the current density increases by a factor of 100 (e.g., 0.01 amp/cm2 to 1 amp/cm2), and the final temperatures increases from 37° C to 77° C” (p. 69).33 Thus, a large active electrode (e.g., ball electrode) will require a higher power setting when compared to a small active electrode (e.g., needle tip) to achieve the same desired tissue effect (see Figure 12).

Power setting requirement decreases

Power High current setting concentration requirement (density) decreases


ReRrr

Patient Return Electrode and Current Density

The patient return electrode size is designed to safely return the high-frequency current back to the electrosurgical unit, by dispersing the current over a large surface area. This results in low current concentration at the patient return electrode site. Should the current inadvertently become concentrated on a patient return electrode, the chance of thermal injury is significantly increased due to the high current concentration (See Figure 5).

Tissue Conductivity

Patient tissue type, muscle and fat result in various resistance/impedance to the flow of electricity. This is attributed to the inherent properties of the tissue type, muscle and fat (see Figure 13). The patient’s physical characteristics also provide impedance to the current flow as current completes the circuit through the patient return electrode and back to the electrosurgical generator. A patient who is muscular with minimal adipose tissue will conduct the current flow better than an obese or emaciated patient. Because each patient has different impedance levels, electrosurgery power settings should be determined on an individual basis.

0 500 1000 1500 2000 2500 3000 3500 4000 4500 OHMS


Power setting requirement increases

Buzz hemostasis Desiccate – stop bleeding

Prostate in nonconductive solution muscle, eye, skin, kidney pancreas

Oral cavity, liver

Gall Bladder

Bowel, brain grey matter, adipose, spleen

Mesentery, brain white matter, omentum

Lung, scar adhesions

Tissue TemperatureTherapeutic current delivered into biological tissue must flow through extracellular and intracellular ions that commonly include electrolytes Na+, Cl-, Ca++, and Mg++.30 Resistance is encountered with the ionic movement as the ions collide with other molecules, resulting in the generation of heat. The greater the resistance to flow of the ions, the greater production of heat. The following equation applies to the temperature rise with use of electrosurgery in biological tissue:30

18

Tissue Temperature

Therapeutic current delivered into biological tissue must flow through extracellular and intracellular ions that commonly include electrolytes Na+, Cl-, Ca++, and Mg++.30 Resistance is encountered with the ionic movement as the ions collide with other molecules, resulting in the generation of heat. The greater the resistance to flow of the ions, the greater production of heat. The following equation applies to the temperature rise with use of electrosurgery in biological tissue:30

ΔT = J2ρt

CD

The increase in temperature ∆T (°C) is designated by the equation: T represents the duration of the current flow (sec), D represents tissue density (kg/m3), C the heat capacity (kcal/kg/°C) of the tissue.30 The temperature rise of patient tissue is proportional to the amount of time that energy is applied. Bioeffects of radiofrequency current to tissue temperature above 50°C results in tissue damage that is irreversible. Tissue response at 90°C includes vaporization of water from the cells. (Figure 14). This process results in tissue desiccation and denaturation of protein.33 The initial tissue appearance of “white coagulation” can be clinically observed.33 At 100°C, the intracellular water boils.33 The cellular walls rupture, resulting in tissue vaporization. Temperatures in the range of 200°C and above result in carbonization (fulguration) and charring of the tissue.33

Figure 14 .Tissue Responses

Surgical Technique

Appropriate tissue effect is achieved with the combined art and science of electrosurgery that includes surgeon knowledge of electrosurgery principles, skilled application and knowledge of equipment and instruments, appropriate selection of current output waveform, lowest power setting to achieve the desire clinical tissue effect, avoiding long dwell times, and selection of appropriate electrode size.

The electrosurgical unit is one of the most widely used tools available to surgeons. As the sophistication of surgical procedures has evolved over time, so too have electrosurgery technologies. Meeting the challenge of improved patient care is one of the goals of the medical manufacturing partner within the healthcare arena. Providing education and information on emerging technology is another. Both the surgeon and the perioperative nurse must be familiar with older technologies and with current safest and most effective care is available to patients wherever surgery and invasive procedures are performed.

The increase in temperature ∆T (°C) is designated by the equation: T represents the duration of the current flow (sec), D represents tissue density (kg/m3), C the heat capacity (kcal/kg/°C) of the tissue.30 The temperature rise of patient tissue is proportional to the amount of time that energy is applied.

21

Bioeffects of radiofrequency current to tissue temperature above 50°C results in tissue damage that is irreversible. Tissue response at 90°C includes vaporization of water from the cells. (Figure 14). This process results in tissue desiccation and denaturation of protein.33 The initial tissue appearance of “white coagulation” can be clinically observed.33 At 100°C, the intracellular water boils.33 The cellular walls rupture, resulting in tissue vaporization. Temperatures in the range of 200°C and above result in carbonization (fulguration) and charring of the tissue.33

Figure 14 .Tissue Responses

Surgical TechniqueAppropriate tissue effect is achieved with the combined art and science of electrosurgery that includes surgeon knowledge of electrosurgery principles, skilled application and knowledge of equipment and instruments, appropriate selection of current output waveform, lowest power setting to achieve the desire clinical tissue effect, avoiding long dwell times, and selection of appropriate electrode size.

ELECTROSURGICAL TECHNOLOGIESThe electrosurgical unit is one of the most widely used tools available to surgeons. As the sophistication of surgical procedures has evolved over time, so too have electrosurgery technologies. Meeting the challenge of improved patient care is one of the goals of the medical manufacturing partner within the healthcare arena. Providing education and information on emerging technology is another. Both the surgeon and the perioperative nurse must be familiar with older technologies and with the current safest and most effective care is available to patients wherever surgery and invasive procedures are performed.

GROUND REFERENCED ELECTROSURGICAL GENERATOR It is important to understand how to establish a safe closed circuit during electrosurgery, to minimize untoward patient outcomes. Ground-referenced or spark-gap systems were the first generation electrosurgery generators. Ground-referenced generators were designed to allow for current to flow from the wall outlet to the generator, active electrode

22

(pencil), surgical tissue, return electrode, and back to the generator with the current returning through the wall outlet to earth ground as shown in Figure 15.

Figure 15. Ground Reference Electrosurgical Generator

A major potential hazard with ground-reference generators was the ease in which the current could exit through an alternate pathway. For example, if the patient’s body was in contact with any type of conductor such as a metal intravenous pole or metal surface of the surgical bed there was potential for current division. Current division allowed for the current to deviate from the intended pathway to an easier pathway (lower impedance/resistance) to return to ground. If the current became significantly concentrated at an alternate exit site, an injury occurred as shown in Figure 16. Other potential hazards included the lack of an alarm in the event the patient return electrode was not attached to the unit or on the patient. Later models included a cord fault alarm that activated if the patient return electrode was not attached to the unit. However, this resulted in injuries when the cord was attached to the unit, but was inadvertently not on the patient. In 1995, ECRI stated that “spark-gap units are outdated and have been largely superseded by modern technology.”36 Due to safety issues, ground-reference generators have been replaced with isolated generator systems.

Figure 16. Alternate Site Burn

23

ISOLATED ELECTROSURGICAL GENERATORIn 1968, isolated generators were introduced as a significant patient safety innovation. These generators utilize isolated circuitry designed to prevent current division (See Figure 17). Isolated generators allow current to flow from the wall outlet to the generator, active electrode (pencil), surgical tissue, return electrode, and back to an isolated transformer contained within the generator. In order to function appropriately, a closed circuit is required. A patient return electrode must be applied to the patient and connected to the generator. If a patient return pad is not applied or is not connected to the generator, detectors will disable the generator function and alarm to alert the perioperative team. The utilization of isolated generators for patients undergoing minimally invasive and surgical procedures is considered as the acceptable standard of care due to the enhanced safety feature designed to reduce alternate site burns.

Figure 17. Isolated Circuit

CONTACT QUALITY MONITORINGThe next major innovation in electrosurgery came about in 1982 when an interrogation circuit was added to the patient return electrode. The interrogation circuit in a contact quality monitoring patient return electrode continuously monitors the quality/quantity of the contact area between the pad and the patient (see Figure 18). The contact quality monitoring system is designated to deactivate the generator while giving audible and visual feedback before a patient burn can occur due to a contact quality issue. Return electrode monitoring is a major safety improvement for patients as return electrode burns (ie, due to a reduction in the quality or quantity of contact area) account for a majority of adverse patient outcomes during electrosurgery. This technological breakthrough represents the first time since the development of electrosurgery that the patient’s own tissue status was taken into consideration as part of a feedback mechanism. According to ECRI, many electrosurgery burns could be eliminated by a patient return electrode contact quality monitoring system.37 It is important that the pad type is compatible

24

with the electrosurgery unit and instructions for use are followed to avoid untoward patient outcome.38 The single use pad should be inspected for existing damage or integrity issues that may affect performance. The pad should be placed on a clean, well vascularized muscle, as close to the surgery site as possible according to instructions for use. Following use, the single use pad should be discarded.

Figure 18. Return Electrode Contact Quality Monitoring (RECQM) System

ARGON-ENHANCED ELECTROSURGERYIn the late 1980’s the argon delivery system was combined with the electrosurgery generator to create argon-enhanced electrosurgery. This electrosurgery technology should not be confused or compared to laser technology. Argon is an inert, nonreactive gas that is heavier than air and easily ionized. The argon shrouds the electrosurgery current in a stream of ionized gas that delivers the spark to tissue in a beamlike fashion (See Figure 19). Because the beam concentrates the electrosurgical current, a smoother, more pliable eschar is produced. At the same time, the argon gas disperses the blood, improving visualization. Because the heavier argon displaces some of the oxygen at the surgery site, less smoke is produced. When used during surgery, argon-enhanced electrosurgery can reduce blood loss, decrease the risk of rebleeding, and decrease the amount of surgical plume.39

25

Figure 19. Argon-Enhanced Electrosurgery

TISSUE DENSITY FEEDBACK TECHNOLOGYDuring the mid-1990s, electrosurgery generators were introduced that incorporated computer controlled feedback systems. Referred to as tissue response, or tissue effect generators, the instant response technology could sense tissue impedance/resistance. The feedback system provided the surgeon with consistent clinical effect through all tissue types in the cut (vaporization) mode. Generators equipped with the feedback mechanism rapidly sense tissue resistance and automatically adjust output voltage to maintain constant generator effect. What that means to the surgeon is that if 40 watts is selected as the desired power setting, the generator will deliver 40 watts through tissue of varying ohms of resistance (see Figure 20). The constant power output has an added advantage: perioperative staff is not required to frequently adjust generator power settings, and voltages are kept as low as possible. Instant generator response to changing patient tissues represented a “first” in patient safety in which the electrosurgery generator used information from the patient throughout the procedure. To take advantage of tissue density feedback technology, it was required that the surgeon use the cut or vaporization mode.

Figure 20. Tissue Response Technology

21

of varying ohms of resistance (see Figure 20). The constant power output has an added advantage: perioperative staff is not required to frequently adjust generator power settings, and voltages are kept as low as possible. Instant generator response to changing patient tissues represented a “first” in patient safety in which the electrosurgery generator used information from the patient throughout the procedure. To take advantage of tissue density feedback technology, it was required that the surgeon use the cut or vaporization mode.

45 Tissue Response Technology

35 Lung,scar,adhesions

30 Mesentery, brain white 25 Bowel, brain matter, omentum

grey matter 20 adipose, spleen Gall Bladder 15 Oral cavity, liver Conventional Technology 10 Prostate in nonconductive solution, muscle, eye, skin, kidney, pancreas

5 Buzz hemostasis Desiccate- stop bleeding

0 500 1000 1500 2000 2500 3000 3500 4000 OHMS

Figure 20. Tissue Response Technology

TISSUE FUSION TECHNOLOGY

In 1999 a technology was developed that gave surgeons a new way to achieve hemostasis. The specialized generator instrument system reliably sealed vessels and tissue bundles in both laparoscopic and open surgery applications. It applies a unique form of bipolar-type energy in combination with pressure to fuse vessel walls and create a permanent seal. Computer feedback controls the output of the generator so that a reliable seal is achieved in minimal time when the tissue is held between the tines of specialty designed instruments. The result is a reliable seal on vessels up to and including 7 mm in diameter and tissue bundles using a single generator activation. The seal is strong and permanent and has been shown to withstand three times the normal systolic pressure. Thermal spread is reduced when compared to traditional bipolar, and is comparable to ultrasonic coagulation. The site has a translucent appearance that is the reformed collagen and elastin that actually changes the nature of the tissue to form a permanent seal. An important consideration is the bipolar-type nature of this technology. The electrical current only travels between the tines of the forceps and never goes through the patient’s body, making it a very safe treatment option for patients for whom monopolar might be contraindicated, such as those with pacemakers.40

The specifications of tissue fusion technology make it unique among surgery hemostatic devices that include:

First Generation Vessel Sealing • Reactive tissue analysis • 200 decisions per second • Initial impedance sets energy delivery • Average 5-8 second seal cycle • Plastic-like seal area • Surgeon determines bar setting

Second Generation Tissue Fusion • Adjusts output in real time • 3,333 decisions per second • Real time tissue impedance controls each energy delivery decision • Average 2-4 second fusion cycle • Flexible fusion zone • Automatic instrument bar settings

WAT

TS

26

TISSUE FUSION TECHNOLOGYIn 1999 a technology was developed that gave surgeons a new way to achieve hemostasis. The specialized generator instrument system reliably sealed vessels and tissue bundles in both laparoscopic and open surgery applications. It applies a unique form of bipolar-type energy in combination with pressure to fuse vessel walls and create a permanent seal. Computer feedback controls the output of the generator so that a reliable seal is achieved in minimal time when the tissue is held between the tines of specialty designed instruments. The result is a reliable seal on vessels up to and including 7 mm in diameter and tissue bundles using a single generator activation. The seal is strong and permanent and has been shown to withstand three times the normal systolic pressure. Thermal spread is reduced when compared to traditional bipolar, and is comparable to ultrasonic coagulation. The site has a translucent appearance that is the reformed collagen and elastin that actually changes the nature of the tissue to form a permanent seal. An important consideration is the bipolar-type nature of this technology. The electrical current only travels between the tines of the forceps and never goes through the patient’s body, making it a very safe treatment option for patients for whom monopolar might be contraindicated, such as those with pacemakers.40

The specifications of tissue fusion technology make it unique among surgery hemostatic devices that include:

First Generation vessel Sealing• Reactive tissue analysis• 200 decisions per second• Initial impedance sets energy delivery• Average 5-8 second seal cycle• Plastic-like seal area• Surgeon determines bar setting

Second Generation Tissue Fusion• Adjusts output in real time• 3,333 decisions per second• Real time tissue impedance controls each energy delivery decision• Average 2-4 second fusion cycle• Flexible fusion zone• Automatic instrument bar settings

27

CLOSED-LOOP COAGULATION TECHNOLOGYThe steady increase in electrosurgery generator improvement culminated with the engineering breakthrough that created closed-loop controlled coagulation in 2006. The introduction of closed-loop controlled coagulation allowed for the development of a radiofrequency electrosurgery generator capable of including tissue feedback data in every mode available on the generator. The tissue-sensing energy platform is a computer controlled system that senses resistance in patient tissues and adjusts voltage output, electrical current and generator power 3,333 times per second. As with tissue response in the cut mode of earlier generators, this provides consistent electrosurgical effect across a wide range of varying patient tissue resistance/impedance. The dramatic differences between the tissue sensing capabilities of closed-loop controlled coagulation are most obvious when comparing actual oscilloscope printouts of traditional coagulation and closed-loop controlled coagulation (See Figure 21). In the coagulation mode, without closed loop control, the positive and negative poles of the duty cycle are unequal. When the peak-to-peak voltage is controlled, the voltage is similar in both the positive and negative poles of the duty cycle, which gives a more consistent generator tissue effect. The ability of the tissue-sensing generator to include tissue information during each activation is advancement in patient safety and makes each and every surgical procedure specific to every patient.

Figure 21. Coagulation without Closed-Loop Control, Coagulation with Closed-Loop Control

22

CLOSED-LOOP COAGULATION TECHNOLOGY

The steady increase in electrosurgery generator improvement culminated with the engineering break through that created the closed-loop controlled coagulation in 2006. The introduction of closed-loop controlled coagulation allowed for the development of a radiofrequency electrosurgery generator capable of including tissue feedback data in every mode available on the generator. The tissue-sensing energy platform is a computer controlled system that senses resistance in patient tissues and adjusts voltage output, electrical current and generator power 3,333 times per second. As with tissue response in the cut mode of earlier generators, this provides consistent electrosurgical effect across a wide range of varying patient tissue resistance/impedance. The dramatic differences between the tissue sensing capabilities of closed-loop controlled coagulation are most obvious when comparing actual oscilloscope printouts of traditional coagulation and closed-loop controlled coagulation (See Figure 21). In the coagulation mode, without closed loop control, the positive and negative poles of the duty cycle are unequal. When the peak-to-peak voltage is controlled, the voltage is similar in both the positive and negative poles of the duty cycle, which gives a more consistent generator tissue effect. The ability of the tissue-sensing generator to include tissue information during each activation is advancement in patient safety and makes each and every surgical procedure specific to every patient.

Figure 21. Coagulation without Closed-Loop Control, Coagulation with Closed-Loop Control

SMOKE EVACUATION

In 1994 the Association of periOperative Registered Nurses (AORN) published a recommended practice stating that patients and perioperative personnel should be protected from inhaling the smoke generated during the use of electrosurgery. The recommendation to evacuate and appropriately filter surgical smoke has remained a standard supported by AORN since that time.41 The recommended practice is applicable whenever a smoke plume is produced whether it is from laser, electrosurgery, or any other surgical device that aerosolizes human tissue.

The Joint Commission 2009 Environment of Care Standard EC.02.02.01 stated “The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing hazardous gases and vapors. Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide.”42 It is expected that surgical smoke from cauterizing equipment such as the electrosurgery and laser can be appropriately managed to minimize associated risks related to use.

Toxic fumes and carcinogens have been isolated from surgical smoke.43 Formaldehyde and benzene are two of a long list of substances that are contained in smoke.43 Acrylonitrile and hydrogen cyanide are toxic, colorless gases present in smoke that are easily absorbed through the skin and lungs. Acrylonitrile is shown to be toxic by liberating the cyanide; the cyanide combines with other substances to impair tissue oxygenation.44

SMOKE EvACUATIONIn 1994, the Association of periOperative Registered Nurses (AORN) published a recommended practice stating that patients and perioperative personnel should be protected from inhaling the smoke generated during the use of electrosurgery. The recommendation to evacuate and appropriately filter surgical smoke has remained a standard of practice supported by AORN since that time.41 The recommended practice is applicable whenever a smoke plume is produced whether it is from laser, electrosurgery, or any other surgical device that aerosolizes human tissue.

The Joint Commission 2009 Environment of Care Standard EC.02.02.01 stated “The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing hazardous gases and vapors. Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide.”42 It is expected that

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surgical smoke from cauterizing equipment such as the electrosurgery and laser can be appropriately managed to minimize associated risks related to use.

Toxic fumes and carcinogens have been isolated from surgical smoke.43 Formaldehyde and benzene are two of a long list of substances that are contained in surgical smoke.43 Acrylonitrile and hydrogen cyanide are also toxic, colorless gases present in smoke that are easily absorbed through the skin and lungs. Acrylonitrile is shown to be toxic by liberating the cyanide; the cyanide then combines with other substances to impair tissue oxygenation.44

Air quality in hospital and operating rooms has been described as a “chemical soup” that can cause symptoms such as shortness of breath, eye and respiratory irritation, rhinitis, contact dermatitis, headaches, joint pain, memory problems and difficulty concentrating, to name a few.45 There has been no quantitative way to measure long-term effects on healthcare workers. The alert still appears as a recommendation on the National Institute for Occupational Safety and Health Web site.46

Laparoscopic procedures expose the patient and staff to surgical smoke. There is a high concentration of carbon monoxide in surgical smoke. Carbon monoxide can cause symptoms that include headache, tinnitus, shortness of breath, lower extremity weakness, clumsiness, palpitations, chest pain, abdominal pain, diarrhea, nausea and vomiting.47 When carbon monoxide is absorbed through the peritoneal membrane during laparoscopic surgery elevated levels of methemoglobin and carboxyhemoglobin are produced in the patient’s bloodstream. This can pose a potential risk to patients during surgery.48 Surgeons and perioperative scrubbed staff are also at increased risk from inhaling surgical smoke during laparoscopic procedures due to a surge of concentrated smoke being released from the cannula system. It is recommended that a smoke evacuation laparoscopic handpiece be used to maintain visualization throughout the procedure through metered smoke evacuation. A list of chemicals contained in surgical smoke is reason enough to institute a policy that all smoke be evacuated and filtered (See Table 1).

Table 1. Chemicals Contained in Surgical Smoke

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Air in hospital and operating rooms has been described as a “chemical soup” that can cause symptoms such as shortness of breath, eye and respiratory irritation, rhinitis, contact dermatitis, headaches, joint pain, memory problems and difficulty concentrating, to name a few.45 There has been no quantitative way to measure long-term effects on healthcare workers. The alert still appears as a recommendation on the National Institute for Occupational Safety and Health Web site.46


Acetylene Ethane 4-Methy phenol Acroloin Ethene 2-Methyl propanol (aldehyde) Acrylonitrile Ethylene Methyl prazine Alkyl benzene Ethyl benzene PhenolBenzaldehyde Ethynyl benzene PropeneBenzene Formaldehyde 2-Propylene nitrile Butadiene Furfural (aldehyde) Pyridine Butene Hexadeconic acid Pyrrole (amine) 3-Butenenitrile Hydrogen cyanide StyreneCarbon monoxide Indole (amine) Toluene (hydrocarbon) Creosol Isobutene 1-Undecene (hydrocarbon) 1-Decene (hydrocarbon) Methane Xylene 2,3-Dihydro indene (hydrocarbon) 3-Methyl butenal (aldehyde)

6-Methyl indole (amine)


Before the procedure, the perioperative nurse should determine the volume of smoke that will be produced and select the appropriate smoke evacuation system. A vacuum source with a triple filter offers the greatest protection. The systems consist of a prefilter to filter out large particles, an ultra low penetrating air (ULPA) filter to capture microscopic particles and a charcoal filter to absorb or bind to toxic gases produced during the procedure (Figure 22).

Figure 22. Filter System

The vacuum source should be able to adequately pull sufficient air through the system to capture the smoke (about 50 cubic feet per minute of air). A system powerful enough to handle the amount of smoke produced is the most

Prefiltercaptures large particles and some fluids ULPA Filtercaptures small particles Activated Carbonabsorbs toxic gases and odors Final/post filter

Before the procedure, the perioperative nurse should determine the volume of smoke that will be produced and select the appropriate smoke evacuation system. A vacuum

29

source with a triple filter offers the greatest protection. The systems consist of a prefilter to filter out large particles, an ultra low penetrating air (ULPA) filter to capture microscopic particles and a charcoal filter to absorb or bind to toxic gases produced during the procedure (Figure 22).


23

Air in hospital and operating rooms has been described as a “chemical soup” that can cause symptoms such as shortness of breath, eye and respiratory irritation, rhinitis, contact dermatitis, headaches, joint pain, memory problems and difficulty concentrating, to name a few.45 There has been no quantitative way to measure long-term effects on healthcare workers. The alert still appears as a recommendation on the National Institute for Occupational Safety and Health Web site.46


Acetylene Ethane 4-Methy phenol Acroloin Ethene 2-Methyl propanol (aldehyde) Acrylonitrile Ethylene Methyl prazine Alkyl benzene Ethyl benzene PhenolBenzaldehyde Ethynyl benzene PropeneBenzene Formaldehyde 2-Propylene nitrile Butadiene Furfural (aldehyde) Pyridine Butene Hexadeconic acid Pyrrole (amine) 3-Butenenitrile Hydrogen cyanide StyreneCarbon monoxide Indole (amine) Toluene (hydrocarbon) Creosol Isobutene 1-Undecene (hydrocarbon) 1-Decene (hydrocarbon) Methane Xylene 2,3-Dihydro indene (hydrocarbon) 3-Methyl butenal (aldehyde)

6-Methyl indole (amine)


Before the procedure, the perioperative nurse should determine the volume of smoke that will be produced and select the appropriate smoke evacuation system. A vacuum source with a triple filter offers the greatest protection. The systems consist of a prefilter to filter out large particles, an ultra low penetrating air (ULPA) filter to capture microscopic particles and a charcoal filter to absorb or bind to toxic gases produced during the procedure (Figure 22).


The vacuum source should be able to adequately pull sufficient air through the system to capture the smoke (about 50 cubic feet per minute of air). A system powerful enough to handle the amount of smoke produced is the most

Prefiltercaptures large particles and some fluids ULPA Filtercaptures small particles Activated Carbonabsorbs toxic gases and odors Final/post filter

The vacuum source should be able to adequately pull sufficient air through the system to capture the smoke (about 50 cubic feet per minute of air). A system powerful enough to handle the amount of smoke produced is the most effective evacuator, and offers the perioperative nurse the flexibility to select the appropriate capture device. A smoke evacuator that has variable power settings will be of most use in a wide variety of surgical procedures.

There are different capture devices that can be attached to the smoke evacuator. The most convenient is the smoke carriage that attaches to the electrosurgical pencil (See Figure 23). This device has the advantage of being in direct proximity to where the smoke originates, which is the recommended location to most efficiently capture smoke. For larger volumes of smoke, the larger capture tubing may be needed. The most efficient and effective system configuration should be selected for every surgical procedure in which smoke is produced.

Figure 23. Electrosurgical Pencil with Smoke Evacuation Attachment

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effective evacuator, and offers the perioperative nurse the flexibility to select the appropriate capture device. A smoke evacuator that has variable power settings will be of most use in a wide variety of surgical procedures.

There are different capture devices that can be attached to the smoke evacuator. The most convenient is the smoke carriage that attaches to the electrosurgical pencil (See Figure 23). This has the advantage of being in direct proximity to where the smoke originates, which is the recommended location to most efficiently capture smoke. For larger volumes of smoke, the larger capture tubing may be needed. The most efficient and effective system configuration should be selected for every surgical procedure in which smoke is produced.


POTENTIAL MONOPOLAR ELECTROSURGICAL HAZARDS

Since the 1980s the number and type of minimally invasive surgery (MIS) procedures has steadily increased, and that trend is expected to continue. The surgery suite and outpatient surgery department are not the only places where MIS procedures are done. Endoscopy as well as radiology suites have seen a rise in the number of cases, and the complexity of procedures done in a minimally invasive manner. As the number of MIS procedures has increased, so too have patient safety issues related to the use of monopolar electrosurgery. There are hazardous situations that may develop as a result of the endoscopic use of electrosurgery. Some of these include:

• Direct coupling • Insulation failure• Capacitive coupling • Residual heat injuries • Endosurgical smoke • Electromagnetic interference

Each of these can cause adverse patient outcomes that may result in injury. Perioperative practitioners should be aware of how and when these factors occur, and how to reduce patient risks. In determining the root cause of potential hazards it is useful to divide the active electrode and cannula system into four zones (see Figure 24).

Figure 24. Four Zones of Injury

• Zone 1 – The small area at the tip of the active electrode, and the only area in direct view of the surgeon • Zone 2 – The area just beyond the active electrode tip to the end of the cannula, outside the surgeon’s view

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MINIMALLY INvASIvE SURGERY

POTENTIAL MONOPOLAR ELECTROSURGICAL HAZARDS Since the 1980s the number and type of minimally invasive surgery (MIS) procedures has steadily increased, and that trend is expected to continue. The surgery suite and outpatient surgery department are not the only places where MIS procedures are done. Endoscopy as well as radiology suites have seen a rise in the number of cases, and the complexity of procedures done in a minimally invasive manner. As the number of MIS procedures has increased, so too have patient safety issues related to the use of monopolar electrosurgery. There are hazardous situations that may develop as a result of the endoscopic use of electrosurgery. Some of these include:

• Direct coupling • Insulation failure • Capacitive coupling • Residual heat injuries • Endosurgical smoke • Electromagnetic interference

Each of these can cause adverse patient outcomes that may result in injury. Perioperative practitioners should be aware of how and when these factors occur, and how to reduce patient risks. In determining the root cause of potential hazards, it is useful to divide the active electrode and cannula system into four zones (see Figure 24).


24

effective evacuator, and offers the perioperative nurse the flexibility to select the appropriate capture device. A smoke evacuator that has variable power settings will be of most use in a wide variety of surgical procedures.

There are different capture devices that can be attached to the smoke evacuator. The most convenient is the smoke carriage that attaches to the electrosurgical pencil (See Figure 23). This has the advantage of being in direct proximity to where the smoke originates, which is the recommended location to most efficiently capture smoke. For larger volumes of smoke, the larger capture tubing may be needed. The most efficient and effective system configuration should be selected for every surgical procedure in which smoke is produced.


POTENTIAL MONOPOLAR ELECTROSURGICAL HAZARDS

Since the 1980s the number and type of minimally invasive surgery (MIS) procedures has steadily increased, and that trend is expected to continue. The surgery suite and outpatient surgery department are not the only places where MIS procedures are done. Endoscopy as well as radiology suites have seen a rise in the number of cases, and the complexity of procedures done in a minimally invasive manner. As the number of MIS procedures has increased, so too have patient safety issues related to the use of monopolar electrosurgery. There are hazardous situations that may develop as a result of the endoscopic use of electrosurgery. Some of these include:

• Direct coupling • Insulation failure• Capacitive coupling • Residual heat injuries • Endosurgical smoke • Electromagnetic interference

Each of these can cause adverse patient outcomes that may result in injury. Perioperative practitioners should be aware of how and when these factors occur, and how to reduce patient risks. In determining the root cause of potential hazards it is useful to divide the active electrode and cannula system into four zones (see Figure 24).


• Zone 1 – The small area at the tip of the active electrode, and the only area in direct view of the surgeon • Zone 2 – The area just beyond the active electrode tip to the end of the cannula, outside the surgeon’s view

• Zone 1 – The small area at the tip of the active electrode, and the only area in direct view of the surgeon

• Zone 2 – The area just beyond the active electrode tip to the end of the cannula, outside the surgeon’s view

• Zone 3 – The area of the active electrode covered by the cannula system, also outside the view of the surgeon

• Zone 4 – The portion of the active electrode and cannula that is outside the patient’s body

The greatest concern and potential patient hazard is the incidence of unseen stray radiofrequency current in Zones 2 and 3, outside the surgeon’s view, due to stray current from insulation failure, direct coupling or capacitive coupling.33

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Direct CouplingDirect coupling occurs when the active electrode is activated in close proximity or in direct contact with other conductive instruments within the patient’s body. Direct coupling can occur in Zones 1, 2 or 3. If direct coupling occurs outside the field of vision of the surgeon and the current is sufficiently concentrated, patient injury can occur (See Figure 25).

Figure 25. Direct Coupling

Insulation FailureInsulation failure occurs when the insulating coating on the active electrode is compromised. This can happen in multiple ways that range from instrument damage due to rough handling to an insulation defect that result from using a high voltage electrosurgical current, such as coagulation. Insulation damage can occur during instrument cleaning, but it can also develop during surgery from repeated insertions into the cannula system (See Figure 26). High voltage radiofrequency current can be powerful enough to blow a hole through intact active electrode insulation. The voltage can be as high as 8,000 to 10,000 volts of electricity, depending on how the surgeon uses the active electrode. There is also concern that some active electrodes may not meet the standards for electrosurgical devices set by the Association for the Advancement of Medical Instrumentation (AAMI). Integrity of insulation coating may vary among manufacturers. Insulation failure that occurs in Zones 2 or 3 could escape detection by the surgeon and cause injury to adjacent body structures if the current is delivered in a concentrated manner.

Figure 26. Insulation Failure

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Capacitive CouplingCapacitive coupling is perhaps the least understood of the potential endoscopic electrosurgical hazards. The definition of a capacitor is two conductors separated by an insulator. Laparoscopically, a capacitor is created by inserting an active electrode, surrounded by its insulation, into a metal cannula. When the active electrode is activated by the surgeon, capacitively coupled electrical current can be induced from coming in contact with body structures, the energy can be discharged into adjacent structures and cause injury.49 When using an all-metal cannula any electrical energy stored in the cannula will tend to disperse into the patient through the relatively large contact area between the cannula and the muscular abdominal wall (See Figure 27). The large area of contact serves to disperse the electrical energy, which is far less dangerous than areas of higher concentration. For this reason, it is unwise to use plastic anchors to secure the cannula because the plastic anchors isolate the electrical current from the abdominal wall and increase the likelihood it will accumulate in other areas of the cannula.

Figure 27. Electrical Energy Dispersal Compared to All Metal and Plastic

Risk Reduction StrategiesThere are some steps perioperative personnel and surgeons can take to reduce the risk of patient injury during laparoscopic use of electrosurgery:

• Inspect insulation carefully. • Use the lowest possible power setting. • Use the low voltage (cut) waveform.49 • Use brief intermittent activations versus prolonged activations of the active

electrode. • Do not open air activate the active electrode. • Do not activate the active electrode in close proximity or in direct contact with

metal or conductive objects in the abdomen. • Use bipolar electrosurgery when possible.

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In the active electrode operative channel, select an all-metal cannula system as the best choice to disperse electrical buildup along the cannula.

Do not use hybrid systems (metal and plastic components).

One of the most important ways to increase patient safety during laparoscopy is to take advantage of improvements in technology. Advancements in technology most often exist to solve problems that were present in older generations of devices, and the improvements make surgery safer for patients and practitioners alike. Technological improvements include:

• Tissue response generators to reduce capacitive coupling in the low voltage waveform.

• Tissue-sensing generators to reduce capacitive coupling in both the cut and coagulation waveforms.

• Vessel sealing generators to take advantage of the full capabilities of bipolar-type instruments.

• Active electrode monitoring (AEM) to minimize concerns about insulation failure and capacitive coupling.

Risks posed to the patient by insulation failure and capacitive coupling can be reduced by using an AEM system. The AEM system is used with an electrosurgical generator (See Figure 28). The system continuously monitors and actively shields against stray electrosurgical current. The AEM system is one of the most effective means to minimize the potential for patient injuries due to insulation failure or capacitive coupling.50

Figure 28. Active Electrode Monitoring

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Trocar Cannula

Conductive Shield

Internal

energy, which is far less dangerous than areas of higher concentration. For this reason, it is unwise to use plastic anchors to secure the cannula because the plastic anchors isolate the electrical current from the abdominal wall and increase the likelihood it will accumulate in other areas of the cannula.

Risk Reduction Strategies

There are some steps perioperative personnel and surgeons can take to reduce the risk of patient injury during laparoscopic use of electrosurgery:

• Inspect insulation carefully. • Use the lowest possible power setting. • Use the low voltage (cut) waveform.49

• Use brief intermittent activations versus prolonged activations of the active electrode. • Do not open air activate the active electrode. • Do not activate the active electrode in close proximity or in direct contact with metal or conductive objects in

the abdomen. • Use bipolar electrosurgery when possible.

In the active electrode operative channel, select an all-metal cannula system as the best choice to disperse electrical buildup along the cannula.

Do not use hybrid systems (metal and plastic components).

One of the most important ways to increase patient safety during laparoscopy is to take advantage of improvements in technology. Advancements in technology most often exist to solve problems that were present in older generations of devices, and the improvements make surgery safer for patients and practitioners alike. Technological improvements include:

• Tissue response generators to reduce capacitive coupling in the low voltage waveform. • Tissue-sensing generators to reduce capacitive coupling in both the cut and coagulation waveforms. • Vessel sealing generators to take advantage of the full capabilities of bipolar-type instruments. • Active electrode monitoring (AEM) to minimize concerns about insulation failure and capacitive coupling.

Risks posed to the patient by insulation failure and capacitive coupling can be reduced by using an AEM system. The AEM system is used with an electrosurgical generator (See Figure 28). The system continuously

monitors and actively shields against stray electrosurgical current. The AEM system is one of the most effective means to minimize the potential for patient injuries due to insulation failure or capacitive coupling.50

Figure 28. Active Electrode Monitoring

Electrosurgical generators are only part of the electrosurgical system. The generators are only 25 percent of the electrosurgical equation. The other 75 percent of the system are the pencil, the patient return electrode and the user. “These three have much higher problem rates than does the generator”.51 Perioperative practitioners should be knowledgeable about electrosurgical accessories, including their safe and effective use.

ELECTROSURGICAL ACCESSORIESElectrosurgical generators are only part of the electrosurgical system. The generators are only 25 percent of the electrosurgical equation. The other 75 percent of the system are the pencil, the patient return electrode and the user. “These three have much higher problem rates than does the generator”.51 Perioperative practitioners should be knowledgeable about electrosurgical accessories, including their safe and effective use.

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ACTIvE ELECTRODES The active electrode is the component of the electrosurgical system that delivers concentrated electrical current to patient tissues. There is a wide assortment of active electrodes that can be used with both bipolar and monopolar electrosurgery. Active electrode pencils or forceps may be controlled by hand switches on the pencil or by foot pedals. Pencil tips are available in a wide variety of configurations — needles, blades, balls and loops, to name a few (See Figure 29). There are many active electrodes available for laparoscopic use. Some active electrodes offer a combination of suction and coagulation in the same handpiece. Active electrodes are available as disposable and reusable products, and some are what are referred to as “reposable.” Reposable products are used for a certain number of times and then discarded. One of the potential hazards associated with active electrode tips is the buildup of eschar on the tip. Eschar buildup greatly increases the impedance or resistance of the tip, and can represent a fire hazard. With sufficient heating, eschar can become a glowing ember and can pose a fire hazard both as an ignition source and fuel source. If eschar is on the active electrode tip, the scrub person should remove it according to the manufacturer’s recommendations. Scratch pads can be used to remove the eschar, but with each scratch microgrooves are left behind. As the eschar builds up in the grooves, it becomes impossible to remove and the tip assumes a higher impedance (resistance). Nonstick active electrode tips can facilitate the removal of eschar, but does not eliminate the need for frequent cleaning. Tips made of materials such as Teflon® (PTFE) or elastomeric silicone coating can be cleaned with a damp sponge (See Figure 30). A damp sponge is recommended because active electrode tips are extremely hot immediately after activation. Use of a damp sponge will make cleaning easier and reduce the risk of accidental ignition of the sponge. Coated tips should be used according to the manufacturer’s recommendations, which include use of appropriate power settings.

Figure 29. Active Electrodes Figure 30. Coated Active Electrodes

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HOLSTERSHolsters are one of the most important safety devices available to surgeons and perioperative nurses. When the active electrode is not in use, it should be placed in a holster that is visible to the surgical team and in easy reach of the surgeon and scrubbed person. It is the responsibility of the scrubbed person to ensure that the active electrode is placed in the non-conductive holster when not in use. Only holsters recommended by the manufacturer that meet safety standards for heat and fire resistance should be used. Use of plastic pouches, folded towels or other makeshift holsters are a threat to patient safety and should never be used.

PATIENT RETURN ELECTRODESPatient return electrodes, also called grounding pads, Bovie pads, neutral electrodes or patient plates, remove monopolar current safely from the patient. There are many types of return electrodes that can be used ranging from metal plates to large gels pads to dual-section foam pads. Reusable metal plates are made of stainless steel and fit under the patient. A later edition of the metal plate was a foil-coated cardboard plate. Whenever metal plates are used, conductive gel must be used to make the patient’s skin more conductive and to fill any voids in contact between the plate and the patient’s skin. As with anything that is placed under the patient, contact is dependent on patient size and conditions between the patient and the plate. Return electrodes that the patient lies on do not conform to body contours and effectiveness may vary as points of contact with the plate vary. A most important consideration for patient safety is that none of the metal plates have contact quality monitoring capabilities. Water-based gel foam pads replaced the metal or cardboard plates in most operating rooms. They are disposable and come in many sizes and shapes. These adhere well to body contours, and usually have an adhesive edge to hold the pad on the patient. When using a pad that is made of water-based gel, care must be taken to store cartons flat to prevent the gel from migrating to one side of the pad. If a pad is used that has a greater concentration of gel on one side, uneven heating and a pad site burn could occur. The water-based nature of these pads also means that storage time is limited otherwise the gel will dry out. Pads that dry out will provide reduced conductivity and could result in a burn. When using water-based gel pads, care must be taken to rotate stock and store cartons properly. Conductive adhesive pads replace gel with a layer of adhesive over the pad surface. The adhesive maintains good contact with the patient’s skin, increasing the conductivity of the pad. These pads come in two basic types — a dry conductive adhesive or a high-moisture conductive adhesive. Both have the capability of conforming well to the patient’s varying body contours. This type of pad is also available in the split dual section design, a reference that denotes the pad is part of a quality contact monitoring system. If the generator interrogation circuit used with a dual-section pad, senses conditions that could cause a patient injury, the system will deactivate the output of the generator.

Proper placement of the patient return electrode is one of the most important considerations in the safe use of the electrosurgical system. The patient return electrode should always be placed on a large muscle mass as close to the surgical site as possible. Muscle and blood are the best conductors of electrical energy in the patient’s

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body. Higher resistance tissue, such as scar tissue and any bony prominence, should also be avoided. Patient tissues that are higher in resistance slow down the passage of the current through the patient’s body. As more impedance or resistance is encountered, the greater the likelihood that electrosurgical burn could occur.52 Grounding pads should not be placed over metal prostheses because the scar tissue surrounding the implant increases resistance to the flow of electrical current. The pad site should be clean, dry, and free from excessive hair. The grounding pad should not be placed where fluids are likely to pool during surgery. If the patient has a pacemaker, the return electrode should be placed as far from the pacemaker as possible. Consult the pacemaker manufacturer prior to the procedure to determine if the pacemaker is susceptible to electrical interference.

It is also important to read and follow the dispersive electrode manufacturer’s recommendations. Safety features, such as quality contact monitoring systems, should never be bypassed. These recommendations are legal and binding instructions for using the product. Failure to follow recommended procedures could constitute negligence if patient injury occurs.

PERIOPERATIvE CARE OF THE PATIENT Nursing care of the patient during electrosurgery can be enhanced by following routine and systematic procedures. Points to consider during perioperative care of the patient during electrosurgery include, but are not limited to:38, 53, 54

PREOPERATIvE • Know which electrosurgery unit (ESU) will be used and how to use it. Consult the

instruction manual for specific instructions or questions. • Have all equipment and accessories available, and use only accessories

designed and approved for use with the unit. • Check the operation of the alarm systems. • Do not use in the presence of flammable anesthetics. • Place EKG electrodes as far from the surgery site as possible. • Do not use metal needle monitoring electrodes. • Check the line cord and plug on the ESU for breaks, nicks or cracks. • The ESU cord should reach directly to the wall outlet; extension cords should not

be used. • Do not use any power or accessory cord that is broken, cracked, frayed or taped. • Check the biomedical sticker to insure the generator has undergone a current

inspection. • Cover the foot pedal with a plastic bag.• Document the generator serial number on the perioperative record.• Record exact anatomical pad position and skin condition at the pad site.

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• Do not cut a patient return electrode to reduce its size. Patient burns due to high-current density may result.

• Do not use patient return electrodes that disable contact quality monitoring.• Do not turn the activation tone down to an inaudible level.

INTRAOPERATIvE • If an alcohol-based skin preparation is used, allow to dry according to

manufacturer’s instructions for use prior to draping. • Select and use equipment that is compatible with the ESU.• Use the lowest possible power settings to achieve the desired surgical effect. The

need for abnormally high settings may indicate a problem within the system and should be investigated.

• Position cords to avoid creating a tripping hazard. • Do not roll equipment over electrical cords.• If the patient is moved or repositioned, check that the patient return electrode is

still in good contact with the patient. • Patient return electrodes should not be repositioned. If the patient return electrode

is removed for any reason, a new pad should be used. • When not in use, place electrosurgical instruments in a safety holster or safely

away from patients, the surgical team and flammable materials. • Do not coil active electrode cords. This will increase current leakage and may

present a potential danger to the patient. • If possible, avoid “buzzing” hemostats in a way that creates metal to metal

arching. If “buzzing” a hemostat is necessary, touch the hemostat with the active electrode and then activate the generator. This will help eliminate unwanted shocks to surgical team members.

• Use endoscopes with insulated eye pieces. • Keep active electrodes clean. Eschar buildup will increase resistance, reduce

performance and require higher power settings. • Do not submerge active accessories in liquid, unless recommended by

manufacturer’s instructions for use. • Note the type of active electrode used on the perioperative record.• If an ESU alarm occurs, check the system to ensure proper function. • Do not use the generator top as a storage space for fluids. • Spills could cause malfunctions. • Do not use the active electrode when gastrointestinal gases are present.• Do not use the active electrode in the presence of an oxygen-enriched

environment.

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• Do not place the active electrode in close proximity of oxygen source.• Question the need for 100% oxygen during oropharyngeal or head and neck

surgery.• Use electrosurgery modalities cautiously in the head and neck area.• Consult the pacemaker manufacturer or cardiology department for information

when use of electrosurgery or fusion appliances is planned in patient with cardiac pacemakers.

• Consult the implantable cardioverter defibrillator manufacturer for instructions before performing electrosurgical or tissue fusion procedure.

POSTOPERATIvE• Turn all controls to zero (or minimum). • Turn off the electrosurgical unit.• Disconnect all cords by grasping the plug—not the cord. • Inspect patient return electrode site to be sure it is free of injury.• Inspect the patient return electrode after removal. If an undetected problem has

occurred, such as a suspected thermal injury, evidence of that may appear on the pad.

• Discard all disposable items according to hospital policy. • Remove and discard the plastic bag covering the foot pedal. • Clean the ESU, foot pedal and power cord. • Coil power cords for storage. • Clean all reusable accessories. • Routine care and maintenance of ESU equipment. • Routinely replace all reusable cables and active electrodes at appropriate

intervals, depending upon usage. • Have a qualified biomedical engineer inspect the unit at least every six months. • If an ESU is dropped, it should not be used until it can be inspected by a

biomedical engineer. • Replace adapters that do not provide tight connections. • Inspect “permanent” cords and cables for cracks in the insulation. • Proper use and maintenance of electrosurgical equipment can prolong its life and

reduce costly repairs.

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SUMMARY Surgeons and perioperative nurses have the opportunity to combine evidence-based practices with unique technical skills and knowledge to achieve high-quality, safe patient care. The importance of skill and knowledge is particularly critical during the use of electrosurgery. An educated perioperative team is the patient’s best advocate.

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GLOSSARYActive Electrode An electrosurgical instrument or accessory that

concentrates the electric (therapeutic) current at the surgical site.

Active Electrode Monitoring A system that continuously conducts stray current from the laparoscopic electrode shaft back to the generator and away from patient tissue. It also monitors the level of stray current and interrupts the power should a dangerous level of leakage occur.

Alternating Current A flow of electrons that reverses direction at regular intervals.

Bipolar Electrosurgery Electrosurgery in which current flows between two bipolar electrodes that are positioned around tissue to create a surgical effect (usually desiccation). Current passes from one electrode through the desired tissue to another electrode, thus completing the circuit without entering any other part of the patient’s body.

Bipolar Instrument Electrosurgical instrument or accessory that incorporates both an active and return electrode pole.

Blend A waveform that combines features of the cut and coag waveforms; current that cuts with varying degrees of hemostasis.

Capacitive Coupling The condition that occurs when electrical current is transferred from one conductor (the active electrode) into adjacent conductive materials (tissue, trocars, etc.).

Cautery The use of heat or caustic substances to destroy tissue or coagulate blood.

Circuit The path along which electricity flows.

Coagulation The clotting of blood or destruction of tissue with no cutting effect, electrosurgical fulguration and desiccation.

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Contact Quality Monitoring A system that actively monitors tissue impedance (resistance) at the interface between the patient’s body and the patient return electrode, and interrupts the power if the contact quality and/or quantity is compromised.

Current The number of electrons moving past a given point per second, measured in amperes.

Current Density The amount of current flow per unit of surface area; current concentration directly proportional to the amount of heat generated.

Current Division Electrical current leaving the intended electrosurgical circuit and following an alternate path ground; typically the cause of alternate site burns when using a grounded generator.

Cut A low-voltage, continuous waveform optimized for electrosurgical cutting.

Cutting Use of the cut waveform to achieve an electrosurgical effect that results from high-current density in the tissue causing cellular fluid to burst into steam and disrupt the structure. Voltage is low and current flow is high.

Desiccation The electrosurgical effect of tissue dehydration and protein denaturation caused by direct contact between the electrosurgical electrode and tissue. Lower current density/ concentration than cutting.

Diathermy The heating of body tissue generated by resistance to the flow of high-frequency electric current.

Direct Coupling The condition that occurs when one electrical conductor (the active electrode) comes into direct contact with another secondary conductor (scopes, graspers). Electrical current will flow from the first conductor into the secondary one and energize it.

Direct Current A flow of electrons in only one direction.

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Electrosurgery The passage of high-frequency electrical current through tissue to create a desired clinical effect.

ESU ElectroSurgical Unit.

Frequency The rate at which a cycle repeats itself. In electrosurgery, the number of cycles per second that current alternates.

Fulguration Using electrical arcs (sparks) to coagulate tissue. The sparks jump from the electrode across an air gap to the tissue.

Generator The machine that coverts low-frequency alternating current to high-frequency electrosurgical current.

Ground, Earth Ground The universal conductor and common return point for electric circuits.

Grounded Output The output on an electrosurgical generator referenced to ground.

Hertz The unit of measurement for frequency, equal to one cycle per second.

Impedance Resistance to the flow of alternating current, including simple direct current resistance and the resistance produced by capacitance or inductance.

Insulation Failure The condition that occurs when the insulation barrier around an electrical conductor is breached. As a result, current will travel outside the intended circuit.

Isolated Output The output of an electrosurgical generator that is not referenced to earth ground.

Leakage Current Current that flows along an undesired path, usually to ground. In isolated electrosurgery, RF current that regains its ground reference.

Monopolar Electrosurgery A surgical procedure in which only the active electrode is in the surgical wound; electrosurgery that directs current through the patient’s body and requires the use of a patient return electrode.

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Monopolar Output A grounded or isolated output on an electrosurgical generator that directs current through the patient to a patient return electrode.

Ohm The unit of measurement of electrical resistance.

Pad A patient return electrode.

Patient Return Electrode A conductive plate or pad (dispersive electrode) that recovers the therapeutic current from the patient during electrosurgery, disperses it over a wide surface area and returns it to the electrosurgical generator.

Power The amount of heat energy produced per second, measured in watts.

Radio Frequency Frequencies above 100 kHz; the high-frequency current used in electrosurgery.

Resistance The lack of conductivity or the opposition to the flow of electric current, measured in ohms.

RF Radio frequency.

Tissue Response Technology An electrosurgical generator technology that continuously measures the impedance/resistance of the tissue in contact with the electrode and automatically adjusts the output accordingly to achieve a consistent tissue effect.

Tissue Fusion Technology An electrosurgical technology that combines a modified form of electrosurgery with a regulated optimal pressure delivery by instruments to fuse vessel walls and create a permanent seal.

volt The unit of measurement for voltage.

voltage The force that pushes electric current through resistance; electromotive force or potential difference expressed in volts.

Watt The unit of measurement for power.

Waveform A graphic depiction of electrical activity that can show how voltage varies over time.

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