Overview of electrosurgery
- Jon Ivar Einarsson, MD, PhD, MPH
Jon Ivar Einarsson, MD, PhD, MPH
- Director of Minimally Invasive Gynecologic Surgery
- Brigham and Women's Hospital
- Jon Gould, MD
Jon Gould, MD
- Professor of Surgery
- Medical College of Wisconsin
- Section Editors
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles; Quality and Safety
- Professor of Surgery
- SIU School of Medicine
- Tommaso Falcone, MD, FRCSC, FACOG
Tommaso Falcone, MD, FRCSC, FACOG
- Section Editor — Minimally Invasive Gynecologic Surgery
- Professor of Obstetrics and Gynecology
- Cleveland Clinic Lerner College of Medicine
Electrosurgery refers to the cutting and coagulation of tissue using high-frequency electrical current . Physicians using this technique must be knowledgeable about prevention and management of potential complications of electrosurgical procedures. In addition, they should understand the mechanism of action and how to troubleshoot equipment. Education on the principles of electrosurgery is important , as electrosurgical complications are relatively common .
Electrical current is created by the movement of electrons; voltage is the force that causes this movement. There are two types of electrical current: direct current (DC), where the electrons always flow in the same direction (eg, simple battery), and alternating current (AC), where the current changes direction periodically (eg, electrical wall outlet). A cycle is the time required to pass through one complete positive and one complete negative alternation of current or voltage. Frequency refers to the number of cycles in one second and is measured in hertz (Hz).
Electrosurgical units (ESU) used in operating rooms convert standard electrical frequencies from the wall outlet, which are 50 to 60 Hz, to much higher frequencies, 500,000 to 3,000,000 Hz . This is important to minimize nerve and muscle stimulation, which occurs at electrical currents below 10,000 Hz . The possible effects of applying electrical current to tissue are fulguration, desiccation/coagulation, or vaporization/ablation (figure 1).
When comparing the creation of a surgical incision in the skin using a scalpel versus electrosurgery, no significant differences have been identified regarding infection rates or scar appearance; however, postoperative wound pain is less with electrosurgery . In a randomized trial, pain scores on day one were lower for the diathermy group, but were no different on days two through five .
Monopolar versus bipolar — Electrosurgery can be performed using either a monopolar or a bipolar instrument. The main difference between these modalities is the pathway of the current.
- Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: history, principles, and current and future uses. J Am Coll Surg 2006; 202:520.
- Mayooran Z, Pearce S, Tsaltas J, et al. Ignorance of electrosurgery among obstetricians and gynaecologists. BJOG 2004; 111:1413.
- Feldman LS, Brunt LM, Fuchshuber P, et al. Rationale for the fundamental use of surgical Energy™ (FUSE) curriculum assessment: focus on safety. Surg Endosc 2013; 27:4054.
- Tucker RD, Schmitt OH, Sievert CE, Silvis SE. Demodulated low frequency currents from electrosurgical procedures. Surg Gynecol Obstet 1984; 159:39.
- Aird LN, Brown CJ. Systematic review and meta-analysis of electrocautery versus scalpel for surgical skin incisions. Am J Surg 2012; 204:216.
- Aird LN, Bristol SG, Phang PT, et al. Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions. Br J Surg 2015; 102:489.
- Wu MP, Ou CS, Chen SL, et al. Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg 2000; 179:67.
- Alkatout I, Schollmeyer T, Hawaldar NA, et al. Principles and safety measures of electrosurgery in laparoscopy. JSLS 2012; 16:130.
- Lu S, Xiang J, Qing C, et al. Effect of necrotic tissue on progressive injury in deep partial thickness burn wounds. Chin Med J (Engl) 2002; 115:323.
- Sutton PA, Awad S, Perkins AC, Lobo DN. Comparison of lateral thermal spread using monopolar and bipolar diathermy, the Harmonic Scalpel and the Ligasure. Br J Surg 2010; 97:428.
- Matthews BD, Pratt BL, Backus CL, et al. Effectiveness of the ultrasonic coagulating shears, LigaSure vessel sealer, and surgical clip application in biliary surgery: a comparative analysis. Am Surg 2001; 67:901.
- Landman J, Kerbl K, Rehman J, et al. Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a porcine model. J Urol 2003; 169:697.
- Hefermehl LJ, Largo RA, Hermanns T, et al. Lateral temperature spread of monopolar, bipolar and ultrasonic instruments for robot-assisted laparoscopic surgery. BJU Int 2014; 114:245.
- Goldstein SL, Harold KL, Lentzner A, et al. Comparison of thermal spread after ureteral ligation with the Laparo-Sonic ultrasonic shears and the Ligasure system. J Laparoendosc Adv Surg Tech A 2002; 12:61.
- Phillips CK, Hruby GW, Durak E, et al. Tissue response to surgical energy devices. Urology 2008; 71:744.
- Emam TA, Cuschieri A. How safe is high-power ultrasonic dissection? Ann Surg 2003; 237:186.
- Abstracts of the Global Congress of Minimally Invasive Gynecology, 34th Annual Meeting of the American Association of Gynecologic Laparoscopists, Chicago, Illinois, USA, November 9-12, 2005. J Minim Invasive Gynecol 2005; 12:S1.
- Campbell PA, Cresswell AB, Frank TG, Cuschieri A. Real-time thermography during energized vessel sealing and dissection. Surg Endosc 2003; 17:1640.
- Lamberton GR, Hsi RS, Jin DH, et al. Prospective comparison of four laparoscopic vessel ligation devices. J Endourol 2008; 22:2307.
- Vancaillie TG. Active electrode monitoring. How to prevent unintentional thermal injury associated with monopolar electrosurgery at laparoscopy. Surg Endosc 1998; 12:1009.
- Munro, M. Energy sources for operative laparoscopy. In: Diagnostic and Operative Gynecologic Laparoscopy, Gomel, V, Taylor, PJ (Eds), Mosby-Year Book, St Louis 1995. p. 26.
- Brill AI. Energy systems for operative laparoscopy. J Am Assoc Gynecol Laparosc 1998; 5:333.
- LeBlanc KA. Laparoscopic incisional and ventral hernia repair: complications-how to avoid and handle. Hernia 2004; 8:323.
- Sutton C. Hysteroscopic surgery. Best Pract Res Clin Obstet Gynaecol 2006; 20:105.
- Vilos GA. Intrauterine surgery using a new coaxial bipolar electrode in normal saline solution (Versapoint): a pilot study. Fertil Steril 1999; 72:740.
- Berg A, Sandvik L, Langebrekke A, Istre O. A randomized trial comparing monopolar electrodes using glycine 1.5% with two different types of bipolar electrodes (TCRis, Versapoint) using saline, in hysteroscopic surgery. Fertil Steril 2009; 91:1273.
- Bradley LD. Complications in hysteroscopy: prevention, treatment and legal risk. Curr Opin Obstet Gynecol 2002; 14:409.
- Nduka CC, Super PA, Monson JR, Darzi AW. Cause and prevention of electrosurgical injuries in laparoscopy. J Am Coll Surg 1994; 179:161.
- Presthus JB, Brooks PG, Kirchhof N. Vessel sealing using a pulsed bipolar system and open forceps. J Am Assoc Gynecol Laparosc 2003; 10:528.
- Jacobs VR, Morrison JE Jr, Paepke S, Kiechle M. Body piercing affecting laparoscopy: perioperative precautions. J Am Assoc Gynecol Laparosc 2004; 11:537.
- American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the american society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology 2011; 114:247.
- Purday JP, Towey RM. Apparent pacemaker failure caused by activation of ventricular threshold test by a magnetic instrument mat during general anaesthesia. Br J Anaesth 1992; 69:645.
- Bernstein AD, Irwin ME, Parsonnet V, et al. Report of the NASPE Policy Conference on antibradycardia pacemaker follow-up: effectiveness, needs, and resources. North American Society of Pacing and Electrophysiology. Pacing Clin Electrophysiol 1994; 17:1714.
- Robinson TN, Varosy PD, Guillaume G, et al. Effect of radiofrequency energy emitted from monopolar "Bovie" instruments on cardiac implantable electronic devices. J Am Coll Surg 2014; 219:399.
- Chauvin M, Crenner F, Brechenmacher C. Interaction between permanent cardiac pacing and electrocautery: the significance of electrode position. Pacing Clin Electrophysiol 1992; 15:2028.
- Kennedy JS, Stranahan PL, Taylor KD, Chandler JG. High-burst-strength, feedback-controlled bipolar vessel sealing. Surg Endosc 1998; 12:876.
- Levy B, Emery L. Randomized trial of suture versus electrosurgical bipolar vessel sealing in vaginal hysterectomy. Obstet Gynecol 2003; 102:147.
- Dubuc-Lissoir J. Use of a new energy-based vessel ligation device during laparoscopic gynecologic oncologic surgery. Surg Endosc 2003; 17:466.
- Rimonda R, Arezzo A, Garrone C, et al. Electrothermal bipolar vessel sealing system vs. harmonic scalpel in colorectal laparoscopic surgery: a prospective, randomized study. Dis Colon Rectum 2009; 52:657.
- Ikeda M, Hasegawa K, Sano K, et al. The vessel sealing system (LigaSure) in hepatic resection: a randomized controlled trial. Ann Surg 2009; 250:199.
- Romano F, Gelmini R, Caprotti R, et al. Laparoscopic splenectomy: ligasure versus EndoGIA: a comparative study. J Laparoendosc Adv Surg Tech A 2007; 17:763.
- Richter S, Kollmar O, Schilling MK, et al. Efficacy and quality of vessel sealing: comparison of a reusable with a disposable device and effects of clamp surface geometry and structure. Surg Endosc 2006; 20:890.
- Wang CJ, Yuen LT, Yen CF, et al. Comparison of the efficacy of the pulsed bipolar system and conventional bipolar electrosurgery in laparoscopically assisted vaginal hysterectomy. J Laparoendosc Adv Surg Tech A 2005; 15:361.
- Sahin DA, Kusaslan R, Sahin O, et al. Comparison of Ligasure, SurgRx, and suture techniques in intra-abdominal adhesions that occur after liver resection in rats: an experimental study. Int Surg 2007; 92:20.
- Sahin DA, Kusaslan R, Sahin O, et al. Histopathological effects of bipolar vessel sealing devices on liver parenchyma and comparison with suture method: an experimental study. Eur Surg Res 2007; 39:111.
- McCarus SD. Physiologic mechanism of the ultrasonically activated scalpel. J Am Assoc Gynecol Laparosc 1996; 3:601.
- Amaral JF. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc 1994; 4:92.
- Gil-Moreno A, Puig O, Pérez-Benavente MA, et al. Total laparoscopic radical hysterectomy (type II-III) with pelvic lymphadenectomy in early invasive cervical cancer. J Minim Invasive Gynecol 2005; 12:113.
- Ou CS, Harper A, Liu YH, Rowbotham R. Laparoscopic myomectomy technique. Use of colpotomy and the harmonic scalpel. J Reprod Med 2002; 47:849.
- Amaral, JF, Chrostek, C. Depth of thermal injury: Ultrasonically activated scalpel vs electrosurgery. Surg Endosc 1995; 9:226.
- Kandil T, El Nakeeb A, El Hefnawy E. Comparative study between clipless laparoscopic cholecystectomy by harmonic scalpel versus conventional method: a prospective randomized study. J Gastrointest Surg 2010; 14:323.
- El Nakeeb, A, Askar, W, El Lithy, R, Farid, M. Clipless laparoscopic cholecystectomy using the harmonic scalpel for cirrhotic patients: a prospective randomized study. Surg Endosc 2010; Epub ahead of print.
- Catena F, Ansaloni L, Di Saverio S, et al. Prospective analysis of 101 consecutive cases of laparoscopic cholecystectomy for acute cholecystitis operated with harmonic scalpel. Surg Laparosc Endosc Percutan Tech 2009; 19:312.
- Bubenik LJ, Hosgood G, Vasanjee SC. Bursting tension of medium and large canine arteries sealed with ultrasonic energy or suture ligation. Vet Surg 2005; 34:289.
- Verdaasdonk RM, van Swol CF. Laser light delivery systems for medical applications. Phys Med Biol 1997; 42:869.
- Singh S, Maxwell D. Tools of the trade. Best Pract Res Clin Obstet Gynaecol 2006; 20:41.
- Lanzafame RJ. Laser use and research in gastroenterology, gynecology, and general surgery: a status report. J Clin Laser Med Surg 2001; 19:133.
- Ueda M, Ueki K, Kanemura M, et al. Diagnostic and therapeutic laser conization for cervical intraepithelial neoplasia. Gynecol Oncol 2006; 101:143.
- Sutton CJ, Ewen SP, Jacobs SA, Whitelaw NL. Laser laparoscopic surgery in the treatment of ovarian endometriomas. J Am Assoc Gynecol Laparosc 1997; 4:319.
- Penna C, Fallani MG, Fambrini M, et al. CO2 laser surgery for vulvar intraepithelial neoplasia. Excisional, destructive and combined techniques. J Reprod Med 2002; 47:913.
- Overbey DM, Townsend NT, Chapman BC, et al. Surgical Energy-Based Device Injuries and Fatalities Reported to the Food and Drug Administration. J Am Coll Surg 2015; 221:197.
- Hulka JF, Levy BS, Parker WH, Phillips JM. Laparoscopic-assisted vaginal hysterectomy: American Association of Gynecologic Laparoscopists' 1995 membership survey. J Am Assoc Gynecol Laparosc 1997; 4:167.
- Tucker RD. Laparoscopic electrosurgical injuries: survey results and their implications. Surg Laparosc Endosc 1995; 5:311.
- Krebs HB. Intestinal injury in gynecologic surgery: a ten-year experience. Am J Obstet Gynecol 1986; 155:509.
- Humes DJ, Ahmed I, Lobo DN. The pedicle effect and direct coupling: delayed thermal injuries to the bile duct after laparoscopic cholecystectomy. Arch Surg 2010; 145:96.
- Vilos GA, Newton DW, Odell RC, et al. Characterization and mitigation of stray radiofrequency currents during monopolar resectoscopic electrosurgery. J Minim Invasive Gynecol 2006; 13:134.
- Vilos G, Latendresse K, Gan BS. Electrophysical properties of electrosurgery and capacitive induced current. Am J Surg 2001; 182:222.
- Yazdani A, Krause H. Laparoscopic instrument insulation failure: the hidden hazard. J Minim Invasive Gynecol 2007; 14:228.
- Montero PN, Robinson TN, Weaver JS, Stiegmann GV. Insulation failure in laparoscopic instruments. Surg Endosc 2010; 24:462.
- BASIC PRINCIPLES
- Monopolar versus bipolar
- Cutting and coagulation currents
- Desiccation, vaporization, and fulguration
- Time, power, tissue, and electrode
- Thermal spread
- Smoke plume
- CLINICAL USE
- Monopolar electrosurgery
- Bipolar electrosurgery
- Laparoscopic procedures
- Hysteroscopic procedures
- IMPROVING SAFETY
- Electrode monitoring
- Inspect for faulty insulation
- Avoid skin contact with metals
- Avoid electromagnetic interference
- ADVANCED ELECTROSURGICAL DEVICES
- Ligasure device
- PlasmaKinetic tissue management system
- ALTERNATIVE ENERGY SOURCES
- Ultrasonic cutting and coagulating device
- SUMMARY AND RECOMMENDATIONS