SINCE?ITS introduction in the 1970s, minimally invasive surgery has offered patients the significant benefits of faster healing and less postoperative pain. Patients can often leave the hospital sooner and, in some cases, surgery can even be performed at an outpatient center. Convalescence is usually shorter, allowing patients to return to work and resume other activities sooner. Another benefit is to patients wallets, minimally invasive surgery is generally less expensive than traditional open surgical procedures.
One of the most popular methods, electrosurgery, is for the majority of patients safe and effective,however, this is a surgical procedure and can compromise patient safety under certain circumstances.
A patient safety alert from the Pennsylvania Patient Safety Authority stated the risks of electrosurgery. This from of surgery uses current to cut tissue and control bleeding. It has been employed effectively in open operative procedures for over 65 years. In part because of its long history of use in open surgery, it has become the most widely used cutting and coagulation technique in minimally invasive surgery, used by approximately 86% of surgeons performing laparoscopic procedures.
The injuries that have been reported are rare, however in these instances, the surgeon may directly burn non-targeted internal organs or tissue with the tip of the active electrode, through imprecise mechanical operation of a laparoscopic instrument. The second from of injury from this form of surgical procedure results when stray electrical currents emanating from the laparoscopic instruments can inadvertently shock and burn non-targeted tissues beyond the surgeon’s limited field of vision, leading on occasion to grave complications. Such stray energy burns can occur regardless of the surgeon’s skill and judgment.
Published clinical studies and case histories have documented the very real risk of inadvertent tissue injury during electrosurgery, even though prevalence of the problem is currently not well defined. Stray electrical currents may be released either through direct coupling or if the electrical insulation that coats the active electrode fails due to degradation or damage. Another electrical phenomenon known as capacitive coupling can instantaneously transfer significant amounts of stray electrical current to non-targeted tissue, causing serious burns.
Injuries arising from these stray electrical currents usually occur outside the restricted keyhole view of the laparoscope, and thus may go undetected by the surgeon. Unfortunately, symptoms of injury are usually delayed in onset for several days, thereby helping to obscure the underlying cause. The complications resulting from internal electrosurgical burn injuries compounded by delay in diagnosis and treatment can have a profound medical and economic impact on patients.
Electrosurgical burns involve a high risk of tissue necrosis and abscess formation. This can lead to perforation of internal organs, such as the bowel, resulting in bacterial contamination of the abdominal cavity (fecal peritonitis), which necessitates immediate and aggressive treatment. Even in this advanced age of antibiotics, the mortality rate from fecal peritonitis is reported to be as high as 25%.
In patients who survive such burns, the morbidity associated with the resulting complications can have serious and long-lasting physical, emotional, and financial implications. The necrosis of gastrointestinal tissue at a burn site, for example, can necessitate surgical resection of variable lengths of bowel and either temporary or permanent colostomy. Treatment is expensive and convalescence may be extended for many months, requiring long periods of time away from work.
The medicolegal and economic consequences of inadvertent and undetected burns incurred outside the surgeon’s field of view are considerable, diverting healthcare resources and raising the costs of procedures and services. As evidenced by numerous legal cases, internal thermal injuries during laparoscopic surgery can be costly to the surgeons who perform these surgeries and the institutions at which they are performed.
Kay Ball, RN, PhD, CNOR, FAAN is a Nurse Consultant/Educator and a leading authority on patient safety.
“Electrosurgical devices have been popular for many years to cut and coagulate tissue, but this energy also has been associated with numerous patient injuries and accidents, stated Ball, “Education is vital to ensure the safe use of electrosurgery by understanding the principles and actions of this surgical energy.”
Her educational materials explain that while current densities are kept to a clinically safe level such that pad site burns rarely occur. However, three unique problems can occur during endoscopic procedures involving electrosurgery: direct coupling, insulation failure, and capacitive coupling.
DIRECT COUPLING. Direct coupling occurs when the active electrode accidentally touches a noninsulated metal instrument, allowing the electrical energy to flow from one to the other (metal-to-metal sparking).
INSULATION FAILURE. Insulation failure can occur when the insulation coating of an endoscopic instrument has been compromised. If a crack or break is present in the insulation along the shaft of the instrument, the electrical energy can escape at the point of the defect and burn untargeted tissue. Insulation failure results in an instantaneous irreversible death to tissue as a result of the high power density condition that the insulation failure creates on the shaft of the instrument. The resulting tissue burn may not be observed or realized by the operating physician because it may not be within the field of vision.
CAPACITIVE COUPLING. Capacitive coupling is a natural RF (electrosurgical energy) phenomenon that can occur when energy is transferred through intact insulation on the shaft of a laparoscopic instrument to nearby conductive materials.
The use of monopolar electrosurgical instrumentation through metal suction irrigators or shafts increases the risk of visceral burns through capacitive thermal energy. The laparoscope also can cause alternate-site burns if the electrosurgical electrode is used through a narrow-lumen scope. Instruments that are long and narrow with thin insulation combined with high voltage increase the incidence of capacitive coupling.
These burns often go undetected by the operating physician, and the problem is not diagnosed until the patient presents with complications after the surgery. One local patient, who remains anonymous due to fear of possible litigation, was injured during an electrosurgical procedure. The injury presented itself hours after the surgical procedure and the tissue damage was both severe and debilitating. Because these injuries are often not located near the surgical site, they are not even associated as a result of an electrical shock or burn.
Victims of such accidents are usually unaware of these possible complications and are unsure of how they were injured. Unable to prove that they have been shocked or burned, even if they suspect such an event occurred, they are often accused of inventing a psychosomatic injury and left with no recourse but to suffer the complications of the injury on their own.
Ball notes that one manufacturer has introduced a dual layer of insulation on laparoscopic instruments. The outer black insulation layer lies on top of a bright yellow insulation layer. When the top black layer is penetrated, the bright yellow layer can be seen easily and alerts the user that insulation failure may be imminent. Until additional safety measures can be implemented, patients should be aware that these injuries can result during Electrosurgery and ask their physicians to fully inform them of possible dangers.
USE?OF?an electrosurgical unit (ESU) has been a major contributor to improvements in surgical procedures, but proper care must be taken to ensure no unintended injuries are acquired by the patient.