Use of electricity in any field comes with inherent dangers and challenges, which doctors and patients are reminded of every time they gain informed consent. Burns and other injuries are among the list of potential complications for any intended surgery that uses diathermy in any way[i], and injuries related to electrosurgery are now the most common basis of malpractice suits against hospitals in the US[ii]. However, the risks of injury from electrosurgery apply to the operator as well as the patient, and have the potential to impact any nearby staff.
Types of Injuries
There are several types of injury that can arise from electrosurgical accidents[iii]; some are avoidable with the right tools, care and experience, some are unpredictable accidents. Either way, all surgical innovation should aim to minimize risk, with safety inbuilt to every area of practice.
Thermal injuries – burns to the skin or inner organs can be catastrophic – a perforated bowel or other vessel could have serious and severe results. Equipment that is fit for purpose is equipment with no damage or wear and tear to insulating materials; which does not retain residual heat after prolonged contact with heating tissues, and which – and this is crucial – cannot be inadvertently activated[iv]. It is hard to assess how often a diathermy tool is accidentally activated by, for example, stepping on a foot plate unintentionally, but it is likely to be an underreported untoward incident which can have serious consequences to patient and operator alike.
Internal burn injuries can be large, or can be minute – in fact, some may not even be identified until after the procedure, in recovery or even beyond. Bowel perforations from missed surgical burn injuries sometimes don’t present serious symptoms for up to ten days[v]. A fistulating burn injury, if not immediately identified and repaired, can quickly cause peritonitis, sepsis, and death – the worst possible outcome for the patient and their loved ones. Although incomparable, the impact of such a serious untoward incident on the surgeon, their team, and the organization as a whole also shouldn’t be underestimated. A surgeon’s aim is always to do no harm, but not all risk can be eliminated; as long as medicine continues its inexorable march towards safety and excellence, avoidable harm will be relegated to the annals of history.
Some smoke is generally expected when using electrocautery, but its potential impact shouldn’t be underestimated – the smoke from superheated and vaporized body tissues comprises noxious fumes and potential inspired carcinogens. The long-term impact of these inhaled particles on frequent users of diathermy is difficult to quantify, but it’s clear that reducing occupational exposure to smoke and airborne irritants is paramount. Surgical masks protect the operator from exposure to larger particles, but standard masks offer no protection from smoke inhalation[vi], and personal protective equipment needs to be carefully chosen to reflect all potential exposure to inhalable particles.
Fire and explosions
Although fairly uncommon – there are around 500 to 600 reported surgical fires yearly in the US[vii], the potential result of an explosion in surgery is severe. Using electrocautery around oxygen devices or in the presence of truly flammable gases – such as a methane collection in an impacted bowel – could have explosive results. Where there is heat, especially in an oxygen-rich environment, there is also the risk of fire; the use of alcohol-based cleaning products exacerbates the risk, especially if they’re not allowed to dry fully before introducing an electrical current.
Experienced surgeons and protocols minimize the risk of explosions, but the risk of fire and explosion in electrosurgery cannot yet be fully eliminated – as always in surgery, precision, dexterity, and effective, easily-controlled tools are the key to reducing risk.
Implantable Electronic Devices
The increasingly widespread use of a huge variety of cardiac pacemakers, ICDs, loop recorders, deep brain stimulation devices and the like pose their own particular risk in electrosurgery[viii]. The risk of diathermy around implanted metalware is lower with modern devices and materials, but conductive contact leads designed to stimulate the heart, central nervous system or other sites pose clear potential risks. Moreover, the potential complications of accidentally damaging such a device – an electrical malfunction in a pacemaker-dependent patient, for example – could very quickly cause catastrophic arrhythmias. Having facilities for interrogation and reprogramming on site can be helpful in manipulating settings to avoid inappropriate pacing or shocks.
The key to reducing risk of harm is in enhancing precision; using a minimal charge for the shortest possible length of time reduces the risk while retaining the benefits. Robust training for the entire surgical team helps to minimize risk[ix]; the ethics of poorly trained medical, surgical and nursing staff are unequivocable. For effective precision diathermy, a surgeon requires two main attributes from their tools – that they support visibility, and that they are easy to use precisely. That ease-of-use is precisely where a hand-controlled diathermy switch is an essential component of safe, effective surgery.
[i] Alkatout, I., Schollmeyer, T., Hawaldar, N. A., Sharma, N., & Mettler, L. (2012). Principles and safety measures of electrosurgery in laparoscopy. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 16(1), 130–139. https://doi.org/10.4293/108680812X13291597716348 [ii] Assiotis A, Christo T, Raptis DA, Engledow A, Imber C, Huang A. (2009) Diathermy Training and usage trends among surgical trainees–will we get our fingers burnt? Surgeon. https://doi.org/10.1016/S1479-666X(09)80035-8 [iii] Siddaiah-Subramanya, M., Tiang, K. W., & Nyandowe, M. (2017). Complications, Implications, and Prevention of Electrosurgical Injuries: Corner Stone of Diathermy Use for Junior Surgical Trainees. Surgery journal (New York, N.Y.), 3(4), e148–e153. https://doi.org/10.1055/s-0037-1606547 [iv]Wu, M. P. (2011). Electro-Surgery Practices and Complications in Laparoscopy. Advanced Gynecologic Endoscopy, 67. https://www.intechopen.com/books/advanced-gynecologic-endoscopy/electro-surgery-practices-and-complications-in-laparoscopy [v] Huang, H. Y., Yen, C. F., & Wu, M. P. (2014). Complications of electrosurgery in laparoscopy. Gynecology and Minimally Invasive Therapy, 3(2), 39-42. https://doi.org/10.1016/j.gmit.2014.05.004 [vi] Douglas, J., McLean, N., Horsley, C., Higgins, G., Douglas, C. M., & Robertson, E. (2020). COVID-19: smoke testing of surgical mask and respirators. Occupational medicine (Oxford, England), 70(8), 556–563. https://doi.org/10.1093/occmed/kqaa167 [vii] Choudhry, A. J., Haddad, N. N., Khasawneh, M. A., Cullinane, D. C., & Zielinski, M. D. (2017). Surgical fires and operative burns: lessons learned from a 33-year review of medical litigation. The American Journal of Surgery, 213(3), 558-564. https://doi.org/10.1016/j.amjsurg.2016.12.006 [viii] Voutsalath, M. A., Bichakjian, C. K., Pelosi, F., Blum, D., Johnson, T. M., & Farrehi, P. M. (2011). Electrosurgery and implantable electronic devices: review and implications for office-based procedures. Dermatologic surgery, 37(7), 889-899. [ix] El‐Sayed, M., Mohamed, S., & Saridogan, E. (2020). Safe use of electrosurgery in gynaecological laparoscopic surgery. The Obstetrician & Gynaecologist, 22(1), 9-20.https://doi.org/10.1111/tog.12620