Nearly a century after its introduction, electrosurgery is still one of the safest and most effective methods for cutting and coagulating tissue in both complex and minimally invasive procedures. The fact that it's used so frequently has caused some surgeons to take the safety of this technique for granted, an attitude that could have serious consequences. Warns Barry Hainer, MD, director of clinical services at the Medical University of South Carolina, Charleston, SC, "Electrosurgery is the sharpest scalpel a surgeon can use. Unlike other surgical techniques, a surgeon doesn't need to apply pressure to destroy tissue. That takes time to master. Before surgeons can perform electrosurgery safely, they need to work with experienced preceptors. That's the greatest limitation of electrosurgery, in my opinion." Adds James Daniell, MD, clinical professor of gynecology at Vanderbilt University, Nashville, Tenn., "Electrosurgery is a wonderful tool that is very safe nowadays, but it's still nothing to trifle with. Many doctors take a very cavalier attitude about electrosurgery. They think that because they've never had a problem, they never will. They don't seem to recognize that if lightning should strike, it's too late. That's why I think that safety concerns can't be emphasized enough."

Manufacturers have developed some features that make new electrosurgery devices unquestionably safer and more effective than older models; using return electrode monitoring grounding pads and smoke evacuation, for example, is akin to wearing a seatbelt when driving (see sidebar). In other cases, however, determining whether a feature makes electrosurgery better (or whether electrosurgery is the correct option in the first place) depends on many different factors. In this article, we'll present four questions your surgeons and staff may be asking about electrosurgery and tell you what experts think about each one.

1. Is it necessary to buy a high-frequency generator?
Although there are variations from unit to unit and manufacturer to manufacturer, almost all modern electrosurgical units use very high frequencies (at least 300 kHz) of radiofrequency (RF) electrical current.

Says John Pfenninger, MD, BS, FAAFP, president and director of The National Procedures Institute and The Medical Procedures Centers, PC, in Midland, Mich., and clinical professor of family practice, Michigan State College of Human Medicine, East Lansing, Mich., "The use of pure high-frequency cutting has made electrosurgery very safe by greatly reducing the voltages that are used. This has minimized the risk of unwanted burns and tissue damage. You can do almost any kind of procedure-for example, LEEP in gynecology-with minimal tissue damage"

While all our experts agree that higher frequency and lower energy do make electrosurgery safer, clinicians disagree as to whether there is a leveling-off effect in performance once the frequency reaches a certain level. Dr. Pfenniger says, "I teach modern electrosurgery to my students, which is essentially radio frequency surgery. Although I personally like the highest frequency units, it really depends on what you need them for. For the fine dermatologic procedures I do, I think they do a better job. For most uses, though, any of the units from about 500 kHz will probably work fine."

Gary Goldstein, MD, a Voorhees, NJ, orthopedist and plastic surgeon adds, "With almost all of today's electrosurgical units, you are using very high frequencies and the safety profile is very good. I've noticed some differences in cutting performance from one unit to the next, but that had nothing to do with one model using a somewhat higher frequency. It's a matter of personal preference, like the feel you get driving one model of car instead of another comparable model."

2. Will the applications of bipolar electrosurgery ever surpass those of monopolar surgery?
By this point, it is virtually a universal belief that bipolar electrosurgery is inherently safer than the monopolar variety. That's because the energy is self-contained. The electricity is delivered and returned at the same site with no return electrode, because the energy is confined to the area grasped between the bipolar forceps. In monopolar electrosurgery, the electricity is sent through the patient via active electrodes and then returned to the generator via a return electrode. There is more (albeit still low) potential for something to go wrong and for injuries to occur.

However, bipolar surgery will likely never usurp monopolar surgery as the predominant mode of electrosurgery. It is primarily used as a compliment to monopolar mode. Most electrosurgery units allow surgeons to switch back and forth between monopolar and bipolar current. Monopolar electrosurgery is useful for virtually all procedures, including working with thick tissue (which is extremely difficult with bipolar forceps). During a monopolar procedure, a surgeon will often want to switch over to bipolar mode for a period of time, such as when he or she is working near a nerve. Bipolar-only procedures are most common when working with concentrated segments of tissue and are the method of choice for "wet field" neurosurgeries and ophthalmic surgeries. Bipolar is also common for hemostasis.

In most cases, a surgeon would want a universal generator that could provide both options (this is also more cost effective), but in some specialties, such as dermatologic surgery, a clinician may want two separate units. At the Sally Balin Medical Center for Dermatologic and Cosmetic Surgery in Media, Pa., for example, Arthur Balin, MD, PhD, FACP, reports that for bipolar-only procedures such as the removal of small cysts, they use a separate bipolar-only generator. "We do some monopolar-only surgeries, some bipolar-only surgeries, and some where we switch between the two, but we've found the bipolar generator is more effective when we need to do bipolar work on a patient. That's because the current is specifically geared to work with the bipolar instruments."

There are other niches for bipolar surgery. Says gynecological surgeon Harry Reich, MD, FACOG, New York, NY, "Bipolar is gaining wider usage in open procedures. And within minimally-invasive surgeries, bipolar is very common in laparoscopy for hemostasis. Back in the mid-1980s, we went from bipolar mode in laparoscopy to using sutures. However, the more recent trend has been going back to bipolar because it's quicker and it's a good way to seal blood vessels."

What does the future hold? Certainly, bipolar surgery will remain an effective compliment to monopolar surgery. However, says, Dr. Reich, "I think monopolar mode will be used more and more often for desiccation. It's already used extensively by general surgeons for that purpose. Today, many ob/gyn surgeons use blended current settings [i.e., monopolar mode] when they want to seal tissue." Dr. Reich himself favors using cutting current for both cutting and coagulation and reserves bipolar mode as a backup for heavy bleeders. He says that using the "coagulation current" setting on the generator is generally applicable only to surgeons who have very heavy coagulation work to do, such as general surgeons.

How does electrosurgery compare to laser surgery?
A little more than a decade ago, laser surgery (including CO2 lasers and other laser technologies) were generating a lot of buzz-there was some talk that laser technology would usurp electrosurgery as the method of choice for cutting and coagulation. In many fields, the hype has not panned out. If anything, many specialties have gone back to electrosurgery.

The primary reason, say Drs. Pfenninger and Daniell, is cost. Says Dr. Pfenninger, "It's a question of whether you want to spend about $3,000 to $4,000 for a good electrosurgical unit or $25,000 to $30,000, or even more, for a laser. It's not really a matter of effectiveness. [Electrosurgery] does the same thing as the laser-it sends energy into the cells in the surgical site. There are doctors who are very good at using the laser and very comfortable with it. But, to most surgeons, electrosurgery is simpler to do and works just as well." He estimates that 95 percent of ob/gyn procedures that were done with lasers about ten years ago have been replaced by electrosurgery.

Adds Dr. Daniell, "Lasers haven't made much of a comeback in most practices, including gynecology. I doubt they ever will, either. In the US, it's just too expensive to use the laser."

Three fields in which laser surgery has become equally-and often more- widely-favored than electrosurgery are ophthalmology, dermatology, and plastics.

Says David Bank, MD, of the Center for Dermatology, Cosmetic and Laser Surgery in Mount Kisco, NY, "There are cases in my field in which a laser and electrosurgery can be used equally well. But there are also many types of surgery, including tattoo removal, elimination of spider veins, or port wine stains, for which electrosurgery is not an option because of the potential for scarring. Lasers, which can be used as "smart bombs" to target areas very precisely, are preferable for these procedures; they're also excellent for skin resurfacing and for hair removal and for treating vascular lesions and vessels down in the dermis. The laser's ?hot point' of impact is inside the vessel, rather than outside the epidermis. That's why there is much less scarring with the laser."

He continues, "There is still a place for electrosurgery in the field, however. For cautery of skin tags, warts, small cysts on the face, certain types of vessels and for hemostasis in other excisional surgeries such as scraping of skin cancers, electrosurgery is just as viable an option as the laser."

Laser surgery may also be a safer option when treating patients with pacemakers and internal defibrillators. Says Dr. Bank, "Some surgeons may avoid electrosurgery entirely with such patients, although most are convinced that it can be done safely, so long as you are working a sufficiently safe distance away from the chest wall."

Should you use reusable or disposable instruments and accessories?
The key issue with both reusable and disposable instruments and accessories is the quality of the insulation. If the insulation is compromised, stray current can escape and cause thermal injury. There's no way to prevent some insulation degradation; according to Dr. Reich, with every procedure, the insulation becomes increasingly ragged. The thicker the layer of insulation, the greater the protection against capacitive coupling. Notes Dr. Goldstein, "Whether you're working with re-usables or disposables, if you're doing monopolar surgery, you can't cut corners on inspecting the insulation of the active electrodes and the return electrodes. That's especially true if you don't have the fall-back of AEM (active electrode monitoring). Cracked insulation on a re-usable is every bit as dangerous as thin insulation on a disposable."

Don't assume that disposables are safer because they are replaced after each case, experts warn. In one study published in the August 1995 issue of The Journal of Reproductive Medicine, researchers found that disposable accessories generally have thinner insulation and pose more damage to surrounding tissue.

All of the experts we spoke with recommended going the reusable route, provided you have the resources to care for these accessories properly. Says Dr. Daniell, "If you do it right, re-usables are easily more cost-effective. The problem is that most facilities, especially hospitals, end up outsourcing the routine maintenance of electrosurgical instruments, which runs up the cost." In addition to having an internal system for the care of the instruments, the staff must be well-trained and vigilant in inspecting the instruments and accessories.

Adds Dr. Pfenninger, "It's better to take care of the reusables than to keep buying replacements. In the long run, it's cheaper." He hastens to add, however, that reusables are only preferable if the facility has a good system in place for properly sterilizing the instruments and protecting their insulation: "The electrode tips need to be cleaned and sterilized between patients. They should be shiny; all of the carbon should be removed. This can be done with fine sandpaper. Also, the integrity of the wire must be checked to make sure it doesn't break."

If you reprocess the instruments in house, Dr. Balin recommends that you gas sterilize them. At his center, they used to use steam sterilization, but this was "much harder on the instruments and caused them to crack." Dr. Balin uses a new sterile handpiece with each procedure; some surgeons simply use sterile sleeves to cover the handles and eliminate the need to reprocess each time.

If properly maintained, the lifespan and performance of reusable instruments can be quite impressive. Says Dr. Reich, "I've had the same scissors for eight years. Some reusable instruments are so well-constructed that they don't need re-sharpening. There are also real performance benefits with the reusables. For example, with a good pair of reusable scissors, you can cut and seal tissue much more effectively." Says Dr. Hainer, "Generally, I can use active electrode tips five to 10 times before they become brittle and break. When I'm doing small cutaneous lesions, where the reimbursement per procedure is in the $30-60 range, disposable costs need to be kept to a minimum. Using reusable electrode tips is one way to make it more economical."

Four recommended safety practices

Experts agree that the following four features and techniques offer unquestionable safety benefits and should be a part of any monopolar electrosurgery setup: Return electrode monitoring grounding pads. Says Dr. Daniell, "These pads were a major breakthrough in the safe use of electrosurgery. They virtually eliminate the possibility of electrode burns at the site where the energy grounding plate is placed on the patient." However, Dr. Pfenninger says, "I'm not convinced you always need grounding pads, such as in the case of the awake external derm procedures I do. I agree that they should be used in laparoscopy or any time the patient is put to sleep." Isolated electrosurgical generators. This technology, which is about a decade old now, prevents electricity from seeking an alternate path to the ground. An isolated generator won't function if the electricity doesn't recycle properly, notes Dr. Daniell. Active electrode monitoring (AEM). Not all electrosurgery units have active electrode monitoring, a feature that helps warn surgeons of defective insulation and prevents capacitive coupling. Systems with AEM continuously monitor the electrical circuit and automatically shut down and sound an alarm if electricity escapes or reaches dangerous levels. Dr. Daniell is a major proponent of AEM technology, which he believes will eventually become standard for endoscopic procedures. The technology is not yet widespread, which according to Dr. Reich is mainly because electronic monitoring units (or generators with built-in AEM technology) are an added expense and most surgeons feel that they are safe in their practices. Says Dr. Reich, who is on the advisory boards of both the American Association of Gynecologic Laparoscopists (AAGL) and the Society of Laparoendoscopic Surgeons (laparoscopic surgery is one area where AEM is catching on),"It's been a long time in bringing doctors around to active electrode monitoring. Most surgeons feel so confident of themselves that they believe there's no need to take on the added expense-unless there has been an accident. But I think that is starting to change. In another ten years, AEM will be the gold standard of patient care in electrosurgery." Smoke evacuation. Despite clear evidence that the smoke plumes resulting from electrosurgery are a health hazard for patients and staff, many facilities still do not use a smoke evacuator regularly. Dr. Reich says half-jokingly that "It seems that the only place in the hospital where smoking is legal is in the OR." He recommends the penny-vac type of pencil evacuators that many makers produce. Using a smoke evacuator may seem optional in some cases, but there are instances, such as wart removal, where it's imperative, says David Bank, MD, of the Center for Dermatology, Cosmetic and Laser Surgery in Mount Kisco, NY. During these procedures, there's a chance of transmitting infection through the smoke plume, which may contain papilloma virus DNA particles, he says. Plus, studies have shown that the smoke plume can have carcinogenic effects and potentially could transmit the HIV virus. For this reason, Dr. Bank wears face masks in addition to using a smoke evacuator. Dr. Hainer also points out that the smoke evacuator ensures that the surgeon has a clear view of the surgical field and removes offensive odors caused by the cautery of tissue. The only time you don't need one, he says, is "if the time you'd be using the electrosurgical unit is under five seconds and if the surgery is being performed in a well-ventilated operating room."