When Electrosurgery Becomes Too Hot to Handle

As a result, Dr. Jones says electrosurgery instruments should at the very least be visually inspected before every case. Surgeons and other staff members will usually spot a large hole or crack on an instrument, but the dangerous thing about electrosurgery is that the smaller the hole, the more powerful the stray energy streams. "If you see a big hole, you say, 'Well, that instrument is broken, we can't use it,'" says Dr. Jones. "It's really the holes you can't see that can cause more damage."

To find these tough-to-see cracks and evaluate the insulation integrity of electrosurgery instruments, use a porosity detector. "These determine if energy leaks across the insulation of a laparoscopic instrument," says Dr. Robinson. "If energy travels across the insulation to the porosity detector's ring, it signals a tone which represents the presence of an insulation defect."

But porosity detectors, which Dr. Robinson estimates about half of hospitals use, aren't foolproof and require close attention. When his team visited four large medical centers around Denver, he found 19% of their laparoscopic instrument sets had one or more insulation defects. Dr. Robinson says two of the centers used porosity detectors but didn't perform any better on the inspections than the ones that didn't.

Insulation can usually be repaired, and Dr. Robinson says vendors are capable of improving its durability using different thicknesses and laminates. He notes to pay particular attention to L-hooks and spatulas that deliver energy. "You need to be looking disproportionately at the instruments you're passing energy through before every case. Routine inspection of laparoscopic insulation is simple to do, but I think most surgeons aren't aware insulation defects are an issue."

Stray energy is the most common safety problem associated with surgical energy devices, but not the only one. Power settings are also potentially hazardous. "Your power should be at the lowest setting to achieve needed results," says Dr. Jones. "You also want to use shortest bursts of energy. Don't just turn on a device and keep it on, because energy may start to scatter.

"Surgeons need to understand how electrosurgery devices carry energy and how the energy may cause injury," says Dr. Jones. "If they're not thinking about more than just the on/off button, they'll get themselves in trouble."

Drs. Jones and Robinson say many surgeons and OR teams still don't know enough about electrosurgery safety, a continuing educational gap they find troubling.

According to Dr. Robinson, electrosurgery safety isn't taught in medical schools, and that even surgical subspeciality training focuses mostly on disease processes. "At this point, there is no good formal curriculum on the technology used in operating rooms," he says. "There's no curriculum that instructs on the safe and effective use of surgical energy, yet it can lead to this spectrum of complications that, while not common in an individual surgeon's practice, is happening every day across the country."

Both surgeons are proponents of, and directly involved in, an education program developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Association of periOperative Registered Nurses (AORN) called FUSE: the Fundamental Use of Surgical Energy (fuseprogram.org). The free curriculum, developed over the last decade, is intended to bridge the electrosurgery knowledge gap in ORs.

They encourage clinicians to get FUSE certifications, which involves a supervised test. In fact, such certifications are mandatory for surgeons and OR nurses in France. "In the United States, many programs are encouraging it or requiring it as a trainee," says Dr. Jones. "We're making a little headway. For example, in our program, all residents have to take the FUSE certificate before graduating. They've got five to seven years to get it done. Our faculty are also encouraged to get certified."

"It's a question of raising awareness," says Dr. Robinson, who chairs the FUSE committee. "We're saying, 'Look, you can perforate the bowel because you have a sharps injury with the scissors or a knife, or you can have stray energy burning in the tissue unintentionally. These are the patterns to electrosurgery injuries, and FUSE is teaching surgeons to recognize these patterns with the goal of avoiding high-risk situations."

FUSE certification is a lot of work, however, and many clinicians and health systems bristle at the program's density. Dr. Robinson says many mid-career surgeons just don't have the time to invest. In response, an abbreviated, downloadable version of the curriculum called the FUSE Hospital Compliance Module just became available this year.

To highlight the current issues with electrosurgical safety and the positive effects of formal training, Dr. Jones recalls an OR fire safety test of almost 200 surgeons, anesthesiologists, nurses and techs at Beth Israel Deaconess using a virtual reality simulation. "Only five percent of all surgeons, nurses and anesthesiologists did it correctly the first time," he says. "But by the time they've done these scenarios five times, pretty much everyone got it down. If you just go into an OR today like we did and test people, they're woefully unprepared to deal with these rare events."

Dr. Jones says surgical professionals don't understand proper placement of dispersive electrodes with monopolar cautery. They're not thinking about the heat transfer at the tip of the instrument that may burn the bowel or the stray energy that may burn it. In fact, when they take the FUSE course, they realize several of the decisions they make may not be good ones, adds Dr. Jones.

Facilities often don't address electrosurgery safety until after the fact. When there's an adverse event like an OR fire, surgical leaders and surgeons seek information about how the incident could have been prevented. "We use those opportunities to get FUSE curriculum into those centers," says Dr. Robinson.

"The issue is that electrosurgery burns are uncommon events that may impact surgeons once in their careers, so their awareness isn't as heightened as it is, say, for surgical site infections," he adds. "But while an electrosurgery mishap is rare, when it does happen, the outcomes for the patient are catastrophic. A bowel perforation is a huge deal to a patient." It's also a stain on the safety record of your facility. OSM