From collateral tissue damage and insulation failure to grounding burns and OR fires, a lot can go wrong with electrosurgery. And here’s the thing. Your surgeons might not even be aware of the dangers of using high-frequency electrical current to cut and coagulate tissue, let alone the principles of safe electrosurgery. A good place to start? Put these 10 tips into practice today.

1 Always use the lowest power setting possible to get the effect you want. This is something that many surgeons have never learned. To get the desired tissue effect, they almost reflexively choose the “coag” setting and turn it all the way up. Sure, it works, at least usually. The vessel stops bleeding.

But it’s actually the least safe way to operate. If you’re trying to achieve a nice homogeneous seal with coaptive coagulation, the “cut” setting actually does a better job.

Plus, all the things you might be inclined to worry about with electrosurgery are less worrisome with lower settings. For example, lower settings decrease the release of stray energy. And if you happen to have an unrecognized insulation problem, it’s going to be less of a danger at a lower setting.

2 Understand the true functions of cut and coag. The first time most surgeons use an electrosurgical pencil, they’re taught on the fly in the OR, either as a medical student or as a junior resident. The senior surgeon reduces electrosurgery to an either-or proposition: If you want to cut something, use the yellow (cut) button. If you want to have hemostasis and coagulate, use the blue (coag) button.

Unfortunately, not only is it not that simple, that’s not even totally correct. Maybe they should have different names, because cut and coag don’t always have a lot to do with the distinction between cutting and coagulation. What they really represent are different waveforms of energy. The cut setting delivers a continuous waveform, the coag an interrupted waveform set at a certain duty cycle, based on how frequently per minute the energy fires.

So, there’s much more to it than just choosing one or the other. Many modern instruments have a blend option — either on the handle or on the foot pedal — that lets you alter how frequently per minute the energy fires. That lets you fire more rapidly without resorting to the continuous waveform of the cut setting. Properly regulating the waveform lets you use the lowest power setting possible, which, again, should be the goal.

3 Understand that technique is as important as choosing the right settings. You get one type of tissue effect when you actually touch the tissue; you get another if you merely hover near the tissue. For example, if you’re trying to make a skin incision, you should use the cut button, but you shouldn’t touch the tissue. Touching the tissue heats it up too fast and also results in some coagulation. Ultimately, you want the tissue to stay healthy and be able to heal, so you don’t want it to be fried. Keeping the temperature a little lower makes a nice vapor pocket and provides a clean cut.

Another example that almost all general surgeons have to deal with is removing an inflamed gallbladder from the liver bed at the end of a laparoscopic cholecystectomy. You want that superficial very hot temperature to seal off the liver bed, but if you have too much tissue contact, you can actually pull off the clot.

The best bet is to maintain a little distance from the tissue and use an arcing effect. It’s about knowing how the energy is working, and about using the right technique. Instead, the tendency I’ve seen is for people to simply turn the power way up. You might want to turn it up a little, because we want the temperature of the tissue to be hotter, but you don’t need to turn it up much if you’re using the right technique. You can learn technique partly by practicing, but also by learning to understand the mechanisms behind tissue effect. Unfortunately, that’s something that’s really been missing from the surgical curriculum.

4 Understand proper placement for dispersive electrodes. Better education is needed here, too. Location is particularly important, especially if patients have any metal in their bodies. You also want to make sure there’s good contact — that electrodes aren’t on a part of the body that has hair, or on any bony prominences. The best bet is to choose a relatively flat muscular area that’s fairly close to the surgical site and that won’t bear the patient’s weight during surgery. It’s also important to place electrodes in a location that’s not likely to come into contact with any fluids.

5 Choose the right instrument for the case. There are a few big differences between monopolar and bipolar instruments, and surgeons should think about the potential risks and benefits of each in relation to each case.

For example, if I have a patient who has hardware, say a metal hip, that’s not that far from my operative field, I’d be concerned that the metal is potentially in the path between my target tissue and the dispersive electrode path. In a case like that, I might use a bipolar instrument and eliminate that risk. You can’t get a dispersive electrode burn if you don’t have electrodes.

I also opt for bipolar in pregnant women, and in people with pacemakers, so I don’t have to worry about electromagnetic interference. Monopolar energy tends to be a little more precise and a little less expensive, but also a little more dangerous.

6 Beware of insulation failures. One of the challenging realities about insulation failures is that the smaller the defect, the worse the result is likely to be. If all stray energy goes to a very small area, the more severely the tissue in that spot will be affected.

You should always inspect instruments with your eyes before using them, but there are also specific tools with sensors that detect insulation defects. All hospitals and surgery centers should be using them when they reprocess instruments.

Modern-day electrosurgical units monitor the energy flowing through the system and shut down if energy is leaking out. That’s reassuring. But there’s still the potential for injury to occur right as the machine is detecting the problem. In other words, there’s an added level of protection, but the same level of vigilance is always still required.

7 Beware that injuries can happen outside the field of vision. Injuries outside the field of vision are rare but they may also be the most concerning. If you detect a burn while surgery is happening, you can repair it. But if you don’t see, for example, a bowel perforation, you can end up with a life-threatening injury. Patients have actually died from such occurrences.

It’s critical to keep all active parts of the instrument in the view of the camera at all times. If you zoom in too close, you can miss something. Keep this concern in mind post-operatively, too. Patients are bound to have some abdominal distention or pain after gallbladder surgery, but if they’re having pain, you need to get a sense of how serious it is. The possibility of an undetected bowel injury should always be on your radar.

8 Make sure everyone knows where the foot pedal is. It can happen. You’re using an instrument with a foot pedal, and someone inadvertently steps on it before the cord is connected to an instrument, or while the instrument is still in the trocar on its way to the target tissue. That’s obviously concerning. Where is that energy going to go? Make sure everyone knows where the pedal is and that all instruments are holstered properly when they’re not in use.

9 Take smoke evacuation seriously. We’ve only recently come to understand how dangerous surgical smoke is. Thankfully, we can attach filters that trap harmful chemicals in line with the tubing. That’s a big improvement over the long-standing practice of opening a knob on a cannula or trocar to release dangerous smoke out of the field and into the room. I suspect and hope that AORN’s Go Clear curriculum (aorn.org/goclear), which has been very well received, will eventually achieve 100% compliance.

10 Understand the fire triangle. Whenever you have an ignition source, combustible materials and oxygen, you have the potential for an OR fire. And the higher the oxygen level, the greater the risk. Be aware also of potential pools of alcohol combined with electrosurgery in an oxygen-rich environment. OR fires are rare, but they can be devastating.

Safety precautions for all

For the last several years, the SAGES FUSE (Fundamentals for the Use of Safe Energy) program has helped to improve surgeons’ understanding and knowledge of electrosurgery. We’re also now developing a compliance module for everyone else in the OR. Anesthesia providers, nurses, and surgical techs don’t necessarily need to have the same depth of understanding that surgeons can profit from, but everyone in the OR should know enough to follow these 10 basic principles. OSM