Electrosurgical Unit Research Articles

Systematic error compensation for improving accuracy of the electrosurgical unit.

This paper presents an approach to systematic error correction for improving the accuracy of the electrosurgical unit (ESU), through a method that enables safer operation for both surgeons and patients. The equations for systematic errors encountered during the calibration of the eight ESUs were obtained using regression analysis. The ESU calibration was performed using a power analyzer and the reference power value was selected on the ESU panel; the power value indicated by the ESU was noted from the power analyzer and recorded. The fitted regression models were suitable for predicting systematic errors associated with ESU output power values, as a reduction of about 84 % was noted in cutting power (CuP) and about 74 % for coagulation power (CoP). After correction, systematic error values remained below 1.9 W and 0.4 W in cutting and coagulation power, respectively. The maximum error values obtained were less than those specified for the IEC 60601-2-2 standard for all evaluated ESUs.

Possibility of ultrathin endoscopy in radial incision and cutting for esophageal strictures.

Video 1The radial incision and cutting procedure using ultrathin endoscopy.

Uji Filtrasi Heat and Moisture Exchangers (HME) dalam Menyaring Gas Formaldehida

This study aims to examine the use of Heat and Moisture Exchangers (HME) filters in filtering volatile organic compounds (formaldehyde) produced from surgical fumes, a side effect of using hazardous electrical-based surgical instruments. The method used is the descriptive method with a total sample of 15, divided into three groups, namely HME1, HME2 and HME3. The results showed that the HME1 filter obtained the highest formaldehyde value of 15.95 ppm and the lowest of 10 ppm with a mean value of 12.99 ppm; HME2 filter with the highest formaldehyde value of 13.98 ppm, the lowest 7.98 ppm and the mean value of 9.58 ppm; the HME3 filter showed the highest formaldehyde value of 11.98 ppm and the lowest of 4.99 ppm with a mean number of 4.99 ppm. In conclusion, there is a difference in the average amount of smoke after being given the action of the filter modification method (HME1, HME2 and HME3). The modified filter can be used to capture/filter surgical fumes.
 Keywords: Surgical Fumes, Electrosurgical Unit, HME Filter, Formaldehyde, Breast Cancer

Clinical Issues-August 2022.

Use of sterile vests Key words: sterile technique, surgical attire, gown, contaminated, back. Bare arms for unscrubbed personnel Key words: long sleeves, cover jacket, disposable jacket, patient skin antisepsis, surgical site infection (SSI). Preventing thermal injury from electrosurgical devices Key words: electrosurgical unit (ESU), monopolar electrosurgical device, electrode, alternate site thermal injury, burn. Preoperative site marking for minimally invasive procedures Key words: surgical site, wrong-site surgery, alternative site marking, point of access, preprocedure verification.

Safety and efficacy of a low-level radiofrequency thermal treatment in an animal model of obstructive meibomian gland dysfunction.

This study aimed to evaluate the safety and efficacy of a low-level radiofrequency thermal treatment in an obstructive MGD rabbit model. Meibomian gland orifices of the central two-thirds of the upper and lower eyelid margins were coagulated twice at 2-week intervals using a 5-MHz high-frequency electrosurgical unit. Sixteen eyes of eight rabbits were treated with one session of radiofrequency thermal treatment (radiofrequency group) and eight eyes of four rabbits were followed up without treatment (control group). Lid margin abnormality and corneal staining scores, histologic examination of the eyelids and meibombian gland, and meibography imaging were evaluated just before and 4weeks after meibomian gland orifice closure and 4weeks after radiofrequency thermal treatment. Lid margin abnormality score improved significantly for the upper and lower eyelids after radiofrequency thermal treatment (P < 0.001 for both eyelids). Corneal staining score remained unchanged in the radiofrequency group; however, the control group saw an increase at final follow-up. There was a significant improvement to almost baseline levels in the mean area of secretory acini in the radiofrequency group (P = 0.004). Additionally, meibography indicated an improvement in meibomian gland loss rate in the radiofrequency group. Low-level radiofrequency thermal treatment heating the inner and outer eyelid surfaces is safe and effective to treat obstructive MGD in a rabbit animal model of MGD.

Quantifying the magnitude of local tendon injury from electrosurgical transection.

Electrocautery is a common surgical technique and is often used during shoulder arthroplasty to elevate or transect the subscapularis tendon. The relative amount of tissue damage caused by cautery as opposed to sharp transection is not currently known. The purpose of this study was to examine local tissue damage resulting from electrocautery vs. sharp transection with a scalpel. We hypothesized that the electrosurgical unit would cause higher collateral tissue damage and cell death compared with sharp transection. Twelve cadaveric ovine shoulders were randomized to either the electrosurgical or sharp transection group. The infraspinatus tendon was isolated, and a partial-thickness transection was made using either a monopolar electrosurgical device (Bovie) or No. 10 scalpel blade. Tendon explants were then visualized with confocal microscopy to evaluate tissue architecture. A live/dead assay was performed using microscopy imaging analysis software. Comparisons between Bovie and scalpel transection were made using the Mann-Whitney U test, and the cell death percentage at standardized distances from the transection site was compared between groups using a mixed-model analysis. Significance was defined at P < .05. The cellular and tendon fibril architecture was well maintained beyond the scalpel transection site, whereas Bovie transection disrupted the architecture beyond its transection path. The percentage of dead cells in the Bovie group (74.9% ± 31.2%) was significantly higher than that in the scalpel group (27.6% ± 29.9%, P = .0004). Compared with the transection site, the cell death percentage after Bovie transection significantly declined at 2.5 mm whereas that after scalpel transection significantly declined at 1 mm from the transection site. There was a significantly higher dead cell percentage in the Bovie transection group, indicating extensive damage beyond the local incision site, compared with sharp transection. Electrosurgical transection of the ovine infraspinatus tendon exvivo caused higher cell death and greater tissue architecture disruption compared with sharp scalpel transection.

The effects of educational intervention on operating room nurses' use of electrosurgical units

BackgroundElectrosurgical units are used in over 80% of operations worldwide. The consequences of incorrect use of electrosurgical units for patients and the surgical team include skin burns, inhalation of electrosurgical smoke, fire, and disruption to the functioning of cardiac pacemakers. Training operating room personnel in the correct use of electrosurgical units and evaluating their performance plays a crucial role in making optimal use of the units and extending their lifetime, reducing occupational hazards for surgical teams, and enhancing the safety of patients. Therefore, the present study was done to investigate the effects of an educational intervention on electrosurgical units by operating room nurses. MethodsIn this quasi-experimental research, the performance of 100 operating room nurses concerning their application of electrosurgical units in 200 operations (100 before and 100 one month after the educational intervention) was observed and evaluated. The data collection instruments consisted of a Demographic Information Questionnaire, a surgery checklist, and the checklist for the use of electrosurgical units by operating room nurses. The content of the poster was based upon the standard principles of using electrosurgical units based on the guidelines by the Association of periOperative Registered Nurses (AORN), Association of Surgical Technologists (AST), and the Association for PeriOperative Practice (AFFP). ResultsThe average age of the participating nurses were 31.540 ± 6.772 years. Before (18.330 ± 2.666) and after (20.820 ± 3.400) the educational intervention, the results showed a statistically significant difference between the means and standard deviations of the scores of electrosurgical units by operating room nurses. ConclusionIntroducing operating room nurses to the standard guidelines for applying electrosurgical units can improve the quality of services provided by the nurses, increase the safety of patients, and reduce occupational hazards. Thus, medical managers and policymakers should pay more attention to on-the-job training programs to improve the professional performance of operating room nurses in the use of electrosurgical units.

Implementing a Surgical Smoke Evacuation Policy and Procedure: A Quality Improvement Project.

Energy-generating surgical devices (eg, electrosurgical units, lasers) produce surgical smoke that can cause negative health effects in exposed individuals. In 2019, a review of nursing documentation at an urban teaching hospital revealed that personnel were properly evacuating surgical smoke during less than 0.5% of applicable procedures. To address the noncompliance and reduce exposure to surgical smoke, an interdisciplinary team initiated a quality improvement project to implement a surgical smoke evacuation policy for all smoke-generating procedures. The project included creation and implementation of a smoke evacuation policy, staff member education on the hazards of surgical smoke and proper evacuation device use, and acquisition of the proper smoke evacuation equipment. After instituting the policy in June 2020, results of a three-month chart audit showed that there was nursing documentation confirming personnel used energy-generating devices and the corresponding surgical smoke evacuation devices during 664 of 2,224 procedures, for a compliance rate of 30%.

Percutaneous Electromyoneurolysis of the Orbicularis Oculi Muscle: A Permanent Substitute of Botulinum Toxinin Crow’s Feet

The skin is exposed to many factors that cause wrinkling and loss of elasticity. For the past 30 years, Botulinum Toxin (BT) injections have been the gold standard of treatment for wrinkle reduction. In this article, the authors propose a permanent treatment for crow’s feet wrinkles: Percutaneous Electromyoneurolysis (PEMN) of the Orbicularis Oculi Muscle (OOM) which blocks muscular and nerve fibers using an electrosurgical unit. This procedure was performed on 34 patients between 2016 and 2021, with the objective of attenuating lateral periorbital wrinkles (crow’s feet) or benign essential blepharospasm. The results were evaluated and deemed successful after a 9-month follow-up. Our study demonstrates the effectiveness and viability of this approach and may lead to future applications in facial aesthetics.

Endoscopic submucosal dissection for early gastric adenocarcinoma: basic procedures and management of complications

Mastery of endoscopic submucosal dissection (ESD) requires a deep understanding of not only the technique but also the preparation, electrosurgical unit, its peripherals, and probable procedural complications. An endoscope with a water-jet function is suitable for gastric ESD. A transparent attachment on the tip of the endoscope is necessary. The mucosal preparation is important for proper lesion recognition and precise device movement during the procedure and to reduce the risk of complications. A needle-type knife allows accurate tissue dissection and is especially useful for dissecting fibrosis in the submucosa. A partially insulated-type knife prevents current transmission from the tip of the needle to the deep tissues, thus reducing the risk of unintentional perforation or bleeding. When using a scissor-type knife, stable device movement is possible and unintended tissue dissection is minimized. The electrosurgical unit mode must be adjusted according to the different tissue conditions. The basic techniques for ESD incision and dissection should be mastered, and the appropriate knives, accessories, strategy, and traction device should be methodically selected by each operator. The main complications of ESD are bleeding and perforation, which should be treated appropriately when they occur.

Quantification of electrosurgery-related critical events during laparoscopic cholecystectomy – a prospective experimental study among surgical novices

Uncontrolled movement of instruments in laparoscopic surgery can lead to inadvertent tissue damage, particularly when the dissecting or electrosurgical instrument is located outside the field of view of the laparoscopic camera. The incidence and relevance of such events are currently unknown. The present work aims to identify and quantify potentially dangerous situations using the example of laparoscopic cholecystectomy (LC). Twenty-four final year medical students were prompted to each perform four consecutive LC attempts on a well-established box trainer in a surgical training environment following a standardized protocol in a porcine model. The following situation was defined as a critical event (CE): the dissecting instrument was inadvertently located outside the laparoscopic camera’s field of view. Simultaneous activation of the electrosurgical unit was defined as a highly critical event (hCE). Primary endpoint was the incidence of CEs. While performing 96 LCs, 2895 CEs were observed. Of these, 1059 (36.6%) were hCEs. The median number of CEs per LC was 20.5 (range: 1–125; IQR: 33) and the median number of hCEs per LC was 8.0 (range: 0–54, IQR: 10). Mean total operation time was 34.7 min (range: 15.6–62.5 min, IQR: 14.3 min). Our study demonstrates the significance of CEs as a potential risk factor for collateral damage during LC. Further studies are needed to investigate the occurrence of CE in clinical practice, not just for laparoscopic cholecystectomy but also for other procedures. Systematic training of future surgeons as well as technical solutions address this safety issue.

Mobile Surgical Teams Can Help Reduce the Surgical Burden of Disease in Low Income Countries

Introduction: 11% of the global burden of disease is attributable to surgical conditions hence more than 2 billion people have no access to surgery care. In effect there are many neglected cases in low income countries that will never achieve a normal life. The World Surgical Foundation (WSF) was formed in 1997 to help reduce the surgical burden of disease and the WSF Philippines was established in 2018 to provide surgical outreach to all regions of the Philippines who currently has 108 million population with 30% under poverty level. There is insufficient and inequitable distribution of public health resources and surgical manpower in the rural areas. Mobile Surgical Teams are formed that can provide quality multi specialty surgical services to many areas in the Philippines. Methods: This Surgical Outreach Program comprise of General Surgeons, Pediatric Surgeons, ENT Surgeons, Plastic Surgeons, Pediatricians, Internist and Pathologists and OR Nurses. Equipments brought to the missions include: Portable Anesthesia Machines, Electrosurgical Units, Monitors, Harmonic Scalpel, Surgical Instruments and Cryostat. Sterile supplies and medications are provided. The services are free. Follow up care will be done by the local surgeon. Initially, 2 missions per year are performed but it has increased to 10 per year prior to the Covid Pandemic. Results: The average surgical cases done per mission in 100 to 140 both children and adults. No mortality and minor complications. Conclusion: Mobile Surgical Teams can help reduce the surgical burden of disease in low income countries and can be duplicated in other countries.

Optimal mode and power output of electrosurgical units for endoscopic papillectomy based on animal experiments and a preliminary clinical study (with videos)

The optimal electrosurgical unit (ESU) settings for endoscopic papillectomy (EP) have not been investigated. We conducted animal experiments to determine the optimal endoCUT settings with VIO (Erbe, Tübingen, Germany) ESUs and then conducted a small clinical study. Dedicated animal experimental models were created. To investigate the incision force, chicken meat was resected with a snare whose handle was a hung weight. To investigate the coagulation effect, a surgical needle electrode was inserted into a pig liver and energized, and to determine changes over time in the coagulation status, simulated EP was performed using a living pig. These experiments were performed using the knife-setting or snare-setting endoCUT modes and various effect, duration, and interval settings and compared with results for ICC (Erbe) ESUs. Based on the results, we performed EP in a small number of patients. The main factor affecting the incision force was duration. The coagulation effect was related to not only effect but also duration. In the endoCUT mode, knife-setting produced a higher incision force and lower coagulation effect. The nondischarge coagulation effect may cause deep ulceration. Based on the animal experiments, we concluded the ideal ESU setting for EP, "VIO EP mode," is knife-setting with high duration, lowest effect, and low interval settings. In the clinical study, there were no significant adverse events such as bleeding, pancreatitis, or perforation. "VIO EP mode" seems to afford optimal papillectomy. Larger scale clinical studies are needed to accumulate further data and make clinical comparisons with the ICC ESU.

High total Joule heat increases the risk of post-endoscopic submucosal dissection electrocoagulation syndrome after colorectal endoscopic submucosal dissection.

BACKGROUNDWe hypothesized that thermal damage accumulation during endoscopic submucosal dissection (ESD) causes the pathogenesis of post-ESD electrocoagulation syndrome (PECS).AIMTo determine the association between Joule heat and the onset of PECS.METHODSWe performed a retrospective cohort study in patients who underwent colorectal ESD from May 2013 to March 2021 in Japan. We developed a novel device that measures swift coagulation time with a sensor adjacent to the electrosurgical coagulation unit foot switch, which enabled us to calculate total Joule heat. PECS was defined as localized abdominal pain (visual analogue scale ≥ 30 mm during hospitalization or increased by ≥ 20 mm from the baseline) and fever (temperature ≥ 37.5 degrees or white blood cell count ≥ 10000 µ/L). Patients exposed to more or less than the median Joule heat value were assigned to the high and low Joule heat groups, respectively. Statistical analyses included Mann-Whitney U and chi-square tests and logistic regression and receiver operating characteristic curve (ROC) analyses.RESULTSWe evaluated 151 patients. The PECS incidence was 10.6% (16/151 cases), and all patients were followed conservatively and discharged without severe complications. In multivariate analysis, high Joule heat was an independent PECS risk factor. The area under the ROC curve showing the correlation between PECS and total Joule heat was high [0.788 (95% confidence interval: 0.666-0.909)].CONCLUSIONJoule heat accumulation in the gastrointestinal wall is involved in the onset of PECS. ESD-related thermal damage to the peeled mucosal surface is probably a major component of the mechanism underlying PECS.

Brachial plexus injury after clavicle fracture operation: a case report and literature review

BackgroundOpen reduction and internal fixation (ORIF) is the preferred choice for treating clavicle fractures. The brachial plexus injury caused by ORIF of a clavicle fracture is very rare. If it is not treated in time, the function of the brachial plexus will be challenging to recover, which will eventually lead to upper limb dysfunction and seriously affect the patient’s quality of life. Our team recently used ORIF to treat a patient with a clavicle fracture, who developed brachial plexus injury symptoms after surgery.Case presentationA 34-year-old female patient was admitted to the hospital for 13 h due to the right shoulder movement restriction after a fall. Due to the significant displacement of the fracture, we used ORIF to treat the fracture. The surgery went well. When the anaesthesia effect subsided 12 h after the operation, the patient developed right brachial plexus injury symptoms, decreased right upper limb muscle strength, dysfunction, and hypoesthesia. Symptomatic treatments, such as nourishing nerve and electrical stimulation, were given immediately. Sixty days after the operation, the patient’s brachial plexus injury symptoms disappeared, and the function of the right upper limb returned to the preoperative state.ConclusionsPatients with clavicle fractures usually need to undergo a careful physical examination before surgery to determine whether symptoms of brachial plexus injury have occurred. Anaesthesia puncture requires ultrasound guidance to avoid direct damage to the brachial plexus. When the fracture end is sharp, reset should be careful to prevent nerve stump stabbed. When using an electric drill to drill holes, a depth limiter should be installed in advance to prevent the drill from damaging the subclavian nerve and blood vessels. When measuring the screw depth, the measuring instrument should be close to the bone surface and sink slowly to avoid intense hooks and damage to the brachial plexus. Try to avoid unipolar electrosurgical units to prevent heat conduction from damaging nerves, and bipolar electrocoagulation should be used instead. If symptoms of brachial plexus injury occur after surgery, initial symptomatic treatment is drugs and functional exercise, and if necessary, perform surgical exploration.

Guidelines in Practice: Electrosurgical Safety.

Surgeons routinely use electrosurgical devices to cut and coagulate tissue during surgical procedures. However, hazards associated with electrosurgery (eg, burns, electrical shock, fire) can place patients or personnel at risk. Perioperative nurses should standardize processes, preoperatively assess the risks for electrosurgical injuries, and participate in education activities on electrosurgical safety to help prevent injuries from occurring. The AORN "Guideline for electrosurgical safety" provides guidance to perioperative personnel for safe use of electrosurgical units, electrocautery devices, and argon-enhanced coagulators. This article discusses prevention of electrosurgical unit injuries, including those that can be caused by electrosurgical accessories. A scenario describes how a team investigating two incidents related to use of electrosurgery uses an assessment tool to identify risks for injury and includes a report of these risks in the surgical briefing. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures for electrosurgical safety.

ERCP Room Setting: What Doctors Starting ERCP Need to Know

To date, there is no standardization of the endoscopi c retrograde cholangiopancreatography (ERCP) room setting regarding with the size, equipment or space arrangement. Therefore, the authors visited 11 tertiary hospitals that recently remodeled or newly designed the ERCP room to analyze and identify their advantages and disadvantages. The ERCP room should have enough space for equipments including fluoroscopy, endoscopy, electrosurgical unit, preparation table and for patient movement. The EUS room does not require an independent space unless it is a very large scale hospital, and the ERCP room can be shared. Considering the pros and cons of each equipment, adequate fluoroscopic device should be selected depending on the hospital circumstance. Expensive equipment for X-ray fluoroscopy system is not necessarily good, and it is necessary to install equipment suitable for each hospital situation by understanding the advantages and disadvantages of fluoroscopy. For prevention of ERCP-related radiation hazard, both endoscopist and assistants should wear radiation-blocking apron, thyroid protectors, and lead glasses. Furthermore, a shield that can block radiation between the endoscopist and the patient should be installed to protect high-energy scattered waves. One-way direction should be designed to prevent cross infection when moving the endoscopic equipment from the ERCP to the cleaning room. If possible, it is recommended to keep a cardiopulmonary resuscitation cart in the ERCP room.

Endoscopic snare uvulectomy under moderate sedation without endotracheal intubation.

Watch a video of this article.

Sources and components of volatile organic compounds in breast surgery operating rooms

ObjectivesThe composition and concentration distribution of volatile organic compounds (VOCs) in surgical smoke had seldomly been reported. This study aimed to investigate the profile of VOCs and their concentration in surgical smoke from breast surgery during electrocautery in different tissues, electrosurgical units, and electrocautery powers. MethodsThirty-eight surgical smoke samples from 23 patients performed breast surgery were collected using evacuated stainless steel canisters. The concentrations of 87 VOCs in surgical smoke samples were analyzed by gas chromatography-mass spectrometry. The human tissues, electrosurgical units, and electrocautery power were recorded. ResultsThe median level of total VOCs concentrations in surgical smoke samples from mammary glands (total VOCs: 9953.5 ppb; benzene: 222.7 ppb; 1,3-butadiene: 856.2 ppb; vinyl chloride: 3.1 ppb) using conventional electrosurgical knives were significantly higher than that from other tissues (total VOCs: 365.7–4266.8 ppb, P < 0.05; benzene: 26.4–112 ppb, P < 0.05; 1,3-butadiene: 15.6–384 ppb, P < 0.05; vinyl chloride: 0.6–1.8 ppb, P < 0.05) using different electrosurgical units. A high methanol concentration was found in surgical smoke generated during breast surgery (641.4–4452.5 ppb) using different electrosurgical units. An electrocautery power of ≥ 27.5 watts used for skin tissues produced a higher VOCs concentration (2905.8 ppb). ConclusionsThe surgical smoke samples collected from mammary glands using conventional electrosurgical knives had high VOCs concentrations. The carcinogens (including benzene, 1,3-butadiene, and vinyl chloride) and methanol were found in the surgical smoke samples from different electrosurgical units. The type of electrosurgical unit and electrocautery power used affected VOCs concentrations in surgical smoke.

Early experience with a new integrated microwave surgical device, Acrosurg Revo®, for laparoscopic surgery: A case series of two patients

IntroductionAbdominal surgery uses various energy devices for vessel sealing, tissue dissection, and detachment. Currently, Acrosurg Revo® (Nikkiso Co., Ltd., Tokyo, Japan), a novel energy device using microwaves, has been developed for use in laparoscopic surgery. This report describes the early clinical experience of using this device in two cases of laparoscopic surgery. Presentation of caseCase 1 was of a 64-year-old woman who underwent laparoscopic abdominal incisional hernia repair. Case 2 was of a 56-year-old man with a diagnosis of ascending and sigmoid colon cancer who underwent laparoscopic right hemicolectomy and sigmoid colectomy with D3 dissection. Each surgery was completed using Acrosurg Revo® and an endoscopic electrosurgical unit. The postoperative course was uneventful, and both patients were discharged from the hospital without any complications. DiscussionWith this new and novel device, vessel sealing, hemostasis, coagulation, tissue dissection, and detachment were all possible. Notably, there was no spark or mist that hindered the surgical field of view. Furthermore, because microwave coagulation did not result in tissue carbonization, there was a considerable decrease in device tip contamination. ConclusionThe Acrosurg Revo® may be a useful energy device for laparoscopic surgery.