Chapter 24

ELECTROSURGICAL UNITS

OBJECTIVES

• Describe the tissue response to electrosurgical current in terms of des-

iccation, fulguration, and cutting.
• Identify the characteristics of the cut, coagulation, and blended electro-
surgical waveforms.
• Explain the constructions and functions of active bipolar and monopo-
lar electrodes, and the dispersive return electrode.
• Sketch the block diagram of an electrosurgical generator and explain
the functions of each block.
• Analyze ESU waveform generation circuits.
• Perform quality assurance testing on an ESU generator.
• Identify the potential hazards of electrosurgery and safety precautions
during electrosurgical procedures.

CHAPTER CONTENTS

1. Introduction
2. Principle of Operation
3. Modes of Electrosurgery
4. Active Electrodes
5. Return Electrodes
6. Functional Building Blocks and ESU Generators
7. Output Characteristics
8. Quality Assurance
9. Common Problems

391
392 Biomedical Device Technology: Principles and Design

INTRODUCTION

An electrosurgical unit (ESU) delivers high-frequency electrical current

through an active electrode to produce cutting and coagulation effects on tis-
sues. The frequency of electrosurgery for cutting is between 100 kHz and 5
MHz, which is within the radio frequency (RF) band. When appropriately
modulated, this RF frequency can cut through tissues and cauterize bleeding
blood vessels. The simultaneous cutting and hemostatic effect make ESU
useful for procedures on tissues with capillaries and on patients receiving a
high dose of anticoagulant drugs.
Electrosurgical units using spark-gap generators have been used since the
1920s. Most ESUs today use solid-state technology with microprocessor-con-
trolled output for better results and improved safety. Argon-enhanced ESU
systems, using a jet of argon gas to cover the surgical site during electro-
surgery, can provide rapid and uniform coagulation over a large bleeding
surface and are therefore useful in surgeries on organs such as the liver,
spleen, and lung. ESUs are also used in endoscopic procedures to perform
ablation, desiccation, cauterization, and removal of tissues. Special hand-
pieces are designed for different ESU procedures.

PRINCIPLE OF OPERATION

An ESU is a RF generator. Two electrodes, one called active and the

other called passive, are used to apply the RF current from the ESU to the
patient. At the beginning of the procedure, the passive electrode (or return
electrode) is attached to the patient’s body. The surgeon then applies the
active electrode to the surgical site to achieve the surgical effect. The active
electrode is usually a very small tip electrode, while the return electrode has
a large contact surface area with the patient. The high-frequency current
passing through the tissue creates the surgical effect. The surgical effect is due
to heat created by the RF current at the tissue–active electrode interface. The
degree of heating in the tissue depends on the resistivity of the tissue as well
as on the RF current density (the resistivity of soft tissue is about 200
m).
Figure 24–1 shows a typical setup of an electrosurgical procedure.
Different current densities create different effects on living tissues. Table
24–1 shows typical tissue effects at different levels of RF current density.
In practice, a current density much higher than 400 mA/cm2 at the sur-
gical site is necessary to produce electrosurgical effect. However, to prevent
tissue injury beyond the surgical site, the current density must be limited to
below 50 mA/cm2 in tissues outside the surgical site. This is achieved by
 Electrosurgical Units 393

Figure 24–1. Electrosurgery Setup.

Table 24–1.
Tissue Effect of RF Current Density.
Current Density Tissue Effect
2
 50 mA/cm Reddening of tissue
 80 mA/cm2 Pain and blistering
 100 mA/cm2 Intense pain
 400 mA/cm2 Second-degree burn

attaching a large surface area electrode on the opposite side of the active
electrode so that the return current is dispersed over a larger area within the
patient’s body. Figure 24–1 shows the active electrode applied to the surface
of the tissue and the flow of current inside the tissue when the return elec-
trode is placed far from the active electrode. The density of the RF current
flowing in the tissue closest to the active electrode is the highest, and it
decreases rapidly (inversely proportional to the square of the distance from
the surgical site) at locations farther from the active electrode site.
Three different tissue effects can be created by an electrosurgical current
at the active electrode site: desiccation, cut, and fulguration.

Desiccation

When a relatively small RF current flows through the tissue, it produces

heat and raises the tissue temperature at the surgical site. Heat will destroy
and dry out the cells. This process may produce steam and bubbles and
eventually turns the tissue a brownish color. This mechanism of tissue dam-
age is called desiccation. It is achieved by placing the active electrode in con-
394 Biomedical Device Technology: Principles and Design

tact with the tissue and setting the ESU output to low power. As desiccation
is created by the heating (I2R) effect, any current waveform may be used for
desiccation.

Cut

By separating the active electrode by a small distance (about 1 mm) from

the tissue and maintaining a few hundred volts or higher between the active
and return electrodes, RF current may jump across the separation, produc-
ing sparks. Sparking creates intense heat, causing cells to explode. Such
destruction of cells leaves behind a cavity. When the active electrode moves
across the tissue, this continuous sparking creates an incision on the tissue to
achieve the cutting effect. In general, a high-frequency (e.g., 500 kHz) con-
tinuous sine wave is used to create the cutting effect. Cutting usually requires
a high power output setting.

Fulguration

To produce fulguration, the energized active electrode first touches the

tissue and then withdraws a few millimeters to create an air gap separation.
As the active electrode moves away from the tissue, the high voltage creates
an electric arc jumping across the active electrode and the tissue. This long
arc burns and drives the current deep into the tissue. Intermittent sparking
does not produce enough heat to explode cells, but it causes cell necrosis and
tissue charring at the surgical site. Fulguration coagulates blood and seals
lymphatic vessels. To achieve fulguration, most manufacturers use bursts of
a short-duration damped sinusoidal waveform. The sinusoidal waveform is
usually the same frequency used for cutting (e.g., 500 kHz), and the repeti-
tion frequency for the bursts is much lower (e.g., 30 kHz). A higher voltage
waveform is required to maintain the long sparks. Although the peak voltage
is higher, fulguration produces less power than cutting due to its low duty
cycle.
Table 24–2 summarizes the three mechanisms of electrosurgery.

MODES OF ELECTROSURGERY

The cut mode in electrosurgery applies a continuous RF waveform (sinu-

soidal or near sinusoidal) between the active and return electrodes. The
coagulation mode uses bursts of a higher voltage damped RF sinusoidal
waveform (to create fulguration tissue effect). Instead of switching back and
 Electrosurgical Units 395

Table 24–2.
Mechanism of Electrosurgery.
Tissue Effect Active Electrode Power
Desiccation Heat dries up tissue, produces Monopolar or bipolar. Low
steam and bubbles. In contact with tissue.
Turns tissue brown.
Cut Sparking produces intense heat, Monopolar. High
explodes cells leaving cavity. Electrode separated from
Incision on tissue caused by tissue by a thin layer of
continuous sparking. steam.
Fulguration Intermittent sparking does not Monopolar. Medium
produce enough heat to explode Electrode separated by
cells. Heat causes necrosis to an air gap.
tissue.
High voltage drives current deep
into tissue, chars tissue to carbon

forth between cut and coagulation during a procedure, most ESUs have one
or more blended modes, which allow simultaneous cutting and coagulation.
A blended waveform has a lower voltage level but a larger duty cycle than
the coagulation waveform. Figure 24–2 shows an example of the cut, blend-
ed, and coagulation output waveforms of an ESU. A blended mode with a
larger duty cycle will have more cutting effect than one with a lower duty
cycle.
The setup shown in Figure 24–1 with the active electrode and the large
surface return electrode is called a monopolar operation. Instead of placing
a separate return electrode away from the surgical site, a bipolar handpiece
has both the active and return electrodes grouped together (e.g., an ESU for-
ceps). Biopolar electrodes are often used to perform localized desiccation on
tissue. In Figure 24–3, the ESU is switched to bipolar coagulation mode to
cauterize a section of a blood vessel before it is cut apart to avoid profuse
bleeding.
Table 24–3 lists the characteristics of different modes of ESU operations.
The crest factor (last column) is defined as the peak voltage amplitude of the
ESU waveform divided by its root mean square voltage. For a continuous
sine wave, the crest factor is 1.41. Since a pure sine wave has little or no
hemostatic effect on tissues, most manufacturers use a lightly modulated sine
wave to achieve a small degree of hemostatic effect in the cut mode. The
crest factor of the coagulation waveform is the highest (about 9) since it has
the largest peak voltage but the smallest duty cycle. In general, the higher the
crest factor, the more hemostatic effect the ESU waveform will have on tis-
sues.
396 Biomedical Device Technology: Principles and Design

Figure 24-2. ESU Output Waveforms. (a) Cut, (b) Blended, (c) Coagulation.

Figure 24–3. Bipolar Mode of Electrosurgery.

 Electrosurgical Units 397

Table 24–3.
Characteristics of ESU Operation Modes.
Effect Waveform Voltage Power Crest Factor
Monopolar
Cut Pure incision Continuous Low High ~1.41 to 2
plus slight unmodulated
hemostatic effect sine wave to
lightly modulated
sine wave
Coagulation Desiccation or Burst of damped High Low ~9
fulguration sine wave
Blended Cut and Burst of medium Medium Medium Between
coagulation duty factor cut and
sine wave coagulation
Bipolar
Coagulation Desiccation Continuous Lowest Lowest 1.41
unmodulated
sine wave

ACTIVE ELECTRODES

ESU active electrodes for monopolar operations come in different forms

and shapes. The most common active electrode is the flat blade electrode,
which can be used to perform cutting and coagulation. Some of the other
commonly used active electrodes are needle, ball, and loop electrodes. Ball
electrodes are usually used for desiccation (by pressing the electrode against
the tissue and passing the RF current through the tissue). Loop electrode,
with its conductive wire loop, is used to remove protruded tissues such as a
nodule. The metal tips of the electrodes (Figure 24–4b) are usually single-use
disposable units. The electrode handles may be multiple use or single use.
The handle part of the electrode may have a switch to activate the ESU. A
foot switch operated by the surgeon may be used instead of the hand switch.
The combination of an ESU handle and a tip (Figure 24–4a) is often referred
to as an ESU pencil (or a hand-switched ESU pencil if a switch is located on
the handle).

RETURN ELECTRODES

While the function of the active electrode is to create the surgical effects,
the return electrode (or passive electrode) in monpolar ESU operation pro-
398 Biomedical Device Technology: Principles and Design

Figure 24–4. (a) Hand-Switched ESU Pencil with a Flat Blade Electrode;
(b) Monopolar Tips: 1) Loop, 2) Flat Blade, 3) Needle, 4) Ball.

vides the return path for the ESU current. As mentioned earlier, the maxi-
mum RF current density level to avoid causing any tissue damage is 50
mA/cm2. A large surface area electrode (e.g., 100 cm2) is therefore required
to limit the current density below this safe level in tissues away from the sur-
gical site, including those in contact with the return electrode.
There are many types of return electrodes for ESU procedures. Bare
metal plates placed under and in contact with the patient were used in early
days. However, it was noted that burns (primarily heat burns) and tissue
damage sometimes occurred at the return electrode sites. Investigations
revealed that the primary cause of such patient injuries was due to poor elec-
trode–skin contact or insufficient contact surface area between the electrode
and the patient (part of the electrode not in contact with the patient). It was
also noted that burns often appeared in the form of rings at the skin surface.
Laboratory experiments showed that the current density at the skin–return
electrode interface is highest around the rim of the electrode. Figure 24–5
shows the current density distribution of such an experiment. This occur-
rence is due to the fact that electrons are negatively charged particles; when
they are allowed to freely move in a conductive medium, they will repel each
other and therefore more will end up at the perimeter of the medium, in this
case at the perimeter of the return electrode. This phenomenon is known as
the “skin effect” in electrical engineering, where the current density of high-
frequency current in a conductor is very much higher at the surface of the
conductor than in its core.
Today, conductive gel pads are used for ESU return electrodes. A con-
ductive gel pad electrode has a self-adhesive surface to avoid shift and falloff
and is flexible to fit the contour of the patient’s body. Return electrodes are
 Electrosurgical Units 399

designed so that, under normal use, no skin burn will occur at the return
electrode site. To ensure patient safety, technical standards are in place spec-
ifying the performance of return electrodes. For example, the ANSI/AAMI
HF18 Standards stipulate that the overall tissue-return electrode contact
resistance shall be below 75
. In addition, no part of the tissue in contact
with the return electrode shall have more than a 6ºC temperature increase
when the ESU is activated continuously for up to 60 seconds with output cur-
rent up to 700 mA.

Figure 24–5. Current Density Crossing the Return Electrode–Skin Interface.

Due to problems associated with burns, special monitoring devices are

often built into ESUs to monitor the integrity of the return electrode path. If
the integrity is breached, an alarm will sound and the ESU output will be dis-
abled to prevent patient injury. Two levels of monitoring are often available
for high output power ESU (e.g., output greater than 50 W). The first is
return electrode monitoring and the second is return electrode quality mon-
itoring.

Return Electrode Monitor (REM)

A REM system monitors the return path of the electrode to the ESU. It
detects the continuity of the return electrode cable from the electrode to the
ESU. In a typical REM system, a double conductor cable and a low-fre-
quency (relative to the ESU output frequency; e.g., 140 KHz) low-current
(e.g., 3 mA) isolated source from the ESU are used to measure the resistance
400 Biomedical Device Technology: Principles and Design

of the return cables (Figure 24–6a). A high resistance (e.g.,  20
) will trig-
ger the REM alarm.

Return Electrode Quality Monitor (REQM)

REM measures only the continuity of the return electrode cable, not the
quality of contact between the electrode and the patient, whereas REQM
monitors both. Figure 24–6b illustrates the principle of the REQM. In
REQM, a dual conductive pad electrode is used. The right-hand side dia-
gram in Figure 24–6b shows the cross-sectional view of the electrode–skin
interface. The small monitoring current flows from the ESU REQM circuit
to one of the conductive pads, passes through the two electrode–skin inter-
faces, and returns to the ESU via the second pad. Too high a REQM resis-
tance (e.g., greater than 135
) suggests poor electrode–skin contact or open
circuit return cable; too low a resistance (e.g., less than 5
) suggests a short
circuit between the two conductive pads. In addition, some machines may
sound an alarm if the REQM detects a large change in the resistance (e.g.,

Figure 24–6. Return Electrode and Return Electrode Quality Monitors.

 Electrosurgical Units 401

resistance increase by more than 40% from the initial reference value).
FUNCTIONAL BUILDING BLOCKS OF ESU GENERATORS

The spark gap ESU generator developed in the 1920s consists of a step-
up transformer T1, which increases the 60 Hz 120 V line voltage to about
2,000 to 3,000 V (Figure 24–7). As the sinusoidal voltage at the secondary of
T1 increases from zero, electrical charge accumulates in the capacitor C1
and the gas inside the spark gap (a gas discharge tube) starts to ionize until
an arc is formed between its electrodes. Arcing (or sparking) of the spark gap
resembles closing of a switch in the series resonance circuit formed by C1,
L1, and the impedance of the spark gap. The fundamental frequency of the
arcing current is approximately equal to the resonance frequency of L1/C1.
The voltage amplitude of this high-frequency oscillation will decay until the
arc is extinguished. Proper choice of L1 and C1 produces an RF damped
sinusoidal waveform that occurs twice within one period of the 60 Hz input
signal. This RF damped sinusoidal waveform is coupled to the output circuit
by induction between L1 and L2. The output level is selected by the taps
selection on L2. The RF chokes L3 and L4 (or RF shunt capacitor C4) are
used to block the RF signal from entering the power supply. Spark gap gen-

Figure 24–7. Spark Gap ESU Generator.

erators are primarily used for coagulation or cauterization.

Spark gap ESUs were commonly used until the early 1980s, when they
began to be replaced by solid-state generators. In a solid-state ESU, the RF
frequency (e.g., 500 kHz) and the burst repetition frequency (e.g., 30 kHz)
are generated by solid-state oscillators. The shape of the ESU waveform (cut,
blended, or coagulation) is created by combining the frequencies of these
two oscillators. The waveform is then amplified by a power amplifier and a
402 Biomedical Device Technology: Principles and Design

step-up transformer. The output of an ESU can go up to 1,000 watts, 9,000

volts (peak to peak open circuit voltage), and 10 amperes. Figure 24–8 shows

Figure 24–8. Functional Block Diagram of an ESU.

the simplified functional block diagram of a solid-state ESU.

The output stage of an ESU is shown in Figure 24–9. In the circuit, the
waveform created by the gating and wave shaping circuit is fed into the base
of a power amplifier Q1, and the output of the amplifier connects to the pri-
mary winding of the output transformer T1. The transformer and the power
amplifier circuit are connected to a 200 V DC power source. For high-power
output ESUs, a number of power transistors connected in parallel form the
output circuit. Each of these transistors shares a portion of the output power.
The ESU waveform, after steps up by the output transformer to several thou-
sands volts, is fed across the active and return electrodes via a pair of capac-
itors C1 and C2. These capacitors behave like a short circuit to RF but block
low-frequency (60 Hz) leakage current to the patient.
The ESU output circuit shown in Figure 24–9 is considered an isolated
output ESU as there is no connection from the patient circuit (the secondary
of the output transformer) to the power ground. Theoretically, for an isolat-
ed output ESU, a person touching the active electrode but not the return
electrode will not get a shock or burn when the ESU is energized. However,
due to the high frequency and nonzero leakage capacitance, if the person
also touches a grounded object, some RF current will flow from the active
 Electrosurgical Units 403

Figure 24–9. ESU Output Circuit.

electrode to the person and return to the ESU via this ground leakage path.
High-frequency leakage current may be on the order of magnitude of a few
tens of mA.

OUTPUT CHARACTERISTICS

Table 24–4 lists the output characteristics of a typical ESU. Figure 24–10
illustrates the output characteristics of the ESU cut waveform at different val-
ues of patient load. Note that according to the output characteristics, the ESU
is rated to produce 300 W of output only when the patient load is at 300
.
The output power is reduced to 180 W when the patient load becomes 800

. According to the ESU output characteristics, the output power decreases
as the patient load increases. As the tissue impedance depends on the type
of tissue as well as the condition of the tissue, this may create problems dur-
ing the operation as the output power at a particular setting will fluctuate
with the tissue impedance. To overcome this problem, some manufacturers
have produced ESUs that can measure the tissue impedance and automati-
cally restore the output power to the set value.
In most electrosurgical procedures, the active electrode is energized only
404 Biomedical Device Technology: Principles and Design

Table 24–4.
ESU Output Characteristics.
Mode Waveform Max. P-P Rated Patient Output Power
Open Circuit Load (
) (at rated load)
Voltage (V) (W)
Cut 500 kHz sinusoidal 3,000 300 300
Blend 1 500 kHz burst of sinusoidal at 3,500 300 250
50% duty cycle repeating at
30 kHz
Blend 2 500 kHz burst of sinusoidal at 3,700 300 200
37.5% duty cycle repeating at
31 kHz
Blend 3 500 kHz burst of sinusoidal at 4,000 300 150
25% duty cycle repeating at
30 kHz
Coagulation 500 kHz burst of damped 7,000 300 120
sinusoidal repeating at 30 kHz
Bipolar 500 kHz sinusoidal 800 100 70

Figure 24–10. ESU Cut Mode Output Characteristics.

intermittently and each activation lasts for a short period of time (e.g., 15 sec-
onds for cutting in general surgery). Table 24–4 shows the peak to peak open
circuit voltage of different modes of operation. However, when the current
starts to flow (i.e., an arc has been established), the voltage across the active
and return electrodes will drop substantially.
 Electrosurgical Units 405

QUALITY ASSURANCE

Since an ESU delivers high-energy therapeutic current, it is essential to

ensure that the machine is safe and is operating according to its designed
specifications. Other than general electrical safety inspection, the following
performance tests should be carried out periodically.

Output Power Verification Test

The output power of an ESU should be measured against the manufac-

turer’s specifications. Figure 24–11 shows the setup to measure the ESU out-
put power. The output waveform can be sampled across the sample resistor
RS and displayed on the oscilloscope. The output voltage V0 of the ESU is
calculated from the resistance values by the equation:
R + R S V S.
V0 = ———————
RS
If the output voltage is a sine wave, the power output may be calculated from
the equation:
V02 .
P = ———————
R + RS
Note that the load resistance RL is equal to (R + RS) and both should be spe-
cial noninductive resistors and of sufficient power rating to withstand the

Figure 24–11. ESU Output Power Measurement.

406 Biomedical Device Technology: Principles and Design

ESU output.
High-Frequency Leakage Test

High-frequency leakage refers to the current flowing from either the

active electrode to ground or the return electrode to ground when the ESU
output is activated. Ideally, the amount of leakage current should be zero.
However, due to the nature of the high frequency, a significant amount of
capacitive leakage current will flow between the active electrode and ground
as well as between the return electrode and ground. Figure 24–12b shows the
setup to measure the high-frequency leakage from the active electrode to
ground. To measure the leakage from the return electrode to ground, the
load resistor is connected to the return electrode connection of the ESU and
the active electrode connection is left open. The allowable leakage found by
measuring the power dissipated by the load resistance RL (e.g., less than 4.5
W for RL = 200
). Percentage isolation is a common value to represent the
degree of isolation. It is defined as:
P isolation )  100%.
% Isolation = (1 – ———————
P normal

Figure 24–12. ESU Isolation Test.

Some manufacturers (and standards) call for the %Isolation to be greater

that 80% for a load resistance RL within the range of 100 to 1,000
.
Special testers with built-in potential dividers, variable patient load, and
switchable configurations are available to facilitate these measurements.

COMMON PROBLEMS
 Electrosurgical Units 407

Problems associated with electrosurgery may be grouped into four dif-

ferent categories:
• Burns
• Fire
• Muscle/nerve stimulation
• Electromagnetic interference

Burns

Skin burns at the return electrode site are one of the more common safe-
ty problems for patients under electrosurgical procedures. The main causes
of skin burn are poor electrode–skin contact, inadequate site preparation,
and pressure points on the electrode contact surface (which creates a low
resistance pathway for the current).
• Internal tissue burns are caused by the concentration of ESU current
along a low resistance path such as a metal implant or a pacemaker
lead wire near the active or return electrodes sites.
• For grounded ESUs or ESUs with isolation failure, RF current may
flow through a secondary ground path on the patient (e.g., a patient’s
arm may receive a burn at the location where it is touching a ground-
ed object).
• In endoscopic or laparoscopic procedures, an insulation failure on the
shaft of the ESU handpiece will cause tissue burn when such failure
creates a secondary conduction path between the active electrode and
the tissue.
• Too high a power setting and too long an activation period (e.g., dur-
ing a liver tumor ablation procedure) when an undersized return elec-
trode was used or the return electrode was not properly applied.
• Patient or staff burns by an activated ESU pencil when it was inad-
vertently energized (e.g., someone accidentally stepped on the ESU
foot activation switch) while touching the patient or a staff member.

Fire and Explosion

An electrosurgical procedure produces sparks and arcing. The sparks

may ignite flammable materials such as body hair, cotton drapes, or a pool
of alcohol used for disinfection. This situation is worsened under an enriched
oxygen environment, which is commonly found in operating room areas.
There have been incident reports on cases of explosion inside the
abdominal cavity when the ESU ignited flammable bowel gas inside the
patient.
408 Biomedical Device Technology: Principles and Design

Muscle and Nerve Stimulation

The reason ESU frequency is above 100 kHz is to avoid muscle and
nerve stimulation. Under normal circumstances, muscle and nerve fibers are
not triggered by current lower than 100 kHz. However, studies have shown
that arcing may produce lower frequency current, which can stimulate nerve
or muscle fibers. As a precaution, it is contraindicated to perform electro-
surgery near major nerve fibers.

Electromagnetic Interference (EMI)

An ESU is a RF source. Although the machine may be shielded to pre-

vent radiation and conduction of EMI, the electrodes and cables act as
antennae to broadcast the RF frequencies. Older medical devices, with lower
electromagnetic immunity, can be adversely affected by the EMI from elec-
trosurgery. Devices may reset, produce errors, or switch to another mode of
operation under EMI influence. Improperly grounded devices are especial-
ly vulnerable to EMI.