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Electrosurgery

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 Welcome to

Electrosurgery
(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONS

This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning
needs and objectives. At the end of the activity, you will be assessed on the
attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that
reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to re-
read the question and answer choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits

and provide verification, if necessary, for 7 years. Requests for certificates must be
submitted in writing by the learner.
If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

2016
All rights reserved
Pfiedler Enterprises, 2170 South Parker Road, Suite 125, Denver, CO 80231
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
Overview
Electrosurgery may be hazardous. It is important that clinicians understand how electricity
behaves and relates to electrosurgical function and applications can contribute to its safe
use. Knowledge of the intraoperative, intraoperative and postoperative medical and nursing
considerations and interventions can impact positive patient outcomes.

Objectives
After completing this continuing education activity, the participant should be able to:
1. Relate the properties of electricity to the clinical applications of electrosurgery.
2. Discuss four variables the surgeon controls that impact surgical effect.
3. Identify potential patient injuries related to electrosurgery and the technological
advances designed to eliminate these problems.
4. Discuss the tissue effect of tissue fusion technology.
5. Describe best practices to achieve favorable patient outcomes related to
electrosurgery.

Intended Audience
This continuing education activity is intended for perioperative registered nurses and other
health care team members who provide patient care during surgery or other invasive
procedures.

CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hour(s).
Obtaining full credit for this offering depends upon completion, regardless of circumstances,
from beginning to end. Licensees must provide their license numbers for record keeping
purposes.
The certificate of course completion issued at the conclusion of this course must be
retained in the participants records for at least four (4) years as proof of attendance.

RELEASE AND EXPIRATION DATE

This continuing education activity was planned and provided in accordance with
accreditation criteria. This material was originally produced in August 2016 and can
no longer be used after August 2018 without being updated; therefore, this continuing
education activity expires August 2018.

DISCLAIMER
Pfiedler Enterprises does not endorse or promote any commercial product that may be
discussed in this activity.

3
SUPPORT
Funds for the development of this activity were provided by Medtronic.

AUTHORS/PLANNING COMMITTEE/REVIEWER
Julia A. Kneedler, RN, MS, EdD Denver, CO
Program Manager/Reviewer
Pfiedler Enterprises

Judith I. Pfister, RN, BSN, MBA Denver, CO

Program Manager/Planner
Pfiedler Enterprises

Donna S. Watson, MSN, RN, CNOR, FNP Boulder, CO

Director of Professional Societies & Patient Advocacy/Author
Medtronic

Melinda T. Whalen, BSN, RN, CEN Denver, CO

Program Manager/Reviewer
Pfiedler Enterprises

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THOSE IN A POSITION TO CONTROL CONTENT FOR THIS ACTIVITY
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individuals who control content for an educational activity. Information below is provided to
the learner, so that a determination can be made if identified external interests or influences
pose potential bias in content, recommendations or conclusions. The intent is full disclosure of
those in a position to control content, with a goal of objectivity, balance and scientific rigor in
the activity. For additional information regarding Pfiedler Enterprises disclosure process, visit
our website at: http://www. pfiedlerenterprises.com/disclosure
Disclosure includes relevant financial relationships with commercial interests related to
the subject matter that may be presented in this continuing education activity. Relevant
financial relationships are those in any amount, occurring within the past 12 months
that create a conflict of interest. A commercial interest is any entity producing, marketing,
reselling, or distributing health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Julia A. Kneedler, EdD, RN
No conflict of interest

Judith I. Pfister, MBA, RN

No conflict of interest

Donna S. Watson, MSN, RN, CNOR, FNP

Employee of grant provider

4
Melinda T. Whalen, BSN, RN, CEN
No conflict of interest

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5
INTRODUCTION
Modern surgery, as cited by Sullivan, is defined as a branch of medicine concerned with
treatment of injuries or disorders of the body by incision, manipulation or alteration of
organs, etc., with the hands or with instruments.1 Throughout the history of surgery, the
use of instruments and tools to assist in the control of disease and minimize bleeding has
been developed and utilized as a therapeutic treatment. Innovations of the past proved
to provide practical solutions for maintaining and controlling hemostasis to facilitate a
successful surgical outcome. It is this ongoing innovation that has spurred the evolution
of the advanced innovative instruments of todays surgery.

HISTORICAL DEVELOPMENT OF AN ESSENTIAL TOOL

Dr. Morstede in 1446, as cited in Kirkup p. xi, stated that Instruments of iron; some are
used to cut as scissors, scalpels.some are used to burn with as cautery. Some are
used to determine the depth of sores, and some are used to sew as needles and pipes.2
The Egyptians are considered to be among the first to use cautery to treat patient
conditions. Cautery is mentioned as a treatment to control hemorrhage in the Ebers
Papyrus, believed to be written around 1500 BC.3 Continued use and application of
cautery by ancient Egyptian physicians around 1700 BC is described in the Edwin Smith
Papyrus, considered to be the oldest medical text discovered (see Figure 1). The Edwin
Smith Papyrus was written by one of the earliest practicing physicians, Imhotep, and
describes the examination, diagnosis, prognosis and treatment of 48 neurosurgical-type
cases.4 The Papyrus provides a view of the challenges of the time, detailing anatomical
correlations with clinical symptoms, the use of hemostasis with cautery, tape, sutures
and the use of copper salts for antisepsis.5 The Papyrus discusses the use of a fire drill,
considered to be a form of the cautery used.
Figure 1. Edwin Smith Papyrus. Courtesy of the New York Academy of Medicine
Library

Hippocrates (460-377 B.C.) considered the Father of Medicine, described the

application of red-hot iron instruments to cauterize and suppress hemorrhoids.6 Thales,
the Father of Science, described the attraction of certain material to amber when
rubbed. Elecktron, the Greek word for amber, is considered the root of electricity.7

6
The use of cautery during the 16th century declined due to another preferred modality
utilized to control bleeding. Ambroise Par (1510-1590), a French surgeon, used ligature
to control bleeding instead of hot irons for battlefield amputations. Par observed
improved wound healing and less pain with the use of ligature and used this methodology
exclusively. It was presumed that the use of suture required a higher skill level than the
application of cautery, resulting in improved patient outcomes with less tissue damage.8
William Gilbert (1540-1603), provided early contributions to the foundation of the
modern day electrosurgery generators. Gilbert, a practicing court physician to Queen
Elizabeth, was interested in magnetism. He was the first to use the term, electricity.9
De Magnete a book written by Gilbert (1600) details his research with electricity that
included ambers frictional properties. Through this work, he is recognized as the Father
of Electrotherapy.7
Throughout the 17th Century, interest continued to build around electricity and
electrotherapy research. Each discovery and advance contributed to the building of
knowledge in the natural sciences. The progression in the field of electrotherapeutics
occurred during three distinct eras.10, 11 The first era occurred prior to 1786 with the focus
on static electricity; the second era between 1786-1831 with galvanization and muscle
spasm; and the third era began in 1831 and continues through the present.
The first era began with the search for an explanation on the phenomenon of static
electricity. Static electricity starts as a charge accumulation on an object. The charge
does not allow for current to flow; however, the charge can jump from one object to
another. Many researchers of the time started to experiment with static electricity. The
most famous researcher to study static electricity was Benjamin Franklin (1706-1790).
Franklin studied the similarities of static electric sparks and lightning. It was these
similarities that evolved to his renowned kite experiment. He was able to induce lightning
to flow from a kite and collect into a Leyden jar, proving that static electricity and lightning
have similar properties. Later, the work of Franklin resulted in the design of the lightning
rod for building structures, to receive the charge from lightning to serve as a conduit to
the ground in order to minimize structural damage and fires.12
The second era began with muscle spasm and galvanization research by Luigi Galvani
(1737-1798). Galvani was able to reproduce muscle spasms with the direct application
of an electrical charge to a frog leg. Continued work in this area resulted in the study
of electrophysiology.13 The work of Alessandro Volta (1745-1827) contributed to the
development of the first battery. The battery was composed of two types of different
metals, cardboard, and an acidic solution. The result was a battery that could transmit an
electrical current. Current wet cell batteries are designed to apply the same principles.
Volt, the measurement of electrical energy, was named after Volta.14
In 1831, the third era for electrotherapeutics began with electromagnetism research
led by Joseph Henry and Michael Faraday. Both discovered that an electrical current
could be induced by moving a magnet. The discovery resulted in the ability to induce an
electrical current through a wire with a range of applications (eg, electromedical devices,
telegraph, telephone).10

7
In the late 1800s, significant research began related to the therapeutic application of
electricity. In 1881, William J. Morton discovered that the application of around 100 kHz
of high frequency did not result in the pain or shock that was associated with current
in the lower frequency range. In 1891, Jacques-Arsne dArsonval conducted similar
research and made the significant discovery that alternating current greater than 100 kHz
did not result in neuromuscular stimulation.15
Researchers in the 1900s discovered that variations of high frequency current could
result in different waveforms, resulting in different tissue effects. The labels which
indicate a specific tissue effect remain in use today. In 1907, Walter deKeating-Hart
and Simon Pozze used the term fulguration. This is from the Latin word, fulgur which
means lightning. Fulguration is used to describe the tissue effect of superficial tissue
carbonization. In 1909, Doyen described the use of coagulation. Coagulation is from
the Latin phrase indicating to curdle. Additionally, Doyen was the first to experiment
with bipolar coagulation, using a second electrode. This innovation was referred to as
an indifferent electrode and later became used as a patient return electrode.16 The term
desiccate was introduced in 1914 by William Clark. Clark described tissue desiccation as
the application of heat that resulted in tissue effect with ranges between hyperemia and
carbonization, the end result of tissue destruction.17
One of the first clinical applications of electrosurgery is credited to the French surgeon,
Joseph A. Rivire.9 He successfully treated hand ulcers of a musician with repeated
applications of electrical sparks. The results of the new treatment were presented at the
First International Congress of Medical Electrology and Radiology in 1900.9
In 1910, Dr. Edwin Beer published his treatment of bladder tumors with the application of
high frequency current in the Journal of the American Medical Association. He outlined
the treatment methods, equipment, tissue effect and clinical outcomes of the new high
frequency treatment therapy.18 After reading Beers success, A. Raymond Stevens,
M.D. reported two cases in 1913 involving the application of high frequent current for
prostatic obstruction, stating the ease of use and efficiency as a contributing factor to his
successful outcomes.19 In 1917, Dr. Bugbee published his results of treating urological
obstructions in the Urological and Cutaneous Review.20
Early reports of the successful use of high frequency electrical current illustrate that
technology has evolved over time because of the efforts of many scientists and clinicians.
Likewise, during this period, many electrosurgery devices were developed. Lee DeForest
filed the first patent for an electrosurgery generator on February 10, 1907. He described
it as being specifically designed for use on patients during surgery.21
The historical development of electrosurgery tells us that many men have contributed
to its advancement over a long period of time. Despite the efforts of so many, the
technology is most closely associated with William T. Bovie and Harvey Cushing. The
individual genius of each and the collective genius of the partnership greatly contributed
to their success at promoting and facilitating the use of electrosurgery worldwide.

8
William T. Bovie was born in Augusta, Michigan on September 11, 1882. He studied
botany, and then went to Harvard to study for a doctorate in plant physiology. He stayed
on to work at the Harvard Cancer Commission.22 It was there that he became interested
in electrosurgery. His work included treating cancer patients with radium. He came to
believe that the cautery effect achieved from radium emanation could also be achieved
using high frequency current. It was for this use that his generators were first developed.
His work with Harvey Cushing, however, resulted in a generator that was better suited
for the operating room than some that preceded it. Bovie and Cushing also worked with
Liebel-Flarsheim to manufacture a commercial unit. Sales of the electrosugery units
were not profitable for many years because of low demand and constantly changing
improvements. Whenever Bovie or Cushing developed improvements in the technology,
the previous machines were reported scrapped. The Bovie originally sold for $2,000,
but by 1932 the price had dropped to $1,250. Bovie never benefited financially from his
invention. He sold his patent to Liebel-Flarsheim for $1.10.
Harvey Williams Cushing was born in Cleveland, Ohio on April 8, 1869. He entered Yale
College in 1887, Harvard Medical School in 1891. In 1896 he began his residency with
William Halsted at Johns Hopkins in Baltimore. He completed his residency there in
1900. He returned to Boston in 1901 to Peter Bent Brigham Hospital. It was in Boston
that Cushings collaboration began with William T. Bovie.23
Blood control during surgery had always been a concern for Cushing. In a 1911 paper,
The Control of Bleeding in Operations for Brain Tumor, Cushing gives an account
of the methods he used to achieve hemostasis including wax, pledgets and silver
clips.24 Despite the variety of methods to achieve hemostasis, there were still patients
considered to be inoperable because of the fear of bleeding.
It is reported that Cushing first contemplated the use of electrosurgery during a medical
conference in 1925. Two of Cushings residents were watching an electrosurgery
demonstration when Cushing walked up to them. One suggested that Cushing use the
machine on the brain. Cushing paused and looked thoughtfully at the demonstration in
progress.25 He later visited Bovie at Harvard. Their collaboration began with Cushing
making arrangements with Bovie to use his device in the operating room. The two men
worked together over the next two years using the machine on patients, and making
changes and refinements to the machine and its accessories. A 1928 paper reported on
their success, which has stood the test of time.26

BIOPHYSICS OF ELECTROSURGERY
ALTERNATING CURRENT
Electrosurgery is the application of high-frequency alternating electrical current (AC)
delivered into biological tissue, resulting in a desired clinical tissue effect.27-29 High-
frequency electrosurgery devices operate in the range of 200 kilohertz (kHz) to 3.3
megahertz (MHz) to minimize faradic effect or electrocution. The tissue effect is
dependent upon the concentration of the energy, amount of time applied, and electrical
properties of the tissue. When applied correctly, the clinical endpoint of desired tissue
effect will result in controlled cutting, dissection or coagulation.

9
DIRECT CURRENT
Although used interchangeably, electrosurgery is not electrocautery. An electrocautery
device delivers direct current (DC) through a heating element such as a probe or wire
intended to cauterize tissue. The patients body is not part of the circuit. Electrocautery
has a limited application and does not allow for cutting, dissection or the coagulation
of large vessels. Unlike electrocautery, electrosurgery utilizes electromagnetic
energy through tissue to produce heat resulting in the desired tissue effect.30 During
electrosurgery, the patients body becomes part of the electrosurgical circuit.

FUNDAMENTALS OF ELECTRICITY

ELECTRICITY
Understanding the fundamentals of the physics of electrosurgery is important for the
end user. This knowledge increases awareness of the proper application techniques for
electrosurgery. Implementation of appropriate electrosurgery techniques influence and
promote positive patient outcomes.
Electricity is a phenomenon of nature that results from movement of electrons from
one atom to another. Atoms are composed of negatively charged electrons, positively
charged protons, and neutrally charged neutrons. Atoms containing an equal number
of electrons and protons are considered charge neutral. When a force is introduced,
here is a change to the charge due to movement of electrons from one atom base to
another. The net charge results in some atoms becoming positively charged and others
negatively charged, based on the number of electrons and protons present. Movement of
electrons is predictable, unlike charges attract and like charges repel. It is the movement
of electrons that is electricity.

BASIC PRINCIPLES OF ELECTROSURGERY

Basic principles of electricity that impact patient care and outcomes of electrosurgery
include:31, 32
Electricity follows the path of least resistance,
Electricity will always seek to return back to an electron reservoir (eg,
electrosurgery unit or earth ground), and
A closed circuit must be established in order for electricity to flow.

10
Electrosurgery and Radio Frequency Current
Why electrosurgerygenerators do not
Electricity willshock
alwayspatients
seek istoareturn
common question.
back The
to an electron reservoir (e.g
answer is because of theandhigher frequencies at which electrosurgery generators operate.
Electrosurgery generators take 60 Hz current and ramp it up to the radiofrequency range.
A closed circuit must be established in order for electricity to flow.
Radiofrequency current alternates so rapidly between the positive and negative poles
that cells do not depolarize, or react to the current. Neuromuscular stimulation ceases at
about 100,000 Hz. AM radio stations operate in the 550 to 1500 kilohertz (kHz) range.
ElectrosurgeryElectrosurgery andoperate
generators typically RadioinFrequency
the 200 kHz Current
to 3.3 megahertz (MHz)
range (see Figure 2). That is well above the range where neuromuscular
Why do electrosurgery generators not shock patients is stimulation
a common or question. T
electrocution could occur.33
frequencies at which electrosurgery generators operate. Electrosurgery gener
Figure 2. Frequency Spectrum
ramp it up to the radiofrequency range. Radiofrequency current alternates so r
Electricity will always seek to return back to an electron reservoir
negative(e.g.,
pole
and to the curren
A closed circuit must be established in order for electricity to flow.
about 100,00
550 to 1500
Electrosurgery and Radio Frequency Current generators t
Why do electrosurgery generators not shock patients is a common question. The
megahertz (
frequencies at which electrosurgery
60Hz100kHz generators operate. Electrosurgery
5501550kHz54880MHz above the ra
generator
AMRadioTelevision
or electrocut
HouseholdMuscleand
Appliancesramp it up toELECTROSURGERY
nerve the radiofrequency range. Radiofrequency current alternates so rapid
stimulation
200kHz3.3MHz
ceases negative poles t
to the current. N
Bipolar Electrosurgery
Figure 2. Frequency Spectrum
about 100,000 H
Bipolar electrosurgery is the use of alternating electrical current in which the circuit is
550 to 1500 kilo
confined within an instrument using two adjacent poles one positive and one negative
Bipolar Electrosurgery generators typic
located in close proximity to one another. Current flow is restricted between the two
megahertz (MH
poles.27 A variety of bipolar instrument configurations are available including forceps,
Bipolar 60Hz100kHz
electrosurgery is the use of5501550kHz54880MHz alternating electrical current above in whichthe the
rangec
scissors or graspers. HouseholdMuscleand
using two adjacent poles
AMRadioTelevision
Appliances nerve ELECTROSURGERY
stimulation
or electrocution
200kHz3.3MHz
Because the positive and negative poles are so close, lower voltages are
ceases
used toinachieve
located close proximity
tissue effect. Most bipolar units
Figure 2. Frequency Spectrum use a low voltage waveform that achieves hemostasis
restricted between the two
without unnecessary charring. A patient return electrode is not needed when bipolar is
used because current flow is confined to the tissue between the poles of the instrument
configurations are availab
(see Figure 3). Bipolar Electrosurgery graspers.
Bipolar electrosurgery is the use of alternating electrical current in which the circu
Figure 3. Bipolar Circuit Because the positive and
using two adjacent poleson
voltages are used to achie
located in close proximity to o
a low voltage
restricted betweenwaveform
the two poth
unnecessaryare
configurations charring.
availableA inp
Figure 3. Bipolar Circuit when bipolar is used beca
graspers.
tissue between the poles o
Because the positive and neg
voltages are used to achieve
Bipolar is a very safe electrosurgery technology. There a loware newer
voltage bipolar that
waveform genea
bipolar cut mode that has higher voltage and is designed for use with newer
unnecessary charring. A patie
instruments.
Figure 3.Bipolar is widely used in neurosurgery and
Bipolar Circuit whengynecologic
bipolar is usedsurgery.
because
tissue between
question about the efficacy11of using more powerful monopolar the poles of th
electrosurgical
Bipolar is a very safe electrosurgery technology. There are newer bipolar generators
that incorporate a macro or bipolar cut mode that has higher voltage and is designed
for use with newer generations of bipolar cutting instruments. Bipolar is widely used in
neurosurgery and gynecologic surgery. It is also safer to use when there is a question
about the efficacy of using more powerful monopolar electrosurgical units (eg, with
pacemakers and implantable cardioverter/defibrillators).
Monopolar Electrosurgery
The most frequently used method of delivering electrosurgery is monopolar because
it has a greater range of tissue effects and it is more powerful. When using monopolar
electrosurgery the generator produces the current, which travels through an active
electrode into patient tissue. The current then passes through the patients body to
a patient return electrode that collects the current and carries it safely back to the
generator (see Figure 4) as the intended pathway for the electrical current flow. The type
of monopolar generator used, along with appropriate surgeon and perioperative nursing
interventions, can help ensure that this is the path the current takes.
Figure 4. Monopolar Circuit

Current Concentration/Density
The reason for using electrosurgery is to produce high-frequency electrical current that
will create the desired clinical effect.27 Heat is produced when high-frequency current is
concentrated. The amount of heat produced determines the extent of the tissue effect.
Current concentration or density depends on the size of the area through which the
current flows. A small area that concentrates the current produces more impedance/
resistance and will require more force to push the current through the limited space. The
combination of greater force through a smaller space produces more heat. A large area
that spreads out the current has less impedance/resistance to the flow of the current,
which reduces the amount of heat produced (see Figure 5).

12
Figure 5. Current Concentration/Density

VARIABLES OF RADIOFREQUENCY ELECTROSURGERY

An electrical circuit is created when there is a conductive pathway that allows the free
electrons to flow. An example of a closed or complete electrical circuit during surgery
include an electrical current flowing from the electrosurgical generator unit, active
electrode, patient tissue, and returned through a dispersive patient electrode back to the
generator (see Figure 6).
Figure 6. Electrical Circuit

Current (I)
An electrical current (I) is produced when continuous movement of free electrons occurs
through a conductor within a circuit. During electrosurgery, a current is generated by the
electrosurgical unit and delivered through tissue via an instrument electrode tip.

Voltage (V)
The force responsible for moving the generated electrical current through the active
electrode is voltage (V). Voltage measured in amperes (A) or amps, is the electrical
potential to move free electrons from one point to another point within a circuit. Voltage
may range from 2,000 to 10,000 volts depending on the generator. During electrosurgery,
the amount of voltage generated is based on tissue resistance. The greater the tissue

13
 measured in amperes (A) or amps, is the electrical potential to move free el
within a circuit. Voltage may range from 2,000 to 10,000 volts depending on
amount of voltage generated is based on tissue resistance. The greater the
resistance, the higher the voltage
necessary necessary
to push to push
the current thepenetrate
and current andthepenetrate thethe
tissue for tissue
desired clinic
for the desired clinical effect.27
The higher the voltage, the greater the flow of electrons
greater the flow of electrons and potential for an untoward patient outcome.
and potential for an untoward patient outcome.
Impedance/resistance (R)
Impedance/resistance (R)
As free electronsAs freethrough
move electrons move
tissue withinthrough
a circuit,tissue
there within a circuit,
is a degree there is a degree of im
of impedance/
resistance that occurs. Although the terms are used interchangeably,
Although the terms are used interchangeably, impedance refers impedance refers to the oppo
to the opposition the
to the flow of alternating current; the term resistance refers to the
term resistance refers to the opposition to the flow of direct current. This
opposition to the flow of direct current. This results in friction due to the opposition of the
the flow of current, referred to as resistance. Resistance is measured in ohm
flow of current, referred to as resistance. Resistance is measured in ohms (). Different
may
sources of resistance may include, but but
include, areare
notnotlimited
limitedto:to:different
differenttissue types,distance
tissue types, distance between
between electrodes greater the resistance)
(the greater andthe
the distance, thegreater
distance between the
the resistance) andactive
the electrode and t
distance between the active electrode and the intended tissue.
Power (P)
Power (P)
Power is the heat energy that is produced by resistance during surgery. It is
Power is the heat energy that is produced by resistance during surgery. It is the heat
that is produced atsite
thethat results
surgery siteinthat
tissue effect.
results Theeffect.
in tissue desired
Thepower level
desired is expressed
power level as a n
displayed as watts on the light emitting diode (LED) screen
is expressed as a numerical setting selected by the surgeon, displayed as watts on the of an electrosur
coagulation
light emitting diode (LED) screenoutput
of anon a generator unit.
electrosurgical is 120 watts, and
Generally, 300 watts in cut output.
the maximum
coagulation output on a generator is 120 watts, and 300 watts in cut output.
Ohms Law
Ohms Law
Ohms
Ohms Law describes theLaw describes
relationship the relationship
of these variables of of these variables
electricity involving aof electricity involv
electrons. 27, 29, 34
complete circuit with flowing electrons. 27, 29, 34

Ohms Law

Voltage (V) = Current (I) x Resistance (R)

As the electrical current flows through patient tissue and back to the genera
As the electrical current flows through patient tissue and back to the generator, the
tissue different
current passes through types with various
tissue types levels of resistance.
with various It is the resistance
levels of resistance. It is that drives
greater the tissue resistance, the higher the output voltage
the resistance that drives voltage to push the flow of electrons. The greater the tissue or force needed
Applying
resistance, the higher Ohmsvoltage
the output Law, or
theforce
current is inversely
needed, proportional
if the current is to remainto the resistance/
constant. Applying Ohms Law, the current is inversely proportional to the resistance/
impedance: W = I2 x R and W = V2/R.34 CLINICAL APPLICATION
When current APPLICATION
CLINICAL is passed through adipose tissue which has a high r
output
When current is passed will beadipose
through highertissue
to achieve
which the
has desired tissue effect.
a high resistance, the 34
voltage output will be higher to achieve the desired tissue effect.34
Buildup of eschar (carbonized blood and tissue) at the end of an e
Buildup of eschar (carbonized blood and tissue) at the end of an electrode will
resistance.This
result in increased resistance. Thiswillwill require
require an an increased
increased voltage
voltage to deliver the cu
to deliver
the current and desired clinical tissue effect. 27

14
Current Output Waveforms
Electrosurgical generators allow for current output to be modulated, resulting in different
waveforms. Four different waveform options include cut, blend, coagulation, and
hemostasis with dissection. The resulting clinical effect on the tissue is determined by the
application of the specific waveform.
The cut output mode is a low voltage continuous, non-modulated, sinusoidal waveform
(see Figure 7). The current is delivered from the generator continuously. The lower
voltage allows for tissue vaporization to occur with minimal amount of coagulation tissue
effect. Current Output Waveforms
The non-touch technique is applied
Electrosurgical with the active
generators electrode
allow for currenttip, heldtoslightly
output away resulting in di
be modulated,
from the intended waveform
tissue. This technique creates a spark gap or a steam envelope. 32
options include cut, blend, coagulation, and hemostasis with dissection
The electrical sparks cause
tissue higher tissue
is determined by temperatures
the applicationthat mayspecific
of the quicklywaveform.
exceed 100C
resulting in vaporization of the intracellular fluids.27 This mode offers clean tissue division
with minimal thermal
Thespread. Themode
cut output cut mode mayvoltage
is a low also becontinuous,
used to cauterize bleeders by
non-modulated, sinusoidal wave
applying the active electrode directly to tissue.
delivered from the generator continuously. The lower voltage allows for tissue vap
amount of coagulation tissue effect.
Figure 7. Cut Waveform
The non-touch technique
electrode tip, held slightly
technique creates a spark
electrical sparks cause hig
quickly exceed 100C res
intracellular fluids.27 This m
with minimal thermal spre
to cauterize bleeders by a
to tissue.

Figure 7. Cut Waveform

CLINICAL APPLICATION
CUT MODE
CLINICALAPPLICATION
Apply the non-contact CUT technique by placing the active electrode above the
CUTMODE
tissue with continuous movement. This allows for the low voltage current to cut
ApplythenoncontactCUTtechniquebyplacingtheactiveelect
tissue with minimal hemostatic effect.
continuousmovement.Thisallowsforthelowvoltagecurrentt
Apply contact CUT technique directly to tissue for immediate hemostatic effect.
hemostaticeffect.
The contact technique
is referred to as desiccation.
ApplycontactCUTtechniquedirectlytotissueforimmediatehe
A blend mode modifies the cut
techniqueisreferredtoasdesiccation.
continuous waveform into an interrupted blend
waveform.35 The blend mode results in varying degrees of current delivery by modifying
A blend
the duty (on/off) cycle (seemode
Figuremodifies the cut continuous waveform into an interrupted blend wav
8 new).
in varying degrees of current delivery by modifying the duty (on/off) cycle (see Fig

The current is interru

dependent upon the
15
 techniqueisreferredtoasdesiccation.

A blend mode modifies the cut continuous waveform into an interrupted blend wav
Figure 8. Blended Waveforms
in varying degrees of current delivery by modifying the duty (on/off) cycle (see Fig

The current is interru

dependent upon the

The waveform is no
of cutting and hemos
blend waveform sele
Blend 2 (40% on/60%
off). The higher the b
The current is interrupted and the 8.
Figure voltage is increased
Blended Waveformsdependent upon the selected
hemostasis tissue ef
setting.
The waveform is no longer continuous. Varying degrees of cutting and hemostasis are
achieved by the type of blend waveform selected: Blend 1 (50% on/50% off); Blend
2 (40% on/60% off); and Blend 3 (25% on/75% off). The higher the blend setting, the
greater the hemostasis tissue effect.

CLINICAL APPLICATION
BLEND MODE
Select blend mode when hemostasis is desired with cutting.35
Blend mode can be utilized when low voltage coagulation (desiccation) is desired
such as during a laparoscopy.35
Blend mode is activated by using the cut side of the electrosurgery unit.

Cogulation mode delivers a higher voltage modulated waveform with an intermittent

duty cycle that is on about 6% of the time (see Figure 9). Because energy is delivered
only about 6% of the time, the tissue is heated with intermittent spikes of high voltage.
Depending upon the electrosurgical unit and the tissue, the voltage delivered may reach
up to 9,00010,000 volts. During the 94% rest phase of the duty cycle, the cells react by
cooling down and form a coagulum.
A use of the coagulation mode is with a non-contact technique referred to as fulguration
(ie, superficial coagulation or spray coagulation). The active electrode tip is held slightly
above the tissue, creating a spark gap that results in desired tissue effect.
The sparks occur in a random pattern. For superficial oozing vessels and capillaries the
spray coagulation mode may be selected.

16
 Coagulation mode delivers a higher voltage modulated waveform with an
of the timetime
of the (see(see
Figure 9). Because
Figure energy
9). Because is delivered
energy is deliveredonlyonly about 6%6%
about of the
of
intermittent spikes of high voltage. Depending upon the electrosurgical
intermittent spikes of high voltage. Depending upon the electrosurgical unitun a
reach up
reach to 9,00010,000 volts. During the 94% rest phase of
up to 9,00010,000 volts. During the 94% rest phase of the duty cythe duty cycle
Figure 9. Coagulation
formform Waveform 6% on 94% off
a coagulum.
a coagulum.
A use of the
A use coagulation
of the coagulation modemodeis w
as fulguration
as fulguration (i.e.,(i.e.,
superficial coag
superficial c
electrode tip istipheld
electrode is heldslightly above
slightly abo
results in desired
results in desired tissue effect.
tissue effect.
TheThe
sparks occur in a random
sparks occur in a random patt
capillaries the spray coagulation
capillaries the spray coagulatio m

Figure 9. Coagulation
Figure Waveform
9. Coagulation 6% on
Waveform 6%94% off off
on 94%

CLINICAL APPLICATION CLINICALAPPLICATION

CLINICALAPPLICATION
COAGULATIONCOAGULATIONMODE
MODE
COAGULATIONMODE
Apply the spray
coagulation mode for oozing tissue sites and on larger superficial
Applythespraycoagulationmodeforoozingtissuesitesa
Applythespraycoagulationmodeforoozingtissuesit
surfaces.35 35 35
surfaces.
surfaces.
During laparoscopic procedures the use of low voltage coagulation reduces the
Duringlaparoscopicprocedurestheuseoflowvoltageco
potential for insulation Duringlaparoscopicprocedurestheuseoflowvoltage
failure and capacitive coupling.35
35
forinsulationfailureandcapacitivecoupling.
forinsulationfailureandcapacitivecoupling.
35

Desiccation can be used with the coagulation waveform by applying the active electrode
directly on desired tissue. The end result of desiccation is drying out of the tissue. Cutting
Desiccation
Desiccationcancan
be used with the the
bea used coagulation waveform by applying the activ
in the coagulation mode will not deliver clean with
tissue cutcoagulation
as will the cutwaveform
mode.35 by applying the a
TheThe
endend
result of desiccation
result is drying
of desiccation out out
is drying of the tissue.
of the Cutting
tissue. in the
Cutting coagu
in the coa
The newest monopolar mode
cut as will theallows for controlled
cut cut
mode. 35 35 dissection and hemostasis. This option
is different from the cut as will
traditional the
blend mode.
mode. It is a coagulation mode driven waveform,
compared to blend which is a cut-driven waveform (see Figure 10). The mode is an
interrupted 25%The newest
The
sinusoidal monopolar
newest Thismode
monopolar
waveform. mode
allows allows for controlled
forallows dissection
forcombination
a unique controlled andand
dissection
of dissection hemostasis
hemost
with hemostasistraditional
while blend
applying a mode.
lower It
power is a coagulation
setting to mode
achieve driven
desired waveform,
clinical results.
traditional blend mode. It is a coagulation mode driven waveform, compa compared
(see Figure 10). The mode is an interrupted 25% sinusoidal waveform. This
(seewith
Figure 10). Thewaveform
mode is an interrupted 25% sinusoidal waveform. Th
Figure 10. Dissection hemostasis
dissection withwith
dissection hemostasis while
hemostasis applying
while a lower
applying power
a lower setting
power to achieve
setting d
to achiev

Figure 10. Dissection

Figure withwith
10. Dissection hemostasis waveform
hemostasis waveform

17
 CLINICAL APPLICATION
DISSECTION WITH HEMOSTASIS MODE
Application results in lower voltage which reduces the potential for insulation
failure and capacitive coupling.
Fast movement results in enhances tissue division, slow movement results in
enhanced coagulation effect.

INFLUENCING VARIABLES ON TISSUE EFFECT

There are many cognitive decisions indicated to achieve the desired clinical outcomes
with minimal risk to the patient. The variables include, but are not limited to:
Current output waveforms
Power setting
Time of application
Active electrode geometry and current density
Patient return electrode and current density
Tissue conductivity
Surgical technique

Power Setting
When determining the appropriate power setting one should consider the electrosurgery
unit and follow instructions for use. Always select the lowest power setting to achieve
the desired tissue effect. Power setting should be determined by individual patient
characteristics. Muscular patients who are of appropriate height and weight will require
lower power settings than an obese or emaciated patient.
Placement of the patient return electrode should also be considered. The patient return
electrode should be placed as close to the surgery site as possible. Consider the
distance the current must travel from the surgery site to the patient return electrode. The
greater the distance, the more impedance/resistance that will be encountered, requiring
a higher power setting to achieve the desired tissue effect. To minimize impedance/
resistance place the patient return electrode on a large vascular muscle, located as close
to the surgery site as possible.

Time of Application
Dwell time is the length of time the active electrode is in contact with the tissue (see
Figure 11). Selection of the appropriate power setting, observation of the tissue effect,
and appropriate dwell time application is essential in achieving the desired tissue effect.
The ideal application is to apply the lowest power setting to achieve the desired clinical
tissue effects. Long activation time will increase the risk for unintended thermal injury and
too short of activation time may result in the absence of clinical tissue effect.32

18
 Time of Application
Dwellthe
Figure 11. The longer time is the length current
electrosurgery of time is
theapplied
active the
electrode
greaterispotential
in contact
forwith the tis
thermal spread. appropriate power setting, observation of the tissue effect, and appropriate
achieving the desired tiss
the lowest power setting
effects. Long activation ti
thermal injury and too sh
absence of clinical tissue

Figure 11. The longer the electrosurgery current is applied the greater potential f
Active Electrode Geometry and Current Density
The selection of an appropriate size active electrode is as important as determining the
Active Electrode Geometry and Current Density
current output waveform. Active electrode geometry correlates to the current density. It
is the current The
density that relates
selection of antoappropriate
heat productionsizeand tissue
active effect. Current
electrode density is as determ
is as important
dependent upon Active electrode geometry correlates to the current density. Wu
surface contact area
and geometry of the active electrode.33 It isand
the current den
colleagues state, contact area is decreased by a factor of 10 (eg, 2.5 cm2 to 0.25 cm2),
and tissue effect. Current density is dependent upon
the current density increases by a factor of 100 (eg, 0.01 amp/cm2 to 1 amp/cm2), and
surface contact area and
and colleagues
the final temperatures increases state,
from contact areaCis(p.
37 C to 77 decreased
69).33 Thus,by aa large
factoractive
of 10 (e.g., 2.5 cm
electrode (eg,increases by awill
ball electrode) factor of 100
require (e.g.,power
a higher 0.01 setting
amp/cm when
2 to compared
1 amp/cmto 2),aand the final te
small active electrode
77 C (p.(eg, needle
69). tip) toa achieve
33 Thus, the same
large active desired(e.g.,
electrode tissueball
effect (see will require
electrode)
Figure 12).
compared to a small active electrode (e.g., needle tip) to achieve the same des
Figure 12. Geometry Size and Effect on Power Settings

Power setting requirement decreases

Power High current

setting concentration
requirement (density)
decreases

Powersettingrequirementincreases

Figure 12. and
Patient Return Electrode Geometry SizeDensity
Current and Effect on Power Settings
The patient return electrode size is designed to safely return the high-frequency current
ReRrr
back to the electrosurgical unit, by dispersing the current over a large surface area. This
results in low current concentration at the patient return electrode site. Should the current
Patient Return Electrode and Current Density
The patient return electrode19size is designed to safely return the high-frequenc
 Patient Return Electrode and Current Density
inadvertentlyThe patient
become return electrode
concentrated size is
on a patient designed
return to safely
electrode, returnofthe
the chance high-frequency
thermal
unit, by dispersing the current over a large surface area. This results in low curre
injury is significantly increased due to the high current concentration (See Figure 5).
electrode site. Should the current inadvertently become concentrated on a patien
Tissue Conductivity
thermal injury is significantly increased due to the high current concentration (Se
Patient tissue type, muscle and fat result in various resistance/impedance to the flow
of electricity. This is attributed to the inherent properties of the tissue type, muscle and
Tissue
fat (see Figure Conductivity
13). The patients physical characteristics also provide impedance to the
current flowPatient
as current completes the circuit
tissue type, muscle andthrough the patient
fat result returnresistance/impedance
in various electrode and to the
back to the electrosurgical generator. A patient who is muscular with minimal adipose
to the inherent properties of the tissue type, muscle and fat (see Figure 13). The
tissue will conduct the current flow better than an obese or emaciated patient. Because
each patientalsohas provide
different impedance to theelectrosurgery
impedance levels, current flow as current
power completes
settings the circuit throu
should be
determined back
on anto the electrosurgical
individual basis. generator. A patient who is muscular with minimal ad
flow better than an obese or emaciated patient. Because each patient has differ
Figure 13. Tissue Impedance/Resistance Ranges
power settings should be determined on an individual basis.
Lung,scar
adhesions

Mesentery,brain
whitematter,
omentum

Bowel,brain
greymatter,
adipose,spleen

GallBladder

Oralcavity,liver

Prostateinnonconductive
solutionmuscle,eye,skin,
kidneypancreas

Buzzhemostasis
Desiccate
0 stop bleeding
500 1000 1500 2000 2500 3000 3500 4000 4500
OHMS

Tissue Temperature Figure 13. Tissue Impedance/Resistance Ranges

Tissue Temperature
Therapeutic
Therapeutic current delivered
current delivered into biological
into biological tissuetissue
mustmust
flowflow through
through extracellularand
extracellular andintracellular i
intracellular ions that commonly include electrolytes Na+, Cl-, Ca++, and Mg++.30
commonly include electrolytes Na+, Cl-, Ca++, and Mg++.30 Resistance is encountered with the ion
Resistance is encounteredwith the ionic movement as the ions collide withother
the ions collide with other molecules, resulting in the generation of heat. The greater the resistance
molecules, resulting in the generation of heat. The greater the resistance to flow of the
ions, the ions,
greater
the production of heat.of The
greater production heat.following equation
The following applies
equation to the
applies temperature
to the temperaturerise with use
in biological tissue: 30
rise with use of electrosurgery in biological tissue: 30

J2t
T =
CD

The increase in temperature

The increase T (C)
in temperature Tis(C)
designated by the
is designated by equation:
the equation:T represents
T representsthe theduration of the
duration of the
(sec), D represents current
tissue flow (sec),
density D represents
(kg/m3), C the heattissue density(kcal/kg/C)
capacity (kg/m3), C the heattissue.30 The tem
of the
capacity
patient tissue (kcal/kg/C) of
is proportional tothe
thetissue.
amountThe
30
temperature
of time rise ofispatient
that energy tissue is proportional
applied.
to the amount of time that energy is applied.

Bioeffects of radiofrequency current to tissue temperature above 50C results in tissue damage that
Tissue response at 90C includes vaporization of water from the cells. (Figure 14). This process res
desiccation and denaturation of protein.33 The initial tissue appearance of white coagulation can be
2033
observed.33 At 100C, the intracellular water boils. The cellular walls rupture, resulting in tissue va
Bioeffects of radiofrequency current to tissue temperature above 50C results in tissue
damage that is irreversible. Tissue response at 90C includes vaporization of water
from the cells. (Figure 14). This process results in tissue desiccation and denaturation of
protein.33 The initial tissue appearance of white coagulation can be clinically observed.33
At 100C, the intracellular water boils.33 The cellular walls rupture, resulting in tissue
vaporization. Temperatures in the range of 200C and above result in carbonization
(fulguration) and charring of the tissue.33
Figure 14 .Tissue Responses

Surgical Technique
Appropriate tissue effect is achieved with the combined art and science of electrosurgery
that includes surgeon knowledge of electrosurgery principles, skilled application and
knowledge of equipment and instruments, appropriate selection of current output
waveform, lowest power setting to achieve the desire clinical tissue effect, avoiding long
dwell times, and selection of appropriate electrode size.

ELECTROSURGICAL TECHNOLOGIES
The electrosurgical unit is one of the most widely used tools available to surgeons. As the
sophistication of surgical procedures has evolved over time, so too have electrosurgery
technologies. Meeting the challenge of improved patient care is one of the goals of the
medical manufacturing partner within the healthcare arena. Providing education and
information on emerging technology is another. Both the surgeon and the perioperative
nurse must be familiar with older technologies and with the current safest and most
effective care is available to patients wherever surgery and invasive procedures are
performed.

GROUND REFERENCED ELECTROSURGICAL GENERATOR

It is important to understand how to establish a safe closed circuit during electrosurgery,
to minimize untoward patient outcomes. Ground-referenced or spark-gap systems were
the first generation electrosurgery generators. Ground-referenced generators were
designed to allow for current to flow from the wall outlet to the generator, active electrode

21
(pencil), surgical tissue, return electrode, and back to the generator with the current
returning through the wall outlet to earth ground as shown in Figure 15.
Figure 15. Ground Reference Electrosurgical Generator

A major potential hazard with ground-reference generators was the ease in which the
current could exit through an alternate pathway. For example, if the patients body was in
contact with any type of conductor such as a metal intravenous pole or metal surface of
the surgical bed there was potential for current division. Current division allowed for the
current to deviate from the intended pathway to an easier pathway (lower impedance/
resistance) to return to ground. If the current became significantly concentrated at an
alternate exit site, an injury occurred as shown in Figure 16. Other potential hazards
included the lack of an alarm in the event the patient return electrode was not attached
to the unit or on the patient. Later models included a cord fault alarm that activated if the
patient return electrode was not attached to the unit. However, this resulted in injuries
when the cord was attached to the unit, but was inadvertently not on the patient. In 1995,
ECRI stated that spark-gap units are outdated and have been largely superseded by
modern technology.36 Due to safety issues, ground-reference generators have been
replaced with isolated generator systems.
Figure 16. Alternate Site Burn

22
ISOLATED ELECTROSURGICAL GENERATOR
In 1968, isolated generators were introduced as a significant patient safety innovation.
These generators utilize isolated circuitry designed to prevent current division (See
Figure 17). Isolated generators allow current to flow from the wall outlet to the generator,
active electrode (pencil), surgical tissue, return electrode, and back to an isolated
transformer contained within the generator. In order to function appropriately, a closed
circuit is required. A patient return electrode must be applied to the patient and connected
to the generator. If a patient return pad is not applied or is not connected to the generator,
detectors will disable the generator function and alarm to alert the perioperative team.
The utilization of isolated generators for patients undergoing minimally invasive and
surgical procedures is considered as the acceptable standard of care due to the
enhanced safety feature designed to reduce alternate site burns.
Figure 17. Isolated Circuit

CONTACT QUALITY MONITORING

The next major innovation in electrosurgery came about in 1982 when an interrogation
circuit was added to the patient return electrode. The interrogation circuit in a contact
quality monitoring patient return electrode continuously monitors the quality/quantity of
the contact area between the pad and the patient (see Figure 18). The contact quality
monitoring system is designated to deactivate the generator while giving audible and
visual feedback before a patient burn can occur due to a contact quality issue. Return
electrode monitoring is a major safety improvement for patients as return electrode burns
(ie, due to a reduction in the quality or quantity of contact area) account for a majority
of adverse patient outcomes during electrosurgery. This technological breakthrough
represents the first time since the development of electrosurgery that the patients own
tissue status was taken into consideration as part of a feedback mechanism. According
to ECRI, many electrosurgery burns could be eliminated by a patient return electrode
contact quality monitoring system.37 It is important that the pad type is compatible

23
with the electrosurgery unit and instructions for use are followed to avoid untoward
patient outcome.38 The single use pad should be inspected for existing damage or
integrity issues that may affect performance. The pad should be placed on a clean, well
vascularized muscle, as close to the surgery site as possible according to instructions for
use. Following use, the single use pad should be discarded.
Figure 18. Return Electrode Contact Quality Monitoring (RECQM) System

ARGON-ENHANCED ELECTROSURGERY
In the late 1980s the argon delivery system was combined with the electrosurgery
generator to create argon-enhanced electrosurgery. This electrosurgery technology
should not be confused or compared to laser technology. Argon is an inert, nonreactive
gas that is heavier than air and easily ionized. The argon shrouds the electrosurgery
current in a stream of ionized gas that delivers the spark to tissue in a beamlike fashion
(See Figure 19). Because the beam concentrates the electrosurgical current, a smoother,
more pliable eschar is produced. At the same time, the argon gas disperses the blood,
improving visualization. Because the heavier argon displaces some of the oxygen at
the surgery site, less smoke is produced. When used during surgery, argon-enhanced
electrosurgery can reduce blood loss, decrease the risk of rebleeding, and decrease the
amount of surgical plume.39

24
Figure 19. Argon-Enhanced Electrosurgery

TISSUE DENSITY FEEDBACK TECHNOLOGY

During the mid-1990s, electrosurgery generators were introduced that incorporated
computer controlled feedback systems. Referred to as tissue response, or tissue effect
generators, the instant response technology could sense tissue impedance/resistance.
The feedback system provided the surgeon with consistent clinical effect through all
tissue types in the cut (vaporization) mode. Generators equipped with the feedback
mechanism rapidly sense tissue resistance and automatically adjust output voltage to
maintain constant generator effect. What that means to the surgeon is that if 40 watts is
selected as the desired power setting, the generator will deliver 40 watts through tissue
of varying ohms of resistance (see Figure 20). The constant power output has an added
advantage: perioperative staff is not required to frequently adjust generator power settings,
of varying ohms of resistance (see Figure 20). The constant power output h
and voltages are kept as low as possible. Instant generator response to changing patient
staff
tissues is not required
represented a first into frequently
patient safety inadjust generator
which the power
electrosurgery settings,
generator used and volta
information from the
generator patient throughout
response to changingthe procedure.
patient To take advantage
tissues of tissuea density
represented first in patie
feedback technology, it was required that the surgeon use the cut or vaporization mode.
generator used information from the patient throughout the procedure. To t
Figure 20. Tissue Response
technology, Technology
it was required that the surgeon use the cut or vaporization mo
45
Tissue Response Technology

35
Lung,scar,adhesions
30
Mesentery, brain white
25 Bowel, brain matter, omentum
grey matter
WATTS

20 adipose, spleen
Gall Bladder

15
Oral cavity, liver Conventional Technology
10 Prostate in nonconductive solution,
muscle, eye, skin, kidney, pancreas
5 Buzz hemostasis
Desiccate-
stop bleeding
0 500 1000 1500 2000 2500 3000 3500 4000
OHMS

Figure 20. Tissue Response Technology

25
TISSUE FUSION TECHNOLOGY
In 1999 a technology was developed that gave surgeons a new way to achieve
hemostasis. The specialized generator instrument system reliably sealed vessels and
tissue bundles in both laparoscopic and open surgery applications. It applies a unique
form of bipolar-type energy in combination with pressure to fuse vessel walls and create
a permanent seal. Computer feedback controls the output of the generator so that
a reliable seal is achieved in minimal time when the tissue is held between the tines
of specialty designed instruments. The result is a reliable seal on vessels up to and
including 7 mm in diameter and tissue bundles using a single generator activation. The
seal is strong and permanent and has been shown to withstand three times the normal
systolic pressure. Thermal spread is reduced when compared to traditional bipolar, and
is comparable to ultrasonic coagulation. The site has a translucent appearance that is
the reformed collagen and elastin that actually changes the nature of the tissue to form a
permanent seal. An important consideration is the bipolar-type nature of this technology.
The electrical current only travels between the tines of the forceps and never goes
through the patients body, making it a very safe treatment option for patients for whom
monopolar might be contraindicated, such as those with pacemakers.40
The specifications of tissue fusion technology make it unique among surgery hemostatic
devices that include:
First Generation Vessel Sealing
Reactive tissue analysis
200 decisions per second
Initial impedance sets energy delivery
Average 5-8 second seal cycle
Plastic-like seal area
Surgeon determines bar setting

Second Generation Tissue Fusion

Adjusts output in real time
3,333 decisions per second
Real time tissue impedance controls each energy delivery decision
Average 2-4 second fusion cycle
Flexible fusion zone
Automatic instrument bar settings

26
CLOSED-LOOP COAGULATION TECHNOLOGY
The steady increase in electrosurgery generator improvement culminated with the
engineering breakthrough that created closed-loop controlled coagulation in 2006. The
introduction of closed-loop controlled coagulation allowed for the development of a
radiofrequency electrosurgery generator capable of including tissue feedback data in
every mode available on the generator. The tissue-sensing energy platform is a computer
controlled system that senses resistance in patient tissues and adjusts voltage output,
electrical current and generator power 3,333 times per second. As with tissue response in
the cut mode of earlier generators, this provides consistent electrosurgical effect across
a wide range of varying patient tissue resistance/impedance. The dramatic differences
CLOSED-LOOP COAGULATION TECHNOLOGY
between the tissue sensing capabilities of closed-loop controlled coagulation are most
The steady increase in electrosurgery generator improvement culminated with the engineering
obvious when comparingbreak actual oscilloscope printouts of traditional coagulation and
through that created the closed-loop controlled coagulation in 2006. The introduction of closed-loop
closed-loop controlled coagulation (SeeforFigure
coagulation allowed 21). Inofthe
the development coagulation
a radiofrequency mode, without
electrosurgery generator capable of including
closed loop control, the feedback
positivedata and negative
in every poles on
mode available of the
thegenerator.
duty cycle are unequal.
The tissue-sensing When
energy platform is a compute
system that senses resistance in patient tissues and adjusts voltage output, electrical current and generato
the peak-to-peak voltage3,333is controlled, the voltage is similar in both the positive and
times per second. As with tissue response in the cut mode of earlier generators, this provides consis
negative poles of the duty cycle, which
electrosurgical givesaawide
effect across morerangeconsistent generator
of varying patient tissue effect. The
tissue resistance/impedance. The dramatic dif
ability of the tissue-sensing generator
between to include
the tissue sensing tissue
capabilities information
of closed-loop during
controlled each are
coagulation activation
most obvious when comp
actual oscilloscope printouts of traditional coagulation and closed-loop controlled coagulation (See Figure
is advancement in patient safety and makes each and every surgical procedure specific to
coagulation mode, without closed loop control, the positive and negative poles of the duty cycle are unequ
every patient. the peak-to-peak voltage is controlled, the voltage is similar in both the positive and negative poles of the d
which gives a more consistent generator tissue effect. The ability of the tissue-sensing generator to include
Figure 21. Coagulationinformation
withoutduringClosed-Loop
each activation Control, Coagulation
is advancement in patient safetywith Closed-Loop
and makes each and every surgical pro
Control specific to every patient.

Figure 21. Coagulation without Closed-Loop Control, Coagulation with Closed-Loop Control
SMOKE EVACUATION
SMOKE EVACUATION
In 1994, the Association of periOperative Registered Nurses (AORN) published a
In 1994 the Association of periOperative Registered Nurses (AORN) published a recommended practice s
recommended practice stating that patients and perioperative personnel should be
patients and perioperative personnel should be protected from inhaling the smoke generated during the us
protected from inhaling the
electrosurgery. generated
smoke duringto evacuate
The recommendation the useand
of appropriately
electrosurgery. Thesmoke has remained a s
filter surgical
recommendation to evacuate
supportedand appropriately
by AORN filter
since that time. surgical smoke has remained a
41 The recommended practice is applicable whenever a smoke plume

produced whether
standard of practice supported by AORN it is from laser,that
since electrosurgery,
time.41 The recommended practice is
or any other surgical device that aerosolizes human tissue.
applicable whenever a smoke plume is produced whether it is from laser, electrosurgery, or
any other surgical deviceThe Joint Commission 2009 Environment of Care Standard EC.02.02.01 stated The hospital minimizes ris
that aerosolizes human tissue.
associated with selecting, handling, storing, transporting, using, and disposing hazardous gases and vapo
Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors genera
The Joint Commission 2009 Environment of Care Standard EC.02.02.01 stated The
using cauterizing equipment and lasers, and gases such as nitrous oxide.42 It is expected that surgical sm
hospital minimizes riskscauterizing
associated with such
equipment selecting, handling,and
as the electrosurgery storing,
laser cantransporting, using, to minimize ass
be appropriately managed
and disposing hazardous gases
risks relatedand
to use.vapors. Hazardous gases and vapors include,
but are not limited to, glutaraldehyde, ethylenehave
Toxic fumes and carcinogens oxide, vaporsfromgenerated
been isolated surgical smoke.while using and benzene are t
43 Formaldehyde

cauterizing equipment and long lasers, and gases

list of substances that aresuch as innitrous
contained smoke.43oxide.
AcrylonitrileIt is expected that
42 and hydrogen cyanide are toxic, colorles
present in smoke that are easily absorbed through the skin and lungs. Acrylonitrile is shown to be toxic by
the cyanide; the cyanide combines with other substances to impair tissue oxygenation.44
27
surgical smoke from cauterizing equipment such as the electrosurgery and laser can be
appropriately managed to minimize associated risks related to use.
Toxic fumes and carcinogens have been isolated from surgical smoke.43 Formaldehyde
and benzene are two of a long list of substances that are contained in surgical smoke.43
Acrylonitrile and hydrogen cyanide are also toxic, colorless gases present in smoke
that are easily absorbed through the skin and lungs. Acrylonitrile is shown to be toxic by
liberating the cyanide; the cyanide then combines with other substances to impair tissue
oxygenation.44
Air quality in hospital and operating rooms has been described as a chemical soup that
can cause symptoms such as shortness of breath, eye and respiratory irritation, rhinitis,
contact dermatitis, headaches, joint pain, memory problems and difficulty concentrating,
to name a few.45 There has been no quantitative way to measure long-term effects on
healthcare workers. The alert still appears as a recommendation on the National Institute
for Occupational Safety and Health Web site.46
Laparoscopic procedures expose the patient and staff to surgical smoke. There is
a high concentration of carbon monoxide in surgical smoke. Carbon monoxide can
cause symptoms that include headache, tinnitus, shortness of breath, lower extremity
weakness,
Air in hospital clumsiness, palpitations,
and operating rooms chest pain,
has been described abdominal
as a chemical pain,
soup that candiarrhea, nausea
cause symptoms suchand
as
vomiting.
shortness of When carbon monoxide is absorbed through the peritoneal membrane during
47 breath, eye and respiratory irritation, rhinitis, contact dermatitis, headaches, joint pain, memory
problems and difficulty concentrating, to name a few.45 There has been no quantitative way to measure long-term
laparoscopic surgery elevated levels of methemoglobin and carboxyhemoglobin are
effects on healthcare workers. The alert still appears as a recommendation on the National Institute for Occupational
produced in the
Safety and Health Web patients
site.46 bloodstream. This can pose a potential risk to patients during
surgery.48 Surgeons and perioperative scrubbed staff are also at increased risk from
Laparoscopic procedures expose the patient and staff to surgical smoke. There is a high concentration of carbon
inhaling surgical smoke during laparoscopic procedures due to a surge of concentrated
monoxide in surgical smoke. Carbon monoxide can cause symptoms that include headache, tinnitus, shortness of
smoke being
breath, lower released
extremity fromclumsiness,
weakness, the cannula system.
palpitations, It pain,
chest is recommended that a smoke
abdominal pain, diarrhea, nausea and
evacuation
vomiting.47 Whenlaparoscopic handpiece
carbon monoxide is absorbedbe usedthetoperitoneal
through maintain visualization
membrane throughout
during laparoscopic the
surgery
procedure
elevated levelsthrough meteredand
of methemoglobin smoke evacuation.
carboxyhemoglobin areAproduced
list of chemicals
in the patientscontained
bloodstream.inThis
surgical
can pose
a potential risk to patients during surgery.48 Surgeons and perioperative scrubbed staff are also at increased risk from
smoke is reason enough to institute a policy that all smoke be evacuated and filtered
inhaling surgical smoke during laparoscopic procedures due to a surge of concentrated smoke being released from
(See Tablesystem.
the cannula 1). It is recommended that a smoke evacuation laparoscopic handpiece be used to maintain
visualization throughout the procedure through metered smoke evacuation. A list of chemicals contained in surgical
Table
smoke 1. Chemicals
is reason enough toContained inthat
institute a policy Surgical
all smokeSmoke
be evacuated and filtered (See Table 1).
Acetylene Ethane 4-Methy phenol
Acroloin Ethene 2-Methyl propanol (aldehyde)
Acrylonitrile Ethylene Methyl prazine
Alkyl benzene Ethyl benzene Phenol
Benzaldehyde Ethynyl benzene Propene
Benzene Formaldehyde 2-Propylene nitrile
Butadiene Furfural (aldehyde) Pyridine
Butene Hexadeconic acid Pyrrole (amine)
3-Butenenitrile Hydrogen cyanide Styrene
Carbon monoxide Indole (amine) Toluene (hydrocarbon)
Creosol Isobutene 1-Undecene (hydrocarbon)
1-Decene (hydrocarbon) Methane Xylene
2,3-Dihydro indene (hydrocarbon) 3-Methyl butenal (aldehyde)
6-Methyl indole (amine)

Before the procedure, the perioperative nurse should determine the volume of smoke
Table 1. Chemicals Contained in Surgical Smoke

that willthebe
Before produced
procedure, and selectnurse
the perioperative the should
appropriate
determinesmoke evacuation
the volume system.
of smoke that A vacuum
will be produced and
select the appropriate smoke evacuation system. A vacuum source with a triple filter offers the greatest protection.
The systems consist of a prefilter to filter out large particles, an ultra low penetrating air (ULPA) filter to capture
microscopic particles and a charcoal filter to absorb or bind to toxic gases produced during the procedure (Figure 22).
28
Prefilter
 6-Methyl indole (amine)
als Contained in Surgical Smoke
source with a triple filter offers the greatest protection. The systems consist of a prefilter
cedure, the perioperative nurse should determine the volume of smoke that will be produced and
to filter out large particles, an ultra low penetrating air (ULPA) filter to capture microscopic
ropriate smoke
particlesevacuation system.
and a charcoal filter Atovacuum
absorb orsource
bind towith
toxicagases
tripleproduced
filter offers the the
during greatest protection.
consist of procedure
a prefilter (Figure
to filter22).
out large particles, an ultra low penetrating air (ULPA) filter to capture
articles and a charcoal filter to absorb or bind to toxic gases produced during the procedure (Figure 2
Figure 22. Filter System
Prefilter
captureslargeparticlesandsomefluids

ULPA Filter
capturessmallparticles


Activated Carbon
absorbstoxicgasesandodors


Final/post filter

The vacuum source should Figure

be able22.toFilter
adequately
Systempull sufficient air through the system
to capture the smoke (about 50 cubic feet per minute of air). A system powerful enough
to handle the amount of smoke produced is the most effective evacuator, and offers
ource should be able to adequately pull sufficient air through the system to capture the smoke (abou
the perioperative nurse the flexibility to select the appropriate capture device. A smoke
per minuteevacuator
of air). Athat
system powerful
has variable enough
power to handle
settings themost
will be of amount
use inofa smoke produced
wide variety is the most
of surgical
procedures.
effective evacuator, and offers the perioperative nurse the flexibility
There are different captureevacuator that
devices that canhas
be variable
attached power
to the smoke evacuator.
settings will be of most use in a
The most convenient is the smoke carriage that attaches to the electrosurgical pencil
(See Figure 23). This device has the advantage of being in direct proximity to where
There are different capture devices that can be attached to the smo
the smoke originates, which is the recommended location to most efficiently capture
smoke. For larger volumescarriage that
of smoke, theattaches to thetubing
larger capture electrosurgical pencilThe
may be needed. (See Figure 23).
most efficient and effective system configuration should be selected for every surgicalrecommende
proximity to where the smoke originates, which is the
procedure in which smokelarger volumes of smoke, the larger capture tubing may be needed
is produced.
configuration
Figure 23. Electrosurgical should Evacuation
Pencil with Smoke be selectedAttachment
for every surgical procedure in wh

Figure 23. Electrosurgical Pencil with Smoke Evacuation Attachment

29
 ctrosurgical Pencil with Smoke Evacuation Attachment
MINIMALLY INVASIVE SURGERY

POTENTIAL MONOPOLAR ELECTROSURGICAL HAZARDS

Since the 1980s the number and type of minimally invasive surgery (MIS) procedures
MONOPOLAR has steadily increased, and that trend
ELECTROSURGICAL HAZARDSis expected to continue. The surgery suite and
outpatient surgery department are not the only places where MIS procedures are done.
80s the number and as
Endoscopy type
wellofas
minimally
radiologyinvasive
suites havesurgery
seen a(MIS)
rise inprocedures
the numberhas steadily
of cases, andincreased, and
expected tothecontinue.
complexityThe surgery suite
of procedures doneandin aoutpatient surgery manner.
minimally invasive department
As thearenumber
not theof only places
roceduresMISareprocedures has increased,
done. Endoscopy as wellsoastooradiology
have patient safety
suites haveissues
seenrelated
a risetointhe
theuse of
number of cases,
monopolar electrosurgery. There are hazardous situations that may develop
plexity of procedures done in a minimally invasive manner. As the number of MIS procedures has as a result of
the endoscopic use of electrosurgery. Some of these include:
o too have patient safety issues related to the use of monopolar electrosurgery. There are hazardous
asDirect
t may develop coupling
a result of the endoscopic use of electrosurgery. Some of these include:
Insulation failure
ct coupling
lation failure Capacitive coupling
acitive coupling Residual heat injuries
idual heat injuries
Endosurgical smoke
osurgical smoke Electromagnetic interference
tromagnetic interference
Each of these can cause adverse patient outcomes that may result in injury.
e can cause adverse patient outcomes that may result in injury. Perioperative practitioners should be
Perioperative practitioners should be aware of how and when these factors occur, and
and when howthese factors
to reduce occur,
patient andInhow
risks. to reduce
determining thepatient risks.
root cause of In determining
potential theit isroot
hazards, cause of
useful
ards it is useful to the
to divide divide theelectrode
active active electrode andsystem
and cannula cannula
intosystem into(see
four zones fourFigure
zones24).
(see Figure 24).
Figure 24. Four Zones of Injury

Zone 1 The smallFigure

area at24.theFour Zones
tip of of Injury
the active electrode, and the only area in
direct view of the surgeon
area
e 1 The small Zone at
2 the
Thetiparea justactive
of the beyondelectrode,
the active and
electrode tip toarea
the only the end of theview
in direct cannula,
of the surgeon
outside the surgeons view
e 2 The area just beyond the active electrode tip to the end of the cannula, outside the surgeons v
Zone 3 The area of the active electrode covered by the cannula system, also
outside the view of the surgeon
Zone 4 The portion of the active electrode and cannula that is outside the
patients body

The greatest concern and potential patient hazard is the incidence of unseen stray
radiofrequency current in Zones 2 and 3, outside the surgeons view, due to stray current
from insulation failure, direct coupling or capacitive coupling.33

30
Direct Coupling
Direct coupling occurs when the active electrode is activated in close proximity or in
direct contact with other conductive instruments within the patients body. Direct coupling
can occur in Zones 1, 2 or 3. If direct coupling occurs outside the field of vision of the
surgeon and the current is sufficiently concentrated, patient injury can occur (See Figure
25).
Figure 25. Direct Coupling

Insulation Failure
Insulation failure occurs when the insulating coating on the active electrode is
compromised. This can happen in multiple ways that range from instrument damage
due to rough handling to an insulation defect that result from using a high voltage
electrosurgical current, such as coagulation. Insulation damage can occur during
instrument cleaning, but it can also develop during surgery from repeated insertions
into the cannula system (See Figure 26). High voltage radiofrequency current can
be powerful enough to blow a hole through intact active electrode insulation. The
voltage can be as high as 8,000 to 10,000 volts of electricity, depending on how the
surgeon uses the active electrode. There is also concern that some active electrodes
may not meet the standards for electrosurgical devices set by the Association for the
Advancement of Medical Instrumentation (AAMI). Integrity of insulation coating may
vary among manufacturers. Insulation failure that occurs in Zones 2 or 3 could escape
detection by the surgeon and cause injury to adjacent body structures if the current is
delivered in a concentrated manner.
Figure 26. Insulation Failure

31
Capacitive Coupling
Capacitive coupling is perhaps the least understood of the potential endoscopic
electrosurgical hazards. The definition of a capacitor is two conductors separated by
an insulator. Laparoscopically, a capacitor is created by inserting an active electrode,
surrounded by its insulation, into a metal cannula. When the active electrode is activated
by the surgeon, capacitively coupled electrical current can be induced from coming in
contact with body structures, the energy can be discharged into adjacent structures
and cause injury.49 When using an all-metal cannula any electrical energy stored in the
cannula will tend to disperse into the patient through the relatively large contact area
between the cannula and the muscular abdominal wall (See Figure 27). The large area of
contact serves to disperse the electrical energy, which is far less dangerous than areas
of higher concentration. For this reason, it is unwise to use plastic anchors to secure the
cannula because the plastic anchors isolate the electrical current from the abdominal wall
and increase the likelihood it will accumulate in other areas of the cannula.
Figure 27. Electrical Energy Dispersal Compared to All Metal and Plastic

Risk Reduction Strategies

There are some steps perioperative personnel and surgeons can take to reduce the risk
of patient injury during laparoscopic use of electrosurgery:
Inspect insulation carefully.
Use the lowest possible power setting.
Use the low voltage (cut) waveform.49
Use brief intermittent activations versus prolonged activations of the active
electrode.
Do not open air activate the active electrode.
Do not activate the active electrode in close proximity or in direct contact with
metal or conductive objects in the abdomen.
Use bipolar electrosurgery when possible.

32
 There are some steps perioperative personnel and surgeons can take to reduce
during laparoscopic use of electrosurgery:
Inspect insulation carefully.
In the active electrode
Use operative channel,
the lowest select power
possible an all-metal cannula system as the best
setting.
choice to disperse electrical buildup along the cannula.
Use the low voltage (cut) waveform.49
Do not use hybrid systems (metal
Use brief and plasticactivations
intermittent components). versus prolonged activations of the act
Do not open air activate the active
One of the most important ways to increase patient safety during electrode.
laparoscopy is to
take advantage of Do not activate
improvements the activeAdvancements
in technology. electrode in close proximity
in technology mostor in direct contac
the abdomen.
often exist to solve problems that were present in older generations of devices, and the
improvements make surgery safer electrosurgery
Use bipolar for patients and when
practitioners alike. Technological
possible.
improvements include:
In the
Tissue activegenerators
response electrode to
operative channel, coupling
reduce capacitive select anin all-metal cannula system as t
the low voltage
waveform.
buildup along the cannula.
Tissue-sensing generators to reduce capacitive coupling in both the cut and
Do not use hybrid systems (metal and plastic components).
coagulation waveforms.
Onesealing
Vessel of thegenerators
most important
to takeways to increase
advantage patient
of the full safetyofduring
capabilities laparoscopy is
bipolar-type
instruments.
in technology. Advancements in technology most often exist to solve problems th
of devices,
Active electrode and the improvements
monitoring makeconcerns
(AEM) to minimize surgery about
safer insulation
for patients and practitione
failure
andimprovements include:
capacitive coupling.

Risks posed to the Tissue

patient byresponse generators
insulation failure to reducecoupling
and capacitive capacitive coupling
can be reducedin the low vol
by using an AEMsystem.Tissue-sensing generators
The AEM system is used to reduce
with capacitive coupling
an electrosurgical generatorin both the cut
(See Figure 28).The Vessel
system sealing generators
continuously monitorstoand
take advantage
actively shieldsofagainst
the fullstray
capabilities of bi
electrosurgical current. The AEM system is one of the most effective means to minimize
Active electrode monitoring (AEM) to minimize concerns about insulatio
the potential for patient injuries due to insulation failure or capacitive coupling.50
Risks posed to the patient by insulation failure and capacitive coupling can be re
Figure 28. system.
Active Electrode
The AEMMonitoring
system is used with an electrosurgical generator (See Figure 2
monitors and actively
current. The AEM sy
means to minimize th
insulation failure or c

Trocar Cannula

Conductive Shield

Internal

Figure 28. Active Electrode Monitoring

ELECTROSURGICAL ACCESSORIES
Electrosurgical generators are only part of the electrosurgical system. The generators
are only 25 percent of the electrosurgical equation. The other 75 percent of the system
are the pencil, the patient return
Electrosurgical electrodeare
generators andonly
the part
user.ofThese three have much
the electrosurgical system. The gener
higher problem rates than does the generator.51 Perioperative practitioners should be
electrosurgical equation. The other 75 percent of the system are the pencil, the p
knowledgeable about electrosurgical accessories, including their safe and effective use.
These three have much higher problem rates than does the generator. 51 Periop
knowledgeable about electrosurgical accessories,
33
including their safe and effective use.
ACTIVE ELECTRODES
The active electrode is the component of the electrosurgical system that delivers
concentrated electrical current to patient tissues. There is a wide assortment of active
electrodes that can be used with both bipolar and monopolar electrosurgery. Active
electrode pencils or forceps may be controlled by hand switches on the pencil or by foot
pedals. Pencil tips are available in a wide variety of configurations needles, blades,
balls and loops, to name a few (See Figure 29). There are many active electrodes
available for laparoscopic use. Some active electrodes offer a combination of suction
and coagulation in the same handpiece. Active electrodes are available as disposable
and reusable products, and some are what are referred to as reposable. Reposable
products are used for a certain number of times and then discarded. One of the potential
hazards associated with active electrode tips is the buildup of eschar on the tip. Eschar
buildup greatly increases the impedance or resistance of the tip, and can represent a fire
hazard. With sufficient heating, eschar can become a glowing ember and can pose a fire
hazard both as an ignition source and fuel source. If eschar is on the active electrode tip,
the scrub person should remove it according to the manufacturers recommendations.
Scratch pads can be used to remove the eschar, but with each scratch microgrooves
are left behind. As the eschar builds up in the grooves, it becomes impossible to remove
and the tip assumes a higher impedance (resistance). Nonstick active electrode tips can
facilitate the removal of eschar, but does not eliminate the need for frequent cleaning.
Tips made of materials such as Teflon (PTFE) or elastomeric silicone coating can be
cleaned with a damp sponge (See Figure 30). A damp sponge is recommended because
active electrode tips are extremely hot immediately after activation. Use of a damp
sponge will make cleaning easier and reduce the risk of accidental ignition of the sponge.
Coated tips should be used according to the manufacturers recommendations, which
include use of appropriate power settings.
Figure 29. Active Electrodes Figure 30. Coated Active Electrodes

34
HOLSTERS
Holsters are one of the most important safety devices available to surgeons and
perioperative nurses. When the active electrode is not in use, it should be placed in a
holster that is visible to the surgical team and in easy reach of the surgeon and scrubbed
person. It is the responsibility of the scrubbed person to ensure that the active electrode
is placed in the non-conductive holster when not in use. Only holsters recommended by
the manufacturer that meet safety standards for heat and fire resistance should be used.
Use of plastic pouches, folded towels or other makeshift holsters are a threat to patient
safety and should never be used.

PATIENT RETURN ELECTRODES

Patient return electrodes, also called grounding pads, Bovie pads, neutral electrodes or
patient plates, remove monopolar current safely from the patient. There are many types
of return electrodes that can be used ranging from metal plates to large gels pads to
dual-section foam pads. Reusable metal plates are made of stainless steel and fit under
the patient. A later edition of the metal plate was a foil-coated cardboard plate. Whenever
metal plates are used, conductive gel must be used to make the patients skin more
conductive and to fill any voids in contact between the plate and the patients skin. As
with anything that is placed under the patient, contact is dependent on patient size and
conditions between the patient and the plate. Return electrodes that the patient lies on
do not conform to body contours and effectiveness may vary as points of contact with
the plate vary. A most important consideration for patient safety is that none of the metal
plates have contact quality monitoring capabilities. Water-based gel foam pads replaced
the metal or cardboard plates in most operating rooms. They are disposable and come
in many sizes and shapes. These adhere well to body contours, and usually have an
adhesive edge to hold the pad on the patient. When using a pad that is made of water-
based gel, care must be taken to store cartons flat to prevent the gel from migrating to
one side of the pad. If a pad is used that has a greater concentration of gel on one side,
uneven heating and a pad site burn could occur. The water-based nature of these pads
also means that storage time is limited otherwise the gel will dry out. Pads that dry out
will provide reduced conductivity and could result in a burn. When using water-based gel
pads, care must be taken to rotate stock and store cartons properly. Conductive adhesive
pads replace gel with a layer of adhesive over the pad surface. The adhesive maintains
good contact with the patients skin, increasing the conductivity of the pad. These pads
come in two basic types a dry conductive adhesive or a high-moisture conductive
adhesive. Both have the capability of conforming well to the patients varying body
contours. This type of pad is also available in the split dual section design, a reference
that denotes the pad is part of a quality contact monitoring system. If the generator
interrogation circuit used with a dual-section pad, senses conditions that could cause a
patient injury, the system will deactivate the output of the generator.
Proper placement of the patient return electrode is one of the most important
considerations in the safe use of the electrosurgical system. The patient return electrode
should always be placed on a large muscle mass as close to the surgical site as
possible. Muscle and blood are the best conductors of electrical energy in the patients

35
body. Higher resistance tissue, such as scar tissue and any bony prominence, should
also be avoided. Patient tissues that are higher in resistance slow down the passage of
the current through the patients body. As more impedance or resistance is encountered,
the greater the likelihood that electrosurgical burn could occur.52 Grounding pads should
not be placed over metal prostheses because the scar tissue surrounding the implant
increases resistance to the flow of electrical current. The pad site should be clean, dry,
and free from excessive hair. The grounding pad should not be placed where fluids are
likely to pool during surgery. If the patient has a pacemaker, the return electrode should
be placed as far from the pacemaker as possible. Consult the pacemaker manufacturer
prior to the procedure to determine if the pacemaker is susceptible to electrical
interference.
It is also important to read and follow the dispersive electrode manufacturers
recommendations. Safety features, such as quality contact monitoring systems, should
never be bypassed. These recommendations are legal and binding instructions for using
the product. Failure to follow recommended procedures could constitute negligence if
patient injury occurs.

PERIOPERATIVE CARE OF THE PATIENT

Nursing care of the patient during electrosurgery can be enhanced by following routine
and systematic procedures. Points to consider during perioperative care of the patient
during electrosurgery include, but are not limited to:38, 53, 54
PREOPERATIVE
Know which electrosurgery unit (ESU) will be used and how to use it. Consult the
instruction manual for specific instructions or questions.
Have all equipment and accessories available, and use only accessories
designed and approved for use with the unit.
Check the operation of the alarm systems.
Do not use in the presence of flammable anesthetics.
Place EKG electrodes as far from the surgery site as possible.
Do not use metal needle monitoring electrodes.
Check the line cord and plug on the ESU for breaks, nicks or cracks.
The ESU cord should reach directly to the wall outlet; extension cords should not
be used.
Do not use any power or accessory cord that is broken, cracked, frayed or taped.
Check the biomedical sticker to insure the generator has undergone a current
inspection.
Cover the foot pedal with a plastic bag.
Document the generator serial number on the perioperative record.
Record exact anatomical pad position and skin condition at the pad site.

36
 Do not cut a patient return electrode to reduce its size. Patient burns due to high-
current density may result.
Do not use patient return electrodes that disable contact quality monitoring.
Do not turn the activation tone down to an inaudible level.

INTRAOPERATIVE
If an alcohol-based skin preparation is used, allow to dry according to
manufacturers instructions for use prior to draping.
Select and use equipment that is compatible with the ESU.
Use the lowest possible power settings to achieve the desired surgical effect. The
need for abnormally high settings may indicate a problem within the system and
should be investigated.
Position cords to avoid creating a tripping hazard.
Do not roll equipment over electrical cords.
If the patient is moved or repositioned, check that the patient return electrode is
still in good contact with the patient.
Patient return electrodes should not be repositioned. If the patient return electrode
is removed for any reason, a new pad should be used.
When not in use, place electrosurgical instruments in a safety holster or safely
away from patients, the surgical team and flammable materials.
Do not coil active electrode cords. This will increase current leakage and may
present a potential danger to the patient.
If possible, avoid buzzing hemostats in a way that creates metal to metal
arching. If buzzing a hemostat is necessary, touch the hemostat with the active
electrode and then activate the generator. This will help eliminate unwanted
shocks to surgical team members.
Use endoscopes with insulated eye pieces.
Keep active electrodes clean. Eschar buildup will increase resistance, reduce
performance and require higher power settings.
Do not submerge active accessories in liquid, unless recommended by
manufacturers instructions for use.
Note the type of active electrode used on the perioperative record.
If an ESU alarm occurs, check the system to ensure proper function.
Do not use the generator top as a storage space for fluids.
Spills could cause malfunctions.
Do not use the active electrode when gastrointestinal gases are present.
Do not use the active electrode in the presence of an oxygen-enriched
environment.

37
 Do not place the active electrode in close proximity of oxygen source.
Question the need for 100% oxygen during oropharyngeal or head and neck
surgery.
Use electrosurgery modalities cautiously in the head and neck area.
Consult the pacemaker manufacturer or cardiology department for information
when use of electrosurgery or fusion appliances is planned in patient with cardiac
pacemakers.
Consult the implantable cardioverter defibrillator manufacturer for instructions
before performing electrosurgical or tissue fusion procedure.

POSTOPERATIVE
Turn all controls to zero (or minimum).
Turn off the electrosurgical unit.
Disconnect all cords by grasping the plugnot the cord.
Inspect patient return electrode site to be sure it is free of injury.
Inspect the patient return electrode after removal. If an undetected problem has
occurred, such as a suspected thermal injury, evidence of that may appear on the
pad.
Discard all disposable items according to hospital policy.
Remove and discard the plastic bag covering the foot pedal.
Clean the ESU, foot pedal and power cord.
Coil power cords for storage.
Clean all reusable accessories.
Routine care and maintenance of ESU equipment.
Routinely replace all reusable cables and active electrodes at appropriate
intervals, depending upon usage.
Have a qualified biomedical engineer inspect the unit at least every six months.
If an ESU is dropped, it should not be used until it can be inspected by a
biomedical engineer.
Replace adapters that do not provide tight connections.
Inspect permanent cords and cables for cracks in the insulation.
Proper use and maintenance of electrosurgical equipment can prolong its life and
reduce costly repairs.

38
SUMMARY
Surgeons and perioperative nurses have the opportunity to combine evidence-based
practices with unique technical skills and knowledge to achieve high-quality, safe patient
care. The importance of skill and knowledge is particularly critical during the use of
electrosurgery. An educated perioperative team is the patients best advocate.

39
GLOSSARY
Active Electrode An electrosurgical instrument or accessory that
concentrates the electric (therapeutic) current at
the surgical site.

Active Electrode Monitoring A system that continuously conducts stray current

from the laparoscopic electrode shaft back to the
generator and away from patient tissue. It also
monitors the level of stray current and interrupts
the power should a dangerous level of leakage
occur.

Alternating Current A flow of electrons that reverses direction at

regular intervals.

Bipolar Electrosurgery Electrosurgery in which current flows between

two bipolar electrodes that are positioned
around tissue to create a surgical effect (usually
desiccation). Current passes from one electrode
through the desired tissue to another electrode,
thus completing the circuit without entering any
other part of the patients body.

Bipolar Instrument Electrosurgical instrument or accessory that

incorporates both an active and return electrode
pole.

Blend A waveform that combines features of the cut and

coag waveforms; current that cuts with varying
degrees of hemostasis.

Capacitive Coupling The condition that occurs when electrical current

is transferred from one conductor (the active
electrode) into adjacent conductive materials
(tissue, trocars, etc.).

Cautery The use of heat or caustic substances to destroy

tissue or coagulate blood.

Circuit The path along which electricity flows.

Coagulation The clotting of blood or destruction of tissue with

no cutting effect, electrosurgical fulguration and
desiccation.

40
Contact Quality Monitoring A system that actively monitors tissue impedance
(resistance) at the interface between the patients
body and the patient return electrode, and
interrupts the power if the contact quality and/or
quantity is compromised.

Current The number of electrons moving past a given

point per second, measured in amperes.

Current Density The amount of current flow per unit of surface

area; current concentration directly proportional to
the amount of heat generated.

Current Division Electrical current leaving the intended

electrosurgical circuit and following an alternate
path ground; typically the cause of alternate site
burns when using a grounded generator.

Cut A low-voltage, continuous waveform optimized for

electrosurgical cutting.

Cutting Use of the cut waveform to achieve an

electrosurgical effect that results from high-current
density in the tissue causing cellular fluid to burst
into steam and disrupt the structure. Voltage is
low and current flow is high.

Desiccation The electrosurgical effect of tissue dehydration

and protein denaturation caused by direct contact
between the electrosurgical electrode and tissue.
Lower current density/ concentration than cutting.

Diathermy The heating of body tissue generated by

resistance to the flow of high-frequency electric
current.

Direct Coupling The condition that occurs when one electrical

conductor (the active electrode) comes into
direct contact with another secondary conductor
(scopes, graspers). Electrical current will flow
from the first conductor into the secondary one
and energize it.

Direct Current A flow of electrons in only one direction.

41
Electrosurgery The passage of high-frequency electrical current
through tissue to create a desired clinical effect.

ESU ElectroSurgical Unit.

Frequency The rate at which a cycle repeats itself. In

electrosurgery, the number of cycles per second
that current alternates.

Fulguration Using electrical arcs (sparks) to coagulate tissue.

The sparks jump from the electrode across an air
gap to the tissue.

Generator The machine that coverts low-frequency alternating

current to high-frequency electrosurgical current.

Ground, Earth Ground The universal conductor and common return point
for electric circuits.

Grounded Output The output on an electrosurgical generator

referenced to ground.

Hertz The unit of measurement for frequency, equal to

one cycle per second.

Impedance Resistance to the flow of alternating current,

including simple direct current resistance and the
resistance produced by capacitance or inductance.

Insulation Failure The condition that occurs when the insulation

barrier around an electrical conductor is breached.
As a result, current will travel outside the intended
circuit.

Isolated Output The output of an electrosurgical generator that is

not referenced to earth ground.

Leakage Current Current that flows along an undesired path, usually

to ground. In isolated electrosurgery, RF current
that regains its ground reference.

Monopolar Electrosurgery A surgical procedure in which only the active

electrode is in the surgical wound; electrosurgery
that directs current through the patients body and
requires the use of a patient return electrode.

42
Monopolar Output A grounded or isolated output on an
electrosurgical generator that directs current
through the patient to a patient return electrode.

Ohm The unit of measurement of electrical resistance.

Pad A patient return electrode.

Patient Return Electrode A conductive plate or pad (dispersive electrode)

that recovers the therapeutic current from
the patient during electrosurgery, disperses it
over a wide surface area and returns it to the
electrosurgical generator.

Power The amount of heat energy produced per second,

measured in watts.

Radio Frequency Frequencies above 100 kHz; the high-frequency

current used in electrosurgery.

Resistance The lack of conductivity or the opposition to the

flow of electric current, measured in ohms.

RF Radio frequency.

Tissue Response Technology An electrosurgical generator technology that

continuously measures the impedance/resistance
of the tissue in contact with the electrode and
automatically adjusts the output accordingly to
achieve a consistent tissue effect.

Tissue Fusion Technology An electrosurgical technology that combines a

modified form of electrosurgery with a regulated
optimal pressure delivery by instruments to fuse
vessel walls and create a permanent seal.

Volt The unit of measurement for voltage.

Voltage The force that pushes electric current through

resistance; electromotive force or potential
difference expressed in volts.

Watt The unit of measurement for power.

Waveform A graphic depiction of electrical activity that can

show how voltage varies over time.

43
References
1. Sullivan R. The identity and work of the ancient Egyptian surgeon. JRSM.
1996;89(8):467-73. PubMed PMID: WOS:A1996VQ62100013.
2. Kirkup J. The evolution of surgical instruments: an illustrated history from ancient
times to the twentieth century. Novato, CA, Norman Publishing, 2006. Available at:
http://www.historyofscience.com/norman-publishing/instruments/kirkup.php
3. Santoni-Rugiu PS, Sykes PJ. A History of Plastic Surgery. Berlin: Springer; 2007.
4. Mohamed W. The Edwin Smith surgical papyrus: neuroscience in ancient Egypt.
International Brain Research Organization History of Neuroscience [Internet]. 2008.
5. Picket AC. The oath of Imhotep: In recognition of African contributions to western
medicine. J Natl Med Assoc. 1992;84(7):636-7.
6. Laufman H. The history of hemorrhoids. Amer J Surg. 1941;53(2):381-7.
7. Greenwood, E. Amber to Amperes. New York, NY: Harper and Brothers; 1931.
8. Harvey, SC. The History of Hemostasis. New York, NY: Paul B. Hoeber; 1929.
9. Kelly HA, Ward GE. Electrosurgery. Philadelphia, PA: Saunders; 1932.
10. Goldwyn RM. Bovie: The man and the machine. Annals of Plastic Surgery.
1979;2(2):135-53.
11. Vender JR, Miller, J, Rekito, A, McDonnell, DE. Effect of hemostasis and
electrosurgery on the development and evolution of brain tumor in the late 19th and
early 20th centuries. JNS. 2005;18(4):1-7.
12. Isaacson W. Benjamin Franklin: An American Life. New York, NY: Simon & Schuster,
Inc.; 2003.
13. Doctors C. Luigi Galvani (1737-1798). Available at: http://www.corrosion-doctors.org/
Biographies/GalvaniBio.htm
14. Doctors C. Alessandro Voltra (1745-1827). Available at: http://corrosion-doctors.org/
Biographies/VoltaBio.htm
15. Geddes L. Darsonval, physician and inventor. IEEE Eng Med Bio. 1999;18(4):118-
22.
16. Pollack SV, Carruthers A, Grekin RC. The history of electrosurgery. Dermatologic
Surgery. 2000;26(10):904-8.
17. Clark W. The desiccation treatment of congenital and new growths of the skin and
mucous membranes. JAMA. 1914;63(11):925-8.
18. Beer E. Removal of neoplasms of the urinary bladder. JAMA. 1910;54(22):1768-9.
19. Stevens A. On the value of cauterization by high frequency current in certain cases
of prostatic obstruction. New York Medical Journal. 1913;98:170-2.
20. Bugbee H. The use of high frequency spark in the treatment of median bar
obstruction. The Urological and Cutaneous Review. 1917;21(7):361-4.
21. Geddes LA, Roeder RA. De Forest and the first electrosurgical unit. IEEE Eng Med
Bio. 2003;22(1): 84-7.

44
22. OConnor JL, Bloom DA. William T. Bovie and electrosurgery. Surgery.
1996;119(4):390-6.
23. Fulton J. Harvey Cushing: A Biography. Springfield, IL: Charles C. Thomas; 1946.
24. Cushing, H. Original memoirs: The control of bleeding in operations for brain tumors:
With the description of silver clips for the occlusion of vessels inaccessible to the
ligature. Yale J Biol Med. 2001;74:399-412.
25. Voorhees JR, Cohen-Gadol AA, Laws ER, Spencer DD. Battling blood loss
in neurosurgery: Harvey Cushings embrace of electrosurgery. J Neurosurg.
2005;102(4):745-52. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15871521
26. Cushing H. Electro-surgery as an aid to the removal of intracranial tumors. Surgery,
Gyncecology and Obstetrics. 1928;47(6):751-85.
27. Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: History, principles,
and current and future uses. JACS. 2006;202(3):520-30. doi:10.1016/j.
jamcollsurg.2005.11.017. PubMed PMID: WOS:000236233800018.
28. Hay D. Electrosurgery. Surgery. 2007;26(2):66-9.
29. Gallagher K, Dhinsa B, Miles J. Electrosurgery. Surgery. 2010;29(2):70-2.
30. Smith TL, Smith JM. Radiofrequency electrosurgery. Operative Techniques in
Otolaryngology - Head and Neck Surgery. 2000;11(1):66-7.
31. Wu MP. Electro-surgery practices and complications in laparoscopy. Advanced
Gynecologic Endoscopy. 2011:67-86. doi: 10.5772/20301.
32. Wang K, Advincula AP. Current thoughts in electrosurgery. International Journal
of Gynecology & Obstetrics. 2007;97(3):245-50. doi: 10.1016/j.ijgo.2007.03.001.
PubMed PMID: 17451712.
33. Wu MP, Ou CS, Chen SL, Yen EY, Rowbotham R. Complications and recommended
practices for electrosurgery in laparoscopy. The American Journal of Surgery.
2000(179):67-73.
34. Brill AI. Module: Electrosurgery principles & practice. Association of Professors of
Gynecology and Obstetrics. N.D., p. 1-22.
35. Fickling J, Loeffler C. Basics of monopolar electrosurgery. Hotline News.
1999;4(3):2.
36. ECRI. Are spark-gap electrosurgical units safe to use? Health Devices.
1995;24(7):2931.
37. ECRI. Electrosurgery. Operating Room Risk Management. 2007:1-22.
38. Association of periOperative Registered Nurses. Recommended practices for
electrosurgery. Perioperative Standards and Recommended Practices. Denver, CO:
Association of periOperative Registered Nurses; 2011, p. 99-118.
39. Ball K. Surgical Modalities. In: Rothrock JC and McEwen, DR, (Eds). Alexanders
Care of the Patient in Surgery. 14th ed. St. Louis: Elsevier Mosby; 2011, p. 204-249.
40. Association of periOperative Registered Nurses. AORN guidance statement: Care
of the perioperative patient with an implanted electronic device. Perioperative
Standards and Recommended Practices. Denver, CO: Association of periOperative
Registered Nurses; 2012, 583-604.

45
41. Association of periOperative Registered Nurses. Position Statement: Surgical
Smoke and Bio-Aerosols. Available at: http://www.aorn.org/Clinical_Practice/
ToolKits/Surgical_Smoke_Evacuation_ToolKit/Management_of_Surgical_Smoke_
Tool_Kit.aspx
42. The Joint Commission. Environment of Care. Accreditation Program: Hospital.
Oakridge IL: The Joint Commission; 2008. p. 1-20.
43. Ulmer BC. The hazards of surgical smoke. AORN J. 2008;87(4):721-34; quiz 35-8.
Epub 2008/05/09. PubMed PMID: 18461735.
44. Barrett WL, Garber SM. Surgical smoke: A review of the literature. Is this just a lot of
hot air? Surg Endosc. 2003;17(6):979-87. Epub 2003/03/18. doi: 10.1007/s00464-
002-8584-5. PubMed PMID: 12640543.
45. Wilburn S. Health and safety: Is the air in your hospital making you sick? AJN.
1999;99(7):71.
46. Center for Disease Control and Prevention. CDC - NIOSH Publications and
Products - Control of Smoke From Laser/Electric Surgical Procedures (96-128)
1996. Available at: http://www.cdc.gov/niosh/docs/hazardcontrol/hc11.html.
47. Watson DS. Surgical smoke evacuation during laparoscopic surgery. AORN J.
2010;92:347-50.
48. Ott DE. Smoke and particulate hazards during laparoscopic procedures. Surgical
Services Management. 1997;3(3):11-2.
49. Malcolm G, Munro MD. Capacitive coupling: A comparison of measurements in four
uterine resectoscopes. J Am Coll Surg. 2004;11(3):37987. doi: 10.1016/S1074-
3804(05)60055-2.
50. Dennis V. Patient Safety in Laparoscopy. 2005. Available at: http://www.psqh.com/
mayjun05/aems.html.
51. Harrington DP. Electrosurgery fact and fiction. Biomedical Instrumentation &
Technology. 1994: 331-3.

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