Between 20 and 25 percent of open surgical procedures have been converted to laparoscopic surgical access over the past decade, and more than 4 million laparoscopic procedures will take place this year. But along with the rise in this techniques comes a rise in a risk unique to it: laparoscopic burns. Here's what you need to know about the causes of laparoscopic burns and how you can prevent them.
Problems of laparoscopic electrosurgery
Monopolar electrosurgery used during open surgery has always carried a risk of skin injury, usually related to return-electrode placement. Two initiatives have all but eliminated this problem - educating the perioperative staff and instituting isolated generators with return-electrode monitoring.
But laparoscopic application of monopolar electrosurgery introduces risks that would be either negligible or nonexistent during open procedures. First, during laparoscopic surgery, the surgeon views the peritoneal cavity through laparoscopes introduced into the abdominal cavity via small ports - so the surgeon's field of view is limited to 3cm to 5cm. Stray electrosurgical energy occurring outside this field of view can cause unintended burns to non-target tissue, and these burns usually go unnoticed. Unlike electrosurgical skin injuries, the complications of these internal burns can put the patient in a life-threatening condition; even with antibiotic therapy, about 33 percent of patients who develop peritonitis don't survive.
About 85 percent of laparoscopic surgeons routinely use monopolar electrosurgery. By 2010, an estimated 5 million laparoscopies will be performed annually in the United States. According to data compiled by the Physician Insurers Association of America (PIAA), laparoscopy is one of the most common procedures resulting in medical malpractice claims, with 5.4 percent of injuries being traced to the electrosurgical equipment.
In addition, the PIAA study found that in "3 out of every 4 cases in which a [laparoscopic] injury [including thermal injury] occurred, it was not recognized prior to the conclusion of the procedure."1 Because they are difficult to detect, stray electrosurgical burns are likely to be misdiagnosed when they present later2, usually in the form of fever and abdominal pain three days to seven days after surgery.3
Unfortunately, injuries attributable to stray energy burns are less understood than other surgical injuries, partly because they're hard to detect and therefore diagnose. For example, it's not uncommon for the injured area to become compromised by a secondary infection or for the complications of stray electrosurgical burns to be erroneously attributed to instrument laceration.
How it happens
Electrosurgical burns from active electrodes happen in one of three ways:
- Direct coupling. This is when you transfer the energy by means of physical contact between two conductors. It's usually a result of pilot error by the surgeon.
- Insulation failure. This is an instrument defect beyond the control of even the most skilled surgeon.
- Capacitive coupling. Capacitive coupling occurs in the presence of a capacitator and is created when two conductors are separated by an insulator. It can occur many times during a laparoscopic procedure, as tissue, trocar and instrument (itself consisting of active electrode and primary insulation) are in close proximity. Capacitive coupling can transfer current to non-target tissue through intact insulation, thereby causing stray electrosurgical burns.
There's nothing a surgeon can do to prevent the latter two causes of electrosurgical burns. What's more, in an American College of Surgeons survey, 49 percent of surgeons said they had not heard of capacitive coupling. That's why it's especially important that monitored monopolar instruments are in place.
AEM minimizes the risk
AORN recommends active electrode monitoring (AEM) as a way to minimize the risk of stray electrosurgical burns due to insulation failure and capacitive coupling. Under normal operating conditions, AEM technology delivers 100 percent of the power to the surgeon's intended site. Capacitively coupled energy is safely drained to the generator via a protective shield built into 5mm AEM instruments. If primary insulation fails, or the level of capacitively coupled current becomes too much, AEM technology shuts down the generator, protecting the patient from a potentially life-threatening burn, and alerts the perioperative staff. You can prevent unintended laparoscopic burns by introducing AEM to your facility.
Adding AEM doesn't have to be a financial hit, but you do have to keep up with your equipment. The lifespan of a reusable active electrode is about one year, given normal wear and tear on the insulation during procedures and proper sterilization. If your reusable instruments last only a year, there's virtually no difference in supply cost with the acquisition of instruments, which are purchased yearly for a laparoscopic service. Most hospitals and ASCs, however, use their reusable active electrodes well beyond the one-year mark, typically getting two years or more out of them before replacement.
Even more dramatic economizing opportunities are available, regardless of whether you choose to purchase reusable or disposable active electrodes. For example, nine types of active electrodes are usually on a laparoscopic tray, which could include electrosurgical scissors, J-hooks, dissectors and graspers. Most surgeons only use two during a procedure - a spatula or a hook and a dissector. You can reduce the number of active electrodes and save on acquisition costs without affecting patient care.
Don't divorce cost from safety
The cost of treating a single stray electrosurgical burn accident is astronomical in purely financial terms (not to mention physical and psychological trauma to the patient and potential litigation from the case). You can't simply divorce cost from safety in real-life practice management.
Electrosurgery presents a lot of benefits - but you can't be cavalier about its potential for doing damage. Implementing AEM will optimize patient outcomes and patient safety. It's up to you, as a member of the perioperative staff, to recognize you have the power, professional responsibility and opportunity to protect patients from the dangers of stray energy burns.
1. PIAA Laparoscopic Procedure Study. May 1994.
2. Brill AI et al. Patient Safety During Laparoscopic Monopolar Electrosurgery - Principles and Guidelines. Journal of the Society of Laparoendoscopic Surgeons (JSLS). 1998; 2: 222.
3. Nduka CC et al. Cause and Prevention of Electrosurgical Injuries in Laparoscopy. Journal of the American College of Surgeons. August 1994; 179:163.