SWEET SPOT Finding the right blend of current flow and voltage is one key to electrosurgical safety.

Electrosurgery is one of the most complicated disciplines that surgeons perform. There's a steep learning curve and there are numerous variables. Though one of its primary functions is to cut tissue, it's not, as many seem to think, "just like using a scalpel." The other primary function is controlling bleeding, which involves adjusting the flow of current so that it's intermittent, while simultaneously increasing voltage. The goal is to be able to create the perfect waveform. That continuum, the range of possibilities between "cut" and "coag," is one of the areas that manufacturers are targeting in an attempt to give surgeons more options and to improve patient safety.

Manufacturers are now equipping monopolar devices with a "blend" option that's neither pure cut, nor pure coag. That's both a convenience and a safety factor, since traditionally, the coag mode has created a greater potential for unrecognized thermal spread and burn injuries, compared with the cut mode, which delivers current continuously, but at a lower voltage. Where typically we've had 2 buttons on the handpiece — a yellow one for "cut" and a blue one for "coag" — what they're doing now is providing a 3rd button that automatically finds the optimal blend of current, whether it's 80% cut with a 20% coag rate, or 60/40, or a different ratio. They're providing a button you can push for that middle of the road without really having to think about it. That's a smart feature and one that holds promise in terms of minimizing thermal damage.

Some of the other promising developments in electrosurgery involve approaches that aren't technically electrosurgery, but that use the same concept. One, for example, uses small, parallel ceramic plates and a closed feedback loop between the energy source and the handpiece. The heat generated by the plates is applied to tissue, and by changing the heat parameters it's able to seal and cut with no blade. Since the energy is contained in the system, there's no possibility of traditional electrosurgical risks like capacitive coupling (inadvertently generating a current via another conductor) or direct coupling (which happens when an activated electrode touches another metal instrument). The idea is to improve safety by completely bypassing the risks of electrosurgery, and it's definitely a promising approach.

Other manufacturers using similar technology are actually kind of throwbacks to the days when argon was regularly used in electrosurgery. Their devices work by energizing argon as it passes through a low direct-current voltage, creating plasma in the process. The plasma's effect on tissue depends on a series of variables, including how close the ionized gas is to the tissue, and which handpiece is used. My experience has been that the devices work well. Of course, the key with any device is to become familiar with all the different nuances and variables. It's challenging to master one, let alone more than one, which is why most skillful surgeons end up settling on one type of technology.

GET SMART
Education May Be the Best Investment

IN THE KNOW Dr. Advincula believes better education of surgeons would go a long way toward improving electrosurgery safety.

When it comes to the future of electrosurgery, I believe the biggest improvements we can make have less to do with improving devices and more to do with education. In fact, studies have shown that the knowledge level of practitioners — including those trying to teach others — is actually pretty poor.

There's often a dangerous assumption that surgeons can just pick up an electrosurgical device and immediately know how to use it. But when you query surgeons and look at operative notes in cases where injuries have occurred, generally it's not the result of a bad instrument or a mechanical failure. Rather, it's a failure to appreciate some of the risks.

These revelations have helped lead to the creation of one of the best available sources for education for practitioners, the FUSE (Fundamental Use of Surgical Energy) program (fuseprogram.org). In addition to providing educational resources, the website can be used to assess the understanding and application of basic principles associated with electrosurgery. For those who'd like to test their knowledge, the site includes a test during which participants have 90 minutes to answer 80 multiple-choice questions.

We're also working to improve understanding of the fundamentals of energy by developing modules through AAGL (the American Association of Gynecologic Laparoscopists).

Complications in electrosurgery are never going to go away entirely. You can't engineer them out entirely, because at the end of the day the person wielding the instrument is responsible. But I think if companies made additional efforts to invest in the education of physicians, they'd be able to worry less about complications. Education is even a factor where surgical smoke is concerned, because the amount of smoke generated is partially a byproduct of how, and how well, you use the instrument. A less than optimal instrument configuration can end up generating much more smoke.

— Arnold Advincula, MD, FACOG, FACS

SMOKE SCREEN As practitioners become increasingly concerned about the hazards of surgical smoke, manufacturers are creating evacuation devices that feel comfortable in the hands of surgeons.

Monitoring monopolar
One of the most significant advancements in safety is neither terribly new, nor as widely adopted as you might expect, probably, at least in part, because to use it, you also have to use the company's proprietary instrumentation. So while intellectually it makes a lot of sense, it may represent a significant expenditure.

It's called active electrode monitoring (AEM) and it's designed to detect in any reusable instrument any type of leak or stray charge. That's primarily a concern with monopolar devices, since risks like direct coupling, capacitive coupling, open-air activation and insulation failures are predominantly monopolar pitfalls. Ongoing improvements in conventional laparoscopic surgery have been moving the needle more toward bipolar devices, but the advent of robotic surgery has brought monopolar energy back to the forefront, because it's a mainstay of the robotics platform. Surgeons who were previously using ultrasonic devices or advanced bipolar devices are having to go back and learn how to use monopolar.

Monopolar energy has to make a complete circuit from the radiofrequency generator, to the instrument, through the patient, to the grounding pad, and then ultimately back to the generator. AEM works by constantly monitoring the circuit for fluctuations or changes. If there's an issue, such as insulation failure or capacitive coupling, the device is immediately shut down. One study (osmag.net/2PzGuX) found that AEM totally eliminated stray currents caused by insulation failure and capacitive coupling.

No smoking
Where there's electrosurgery, there's smoke. That's unavoidable. But as surgical staff become increasingly aware of the hazards related to smoke, one challenge is to create smoke-evacuation tools that surgeons feel comfortable using. That's led one company to offer a pencil that provides a variety of ways to position tubing — the goal being to accommodate as many surgeons as possible by enabling the 3 most common grips. An alternative, and my preference, is a unique type of insufflation system now on the market that automatically evacuates smoke while it insufflates the abdominal cavity. It works so well that it can obviate the need for any additional smoke evacuation devices.