Whether you preflight electrosurgery active electrodes the traditional way (visual inspection) or the modern way (using safety technologies), here's how to keep your equipment operating safely, case after case after case.

1. Visually inspect the electrode
Your first (but far from best) line of defense against stray site burns is to visually inspect the active electrodes before a case. While this alone is not a reliable way to prevent equipment-related (rather than those caused by surgeon error) accidents, knowing the correct way to inspect the active electrodes can help take many compromised instruments out of circulation before the surgeon uses them near human tissue.

It's helpful to mentally divide the active electrode into four zones and examine each zone for defects. Zone 1 is the area at the tip of the electrode (such as the ball, lancet or loop) that is intended to deliver radiofrequency energy to the patient. Look to see if the tip is brittle or charred. If so, replace it.

Zones 2 and 3 are the sections prone to insulation failure and, overall, represent the greatest risk for the delivery of unintended current. Zone 2 is the insulated electrode area that lies outside the cannula; Zone 3 is covered by the cannula during the case.

Insulation failure can occur with any electrode - regardless of whether it's intended for single or multiple uses. Insulation failure occurs because of the constant introduction and removal of the instrument during surgery, damage caused by high voltages, general handling and, in the case of reusable and reposable electrodes, cumulative stress caused by sterile processing. If the surgeon uses a high-voltage waveform (such as coagulation current) during the procedure, there's a greater chance that the current will pass through damaged or torn insulation.

The hardest-to-spot defects - pinhole cracks or weakened-but-intact (as of inspection) insulation - are more dangerous than more visible tears. The smaller the insulation tear, the more concentrated the current. In general, the more concentrated the current, the more severe the stray site burn. But once the tissue dies, perforation can take place regardless of the concentration.

Zone 4 of the electrode is outside the patient's body during a case but contains another risky area - the top of the electrode and the cord that plugs into the generator. Compromised cords are not an issue to the patient, but insulation failure could shock the staff and physician, or cause a drape fire. Especially if you use reusable or reposable active electrodes, check the cord for damage and fraying. If the instrument has been in use for about a year, throw away the old cord and replace it before you use the electrode again. We put a bar code on our reusable cord, which is scanned during central processing. Once the cord reaches its life limit (manufacturer's recommendations determine the duty cycle), we discard it.

2. Protect against capacitive coupling
While preventing capacitive coupling mostly depends on intraoperative safety precautions, here are a few pre-emptive steps to reduce the danger:

• Educate staff and surgeons. As uncommon as it is dangerous, capacitive coupling is the least-understood electrosurgery risk. You'll likely have to explain how and why capacitive coupling accidents occur. The phenomenon has nothing to do with the insulation of the instrument, nor is it a result of surgeon error. Rather, capacitive couple occurs when you have a layer of intact isolation between two conductors. The combination creates a capacitor.

For example, you may create a capacitor when you insert the well-insulated active electrode down a metal cannula. The electrode tip is one conductor. The cannula is the other. During the case, current may pass from the electrode, through the insulation, to the cannula. If this happens and if the cannula touches body structures, it can discharge the energy to the patient.

Capacitive coupling can also happen with an all-plastic system. Some facility managers mistakenly believe that they'll eliminate the risk by switching to plastic trocars. It isn't that simple. The patient's own body can be a conductor because it contains conductive tissue. For instance, the active electrode can pass current through the insulation and a plastic trocar in contact with a bowel, forming a capacitor. The patient's contacted tissue can then discharge stored energy to adjacent tissue.

• Don't mix and match reusables and disposables. Many facilities do this as a cost-saving measure, but mixing reusables and disposables brings conductive and non-conductive components in close proximity, which can facilitate capacitive coupling. Stick with one or the other.
• Avoid hybrid metal/plastic cannulas. Some facilities use plastic anchors to secure metal cannulas. The problem is that the mixture of metal and plastic isolates current. This is dangerous for the same reason that a small insulation defect is worse than a big one. If capacitive coupling occurs, the concentrated current will produce a much more severe burn than if the current is dispersed over a larger contact area.

3. Test the insulation pre-operatively
Even the most vigilant visual inspection will not catch miniscule insulation breaks. Consider investing in an insulation-testing device. We've had good results with the easy-to-use InsulScan, which costs about $2,000. The user moves a probe over the instrument. The probe interfaces with a hardware device, which informs the user whether the insulation is fully intact.

At my facility, we compared visual inspection to the insulation testing devices. The verdict: technology works much better than the human eye. We carefully inspected a batch of electrosurgery instruments and then ran them through the scanner. Of nine instruments that passed visual inspection, the scanner alerted us to insulation problems with three. We also saved time by switching to a scanning device. A tray of 10 instruments takes about two minutes to scan. It takes considerably longer to visually inspect.

4. Upgrade your electrosurgery unit to AEM
Today, all of our facilities' electrosurgery units have active electrode monitoring (AEM), which is the single-most effective preflighting step we've taken. To upgrade (budget $2,500 to $5,000), you must purchase a generator that uses AEM technology, and must use active electrodes (available in both reusable and disposable varieties) that interface with the AEM. Systems with AEM analyze the electrical circuit and conduct stray current away from patient tissue back to the generator. If a dangerous level of leakage occurs, the AEM mechanism automatically sounds an alarm and shuts down the generator before current can pass through damaged insulation or be transferred to the patient by the capacitor.

Ms. Dennis ([email protected]) is the laser-endoscopic coordinator for Promina Gwinnett Health Systems in Lawrenceville, Ga., overseeing services for four facilities. She is also a member of AORN's Advanced Technology Task Force.

8 Tips for Safer Laparoscopy

Dianne Taylor
Contributing Editor

It can be easy to assume that your outpatient laparoscopic procedures will go smoothly. They are less invasive than open surgeries, and outpatient laparoscopic procedures are often brief. The reality is, however, that laparoscopy is challenging no matter how simple the particular procedure may seem. The surgeon must perform some steps blind with sharp instruments. In addition, complications can arise from insufflation and the CO2 itself. Here are some things you can do to help reduce the risk of laparoscopy-related complications.

1. Ensure proper screening
Busy surgeons may overlook situations that can increase the potential for complications like body habitus, GI distention or prior surgeries like laparotomy, hernia repair or Caesarian section, warned Peter Maher, MD, at the 2001 International Society of Gynecological Endocrinology Congress (ISGEC). Bowel adhesions to the abdominal wall resulting from these prior surgeries increase the risk of bowel perforation. In addition, thin and obese patients pose a greater challenge than patients of average weight, said Dr. Maher. In thin patients, the risk of over-inserting the needle or trocar(s) and injuring the major vessels is higher. In obese patients, the risk of pre-peritoneal trocar placement is greater, and this can cause extensive subcutaneous emphysema, which pushes the peritoneum away from the skin and makes it harder to proceed with surgery. In one recent evaluation of 26 trocar complications in laparoscopy patients (vascular injuries, bowel injuries, bladder perforations and incisional hernias), 70 percent of patients had prior surgery and 50 percent were overweight. "To be sure you are prepared," advises Marlene Brunswick, RN, director of nursing with the Findlay Surgery Center in Findlay, Ohio, "have short, medium and long instruments at the ready."

2. Keep equipment stationary
The complex nature of laparoscopic equipment means that malfunctions are possible. To minimize the risk of equipment breakdown during surgery, Ms. Brunswick advises taking several measures. First, she says, invest in equipment that remains in the same OR. "Frequent movement, assembly and disassembly of equipment greatly increase the rate of equipment malfunction," she says. Second, never forego your regular preventive maintenance inspection, even if all systems appear to operating smoothly. Finally, Ms. Brunswick advises changing both film and paper simultaneously whenever either one needs to be replaced, even if one is not empty.

3. Position the patient carefully
The Trendelenburg position can create pressure points at the ulnar nerve spaces, popliteal space, hip and lower back. Nerve injury is possible, and compression of the leg veins may also predispose patients to venous thrombosis. The brachial plexus may also be injured if the patient's arms are abducted. Position patients carefully and re-check them regularly throughout the procedure. "For gynecological procedures, we typically put the patient in stirrups, then drape her and only then do we tilt the bed," says Ms. Brunswick. "Shifting can occur, so you need to re-evaluate the patient to minimize pressure points." Appoint the circulating nurse as patient liaison, and educate the surgeon and anesthesia provider on proper positioning, adds Ms. Brunswick. "Throughout the whole procedure, we want them to think about the patient as if she is awake, because the patient who is asleep doesn't know she is hurting," says Ms. Brunswick.

4. Consider disposable Veress needles and trocars
Many consider disposable needles and trocars important, as sharp instruments require less force to insert and thereby decrease the risk of puncturing the bowel or blood vessels. Most intraoperative complications result from trocar and needle injuries and include extra-peritoneal insufflation and resultant emphysema, penetration of the omentum, GI tract injury, puncture of the liver or spleen, and intravascular gas insufflation, which can lead to gas embolism if insufflation proceeds unchecked. While there's been a decrease in the use of disposable instruments, Dr. Maher says the one instrument that should remain disposable is the Veress needle because "of its sharpness and because insertion is totally dependent on feel." Some users also say that the spring-loaded safety mechanisms in disposable trocars are less prone to wear and tear, an ultimate cause of malfunction. Depending on trocar design, a safety shield either deploys or the blade tip retracts automatically when the trocar penetrates the abdominal wall. This helps protect the bowel and vessels from blade injury, although the safety mechanisms are not fail-proof because they may not activate when bowel adhesions are present.

5. Flush the system first
Recent reports in the literature implicate room air as the cause of gas embolism during two laparoscopy cases. As a result, researchers and users alike recommend purging the whole system before CO2 insufflation. "If this step is neglected," reported one researcher, "up to 40 cm3 of room air may be insufflated into the patient, considering a connective tubing of 200 cm length and 0.5 cm lumen."

6. Keep pressure alarms on
Modern laparoscopic equipment comes equipped with many safety features, one of which is an insufflation-pressure alarm that will sound if the pressure is too high or too low, which typically results from occlusion or needle/trocar malpositioning. Turning off the alarm, whether inadvertent or purposeful, can prevent early detection of the problem. Ensure that all safety alarms are activated and audible. In general, insufflation should be initiated at a low flow (8 mmHg intra-abdominal pressure maximum), with subsequent operating pressures ideally between 10 to 15 mmHg. Pressures greater than 20 mmHg are potentially dangerous due to the risk of hemodynamic and pulmonary compromise as well as long-term effects on the intra-abdominal wall musculature.

7. Keep the patient warm
Since CO2 can be very cold, it's important to keep the patient warm. "Although laps usually do not take a long time," says Ms. Brunswick, "these patients are often exposed because their legs are in stirrups and they are not tucked into blankets." Keep the room temperature reasonable, consider patient warming units and monitor the patient's temperature throughout the procedure, she advises.

8. Keep the CO2 warm
Warming and humidifying the carbon dioxide used to insufflate the abdominal cavity may decrease the risk of hypothermia, says Duncan Turner, MD, of Santa Barbara, Calif. The patient's abdomen is 98 degrees but the carbon dioxide surgeons use is 70 degrees. What's more, dry carbon dioxide can damage the peritoneum. The dryness can cause dessication of tissue, increasing post-op pain and contributing to potential risks, such as adhesion formation. Also, warm, wet gas does not fog the telescope's lens nearly as much as cold, dry gas. This lets the surgeon perform the procedure more efficiently. Although carbon-dioxide warming devices cost about $2,000, Dr. Turner says that you recoup the costs in safer, more efficient procedures, and less time in the recovery room.

Contact Ms. Taylor at [email protected].