The ultimate success of minimally invasive surgery hinges on a surgeon's ability to effectively cut and seal blood vessels. Thermal and ultrasonic energies (see "Know Your Energy Options") for cutting and coagulation in laparoscopic procedures have superseded clamping, cutting and tying as surgeons' methods of choice. But no technology is foolproof. Keep these ever-present risks in mind to limit the possibility of unwanted outcomes.

• Thermal spread. It's the main hazard when using electrosurgical instruments, says Resad Pasic, MD, PhD, a professor of obstetrics, gynecology and women's health at the University of Louisville School of Medicine in Kentucky and director of the school's gynecologic endoscopy section. As the jaws of a cutting and sealing instrument are applied to tissue, the heat — and the subsequent tissue dessication from the heat — spreads to adjacent tissue. Depending on how long the energy is applied, it could result in unnecessarily damaged tissue after a few seconds. The higher voltage of bipolar devices tends to create a wider thermal spread of a couple of millimeters. Vessel fusion instruments, on the other hand, which employ lower voltage delivered in pulse fashion, create less thermal spread, usually 1mm or less. When electrosurgical instruments are used selectively, thermal spread can be minimized, says Dr. Pasic.
• Over-reaching. In cutting and sealing, "much of what is associated with injury is user error," says perioperative educator and consultant Brenda Ulmer, RN, MN, CNOR, of Snellville, Ga., a past president of AORN and former director of education for a medical device manufacturer. Cutting and sealing devices have a low learning curve, but a thorough familiarity with the technology's recommendations and parameters is important. Ignoring a manufacturer's directions or overconfidently going beyond them is courting trouble. "With vessel fusion devices, you can grasp and seal tissue up to 7mm in size," says Ms. Ulmer. "But I've seen surgeons try to grasp vessels larger than 7mm." Instruments have been tested and validated to certain parameters. Don't try to do too much or take too big a bite, she says.
• Adjacent anatomy. Over-reaching can also create a problem if a surgeon, working too close to an adjacent structure, grabs a portion of the wrong tissue. Other such mishaps include cutting past the tissue that has been sealed, resulting in a bleed, or failing to adequately seal a vessel by grasping tissue with a clip or suture in it. "If you know your anatomy, though, this is not a big deal," says Dr. Pasic. To be on the safe side, he says, an awareness of the vital structures near where you are working will help to apply energies in a safe manner, safely away from where they are not needed.
• Fire hazards. Bipolar, vessel fusion and ultrasonic instruments don't remain as hot for as long as monopolar electrocautery devices do — plus, they're hand-controlled, not foot-pedal-driven, so there's less risk of unintended activation — but in the seconds after their use, you can't be too careful, says Vangie Dennis, RN, BSN, CNOR, CMLSO, administrative director of the Spivey Station Surgery Center in Jonesboro, Ga. "Just as with any heat-generating device, laying them directly on a paper drape could spark a surgical fire," she says. While specially designed holsters are recommended for monopolar devices, cutting and sealing devices tend to be longer and don't fit as practically. Instead, Ms. Dennis advises, lay a damp towel or 4 x 4 on the Mayo stand or impervious drape, and be sure to set the recently hot device on top of it. Also, she says, "be careful how you pass them. The jaw is serrated and could be considered a sharp."
• A rule for reuse. Bipolar cutting and sealing devices are reusable, but vessel fusion instruments are oftentimes single-use. As they represent approximately $700 in supply costs each, facilities may try to economize by sending them for reprocessing. SUD reprocessing remains a controversial decision that at this point is being made on a facility-by-facility basis. But Dr. Pasic maintains that surgeons should be notified if they're using reprocessed and refurbished single-use devices, as it can be difficult to tell otherwise.