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The safe use of surgical energy devices by surgeons may be overestimated

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Abstract

Background

Surgical energy injuries are an underappreciated phenomenon. Improper use of surgical energy or poor attention to patient safety can result in operating room fires, tissue injuries, and interferences with other electronic devices, while rare complications can be devastatingly severe. Despite this, there is no current standard requirement for educating surgeons on the safe use of energy-based devices or evaluation of electrosurgery (ES) education in residency training, credentialing, or practice. The study aimed to assess the current baseline knowledge of surgeons and surgical trainees with regards to ES across varying experiences at a tertiary level care center.

Methods

Surgeons and surgical trainees from seven surgical specialties (General Surgery, Cardiothoracic Surgery, Vascular Surgery, Obstetrics/Gynecology, Orthopedic Surgery, Urology, and Otorhinolaryngology) at a tertiary level care hospital were tested. Testing included an evaluation regarding their background training and experiences with ES-related adverse events and a 15 multiple-choice-question exam testing critical knowledge of ES.

Results

A total of 134 surveys were sent out with 72 responses (53.7%). The mean quiz score was 51.5 ± 15.5% (passing score was 80%). Of staff surgeons, 33/65 (50.8%) completed the survey with mean and median scores of 54.9 and 53.3%, respectively (range 33.3–86.7%). Of surgical trainees, 39/69 (56.5%) completed the survey with mean and median scores of 48.6 and 46.7%, respectively (range 13.3–80.0%). There were no statistically significant differences based on training status (p = 0.08), previous training (p = 0.24), number of cases (p = 0.06), or specialty (p = 0.689).

Conclusion

Surgeons and surgical trainees both have a significant knowledge gap in the safe and effective use of surgical energy devices, regardless of surgical specialty and despite what they feel was adequate training. The knowledge gap is not improved with experience. A formal surgical energy education program should be a requirement for residency training or credentialing.

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Author information

Authors and Affiliations

  1. Departments of General Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96819, USA

    Ally Ha, Carly Richards, Erik Criman, Jillian Piaggione, Christopher Yheulon & Robert Lim

Authors
  1. Ally Ha
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  2. Carly Richards
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  3. Erik Criman
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  4. Jillian Piaggione
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  5. Christopher Yheulon
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  6. Robert Lim
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Corresponding author

Correspondence to Robert Lim.

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Disclosures

Dr. Lim is a member of the SAGES Board of Governors and SAGES is the proprietor of FUSE. He does not receive any monetary or professional compensation for this position. Drs. Ha, Richards, Criman, Piaggione, and Yheulon have no conflicts of interest or financial ties to disclose.

Additional information

The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

Appendix

Appendix

  1. 1.

    When using a monopolar device, what is the purpose of the dispersive electrode?

    1. a.

      Concentrate current to prevent tissue injury

    2. b.

      Complete the electrical circuit

    3. c.

      Collect heat from the patient

    4. d.

      Direct current to the ground

  2. 2.

    In a non-isolated circuit, why should patients not be in contact with objects of high conductivity during an electrosurgical procedure?

    1. a.

      May cause capacitance coupling injury

    2. b.

      May cause an unintended activation injury

    3. c.

      May cause a residual heat injury

    4. d.

      May cause a current diversion injury

  3. 3.

    What is the primary use of bipolar instruments?

    1. a.

      Excising tissue

    2. b.

      Tissue ablation

    3. c.

      Obtaining hemostasis

    4. d.

      Cutting through tissue

  4. 4.

    Which of the following statements describing radiofrequency ablation (RFA) versus electrosurgery (ES) is correct?

    1. a.

      Direct current is applied to tissue in RFA and alternating current is used in ES

    2. b.

      The patient is grounded in ES and the patient is not in RFA

    3. c.

      RFA may require multiple dispersive electrodes

    4. d.

      Temperature monitoring of the dispersive electrode is critical when using ES but less so in RFA

  5. 5.

    Which of the following has no impact on the delivery and effect of ultrasonic energy?

    1. a.

      Voltage setting

    2. b.

      Blade pressure

    3. c.

      Tissue tension

    4. d.

      Energy setting

  6. 6.

    Which of the following statements about placement of dispersive electrodes in pediatric patients is true?

    1. a.

      The dispersive electrode should be as far from the surgical field as feasible

    2. b.

      The dispersive electrode should be placed as close to the surgical field as feasible

    3. c.

      The thigh is the preferred site for the dispersive electrode

    4. d.

      Overlap with pediatric monitoring electrodes in NOT an important factor

  7. 7.

    Which of the following does NOT affect electromagnetic interference on a pacemaker?

    1. a.

      Placement of the leads for the electrocardiographic (ECG) monitor

    2. b.

      Power setting of the monopolar generator

    3. c.

      Choice of monopolar mode (e.g., coagulation or cut mode)

    4. d.

      Distance of active electrode from pacemaker

  8. 8.

    The surgeon is using the “coagulation” waveform and notices adjacent collateral coagulation injury. Which of the following will decrease the voltage?

    1. a.

      Changing to the “blend” waveform

    2. b.

      Increasing the power

    3. c.

      Changing to the “bipolar” waveform

    4. d.

      Changing to the “cautery” waveform

  9. 9.

    What process occurs when one conductive element of the circuit touches or arcs to an instrument outside the intended circuit?

    1. a.

      Alternate site injury

    2. b.

      Direct extension

    3. c.

      Capacitance coupling

    4. d.

      Direct coupling

  10. 10.

    Which of the following characterizes bipolar instruments compared with monopolar instruments?

    1. a.

      Bipolar instruments do not seal vessels as well

    2. b.

      Bipolar instruments require higher voltage

    3. c.

      Bipolar instruments do not function as well in wet surgical fields

    4. d.

      Bipolar instruments carry a lower risk of collateral injury

  11. 11.

    Which of the following is NOT a mechanism by which ultrasonic surgical devices manifest their tissue effect?

    1. a.

      Magnetic polarization

    2. b.

      Cavitation

    3. c.

      Desiccation

    4. d.

      Mechanical cutting

  12. 12.

    Which energy modality is most likely to cause interference with a cardiac implantable electronic device?

    1. a.

      Bipolar electrosurgical instrument

    2. b.

      Ultrasonic energy instrument

    3. c.

      Microwave energy instrument

    4. d.

      Monopolar electrosurgical instrument

  13. 13.

    Which statement is correct regarding the appropriate size of a dispersive electrode for an infant or child?

    1. a.

      Adult-sized dispersive electrodes should be cut to fit an infant’s or child’s lateral thigh

    2. b.

      An infant sized dispersive electrode is adequate for children

    3. c.

      Dispersive electrodes come in weight-based sizes for infants and children

    4. d.

      Adult-sized dispersive electrodes are adequate for infants and children

  14. 14.

    Why does tissue stretching during electrosurgery affect temperature change?

    1. a.

      It causes bonds to break within the tissue

    2. b.

      It increases resistance

    3. c.

      It makes the area smaller

    4. d.

      It decreases current density

  15. 15.

    Does the Joint Commission require reporting of electrosurgical device failures?

    1. a.

      No

    2. b.

      No, unless the device failure resulted in an unanticipated death or loss of function

    3. c.

      No, unless the device failure was not reported to the state

    4. d.

      Yes

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Ha, A., Richards, C., Criman, E. et al. The safe use of surgical energy devices by surgeons may be overestimated. Surg Endosc 32, 3861–3867 (2018). https://doi.org/10.1007/s00464-018-6116-1

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  • DOI: https://doi.org/10.1007/s00464-018-6116-1

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