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Madhok B, Nanayakkara K, Mahawar K. Safety considerations in laparoscopic surgery: A narrative review. World J Gastrointest Endosc 2022; 14:1-16. [PMID: 35116095 PMCID: PMC8788169 DOI: 10.4253/wjge.v14.i1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/11/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.
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Affiliation(s)
- Brij Madhok
- Upper GI Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, United Kingdom
| | - Kushan Nanayakkara
- Upper GI Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, United Kingdom
| | - Kamal Mahawar
- Department of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR4 7TP, United Kingdom
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El‐Sayed M, Mohamed S, Saridogan E. Safe use of electrosurgery in gynaecological laparoscopic surgery. ACTA ACUST UNITED AC 2019. [DOI: 10.1111/tog.12620] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mohsen El‐Sayed
- Consultant Obstetrician and Gynaecologist Darent Valley Hospital Dartford DA2 8DA UK
- Honorary Senior Clinical Lecturer King's College London GKT School of Medical EducationLondon WC2R 2LS UK
| | - Sahar Mohamed
- Consultant Obstetrician and Gynaecologist Southend University Hospital Southend‐on‐Sea SS0 0RY UK
| | - Ertan Saridogan
- Consultant Gynaecologist University College London Hospitals London WC1E 6DB UK
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Vilos GA. Understanding and Practising Safe Electrosurgery in the Operating Room. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1337-1347. [PMID: 30025869 DOI: 10.1016/j.jogc.2018.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/28/2018] [Accepted: 02/26/2018] [Indexed: 10/28/2022]
Affiliation(s)
- George A Vilos
- Department of Obstetrics and Gynecology, Western University, London, ON.
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Bae HS, Lee MY, Park JU. Intraoperative burn from a grounding pad of electrosurgical device during breast surgery: A CARE-compliant case report. Medicine (Baltimore) 2018; 97:e8370. [PMID: 29505504 PMCID: PMC5943117 DOI: 10.1097/md.0000000000008370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONAL Burns at the site of the return electrode (i.e., grounding pad) are possible effects of electrosurgery. Despite this knowledge, however, ignorance or negligence with regards to proper handling of the grounding pads still often occurs. Burn injuries can be easily prevented by taking the necessary precautions; thus, during plastic surgery, careful attention should to be paid. PATIENT CONCERNS A 38-year-old female patient was admitted to our ward to be performed augmentation mammoplasty. Before the start of the procedure, the grounding pad was placed on the surgical table and the left calf of the patient was placed on the grounding pad. Before using the endoscope, we found a burn on patient's left calf, where the grounding pad had been placed. DIAGNOSIS It was a 3-cm-by-3-cm-sized full thickness burn. The surrounding areas had no painful sensation with noninfectious sign. INTERVENTION Debridement and direct closure was performed with elliptical incision of eschar. OUTCOMES The patient did not require additional surgical procedure anymore and satisfied with the scar. LESSONS Through this case, we present the appropriate management of electrical burns from a grounding pad, and emphasize the understanding of the mechanism of burn because of electrosurgery, and how to use the grounding pad optimally to minimize the patient's risk.
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Affiliation(s)
- Hahn-Sol Bae
- Department of Plastic and Reconstructive Surgery, Seoul National University Boramae Medical Center
| | | | - Ji-Ung Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Boramae Medical Center
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Jones DB, Brunt LM, Feldman LS, Mikami DJ, Robinson TN, Jones SB. Safe energy use in the operating room. Curr Probl Surg 2015; 52:447-68. [DOI: 10.1067/j.cpsurg.2015.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/28/2015] [Indexed: 11/22/2022]
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Tawfik HA, Fouad YA, Hafez R. Dual-sided electrosurgery handpiece for simultaneous tissue cutting and coagulation: first report on a conceptual design validated by an animal experiment. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2015; 8:351-7. [PMID: 26316827 PMCID: PMC4540138 DOI: 10.2147/mder.s85262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To introduce and evaluate the safety of a novel dual-sided electrosurgery handpiece design for simultaneous tissue cutting and coagulation. Methods We designed a prototype double-sided handpiece allowing automatic switching between two electrodes with a simple handpiece flip. The concept of the system as a surgical instrument was assessed by an animal experiment. Results The skin of 15 Wistar albino white rats could be successfully incised and coagulated using both ends of the handpiece, thereby confirming the prospects and clinical applications of the system. Conclusion The dual-sided electrosurgery handpiece is a simple and safe alternative to the traditional electrosurgery pencil, allowing the simultaneous use of two electrodes without the hassle of frequent electrode replacement.
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Affiliation(s)
- Hatem A Tawfik
- Department of Ophthalmology, Oculoplastics Service, Ain Shams University, Cairo, Egypt
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Investigating the role of capacitive coupling between the operating table and the return electrode of an electrosurgery unit in the modification of the current density distribution within the patients' body. Biomed Eng Online 2013; 12:80. [PMID: 23937865 PMCID: PMC3751592 DOI: 10.1186/1475-925x-12-80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/02/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Electrosurgery units are widely employed in modern surgery. Advances in technology have enhanced the safety of these devices, nevertheless, accidental burns are still regularly reported. This study focuses on possible causes of sacral burns as complication of the use of electrosurgery. Burns are caused by local densifications of the current, but the actual pathway of current within patient's body is unknown. Numerical electromagnetic analysis can help in understanding the issue. METHODS To this aim, an accurate heterogeneous model of human body (including seventy-seven different tissues), electrosurgery electrodes, operating table and mattress was build to resemble a typical surgery condition. The patient lays supine on the mattress with the active electrode placed onto the thorax and the return electrode on his back. Common operating frequencies of electrosurgery units were considered. Finite Difference Time Domain electromagnetic analysis was carried out to compute the spatial distribution of current density within the patient's body. A differential analysis by changing the electrical properties of the operating table from a conductor to an insulator was also performed. RESULTS Results revealed that distributed capacitive coupling between patient body and the conductive operating table offers an alternative path to the electrosurgery current. The patient's anatomy, the positioning and the different electromagnetic properties of tissues promote a densification of the current at the head and sacral region. In particular, high values of current density were located behind the sacral bone and beneath the skin. This did not occur in the case of non-conductive operating table. CONCLUSION Results of the simulation highlight the role played from capacitive couplings between the return electrode and the conductive operating table. The concentration of current density may result in an undesired rise in temperature, originating burns in body region far from the electrodes. This outcome is concordant with the type of surgery-related sacral burns reported in literature. Such burns cannot be immediately detected after surgery, but appear later and can be confused with bedsores. In addition, the dosimetric analysis suggests that reducing the capacity coupling between the return electrode and the operating table can decrease or avoid this problem.
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van de Berg NJ, van den Dobbelsteen JJ, Jansen FW, Grimbergen CA, Dankelman J. Energetic soft-tissue treatment technologies: an overview of procedural fundamentals and safety factors. Surg Endosc 2013; 27:3085-99. [PMID: 23572215 DOI: 10.1007/s00464-013-2923-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/25/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Energy administered during soft-tissue treatments may cauterize, coagulate, seal, or otherwise affect underlying structures. A general overview of the functionality, procedural outcomes, and associated risks of these treatments, however, is not yet generally available. In addition, literature is sometimes inconsistent with regards to terminology. Along with the rapid expansion of available energetic instruments, particularly in the field of endoscopic surgery, these factors may complicate the ability to step back, review available treatment options, and identify critical parameters for appropriate use. METHODS Online databases of PubMed, Web of Science, and Google Scholar were used to collect literature on popular energetic treatments, such as electrosurgery, plasma surgery, ultrasonic surgery, and laser surgery. The main results include review and comparison studies on the working mechanisms, pathological outcomes, and procedural hazards. RESULTS The tissue response to energetic treatments can be largely explained by known mechanical and thermal interactions. Application parameters, such as the interaction time and power density, were found to be of major influence. By breaking down treatments to this interaction level, it is possible to differentiate the available options and reveal their strengths and weaknesses. Exact measures of damage and alike quantifications of interaction are, although valuable to the surgeon, often either simply unknown due to the high impact of tissue and application-dependent parameters or badly documented in previous studies. In addition, inconsistencies in literature regarding the terminology of used techniques were observed and discussed. They may complicate the formulation of cause and effect relations and lead to misconceptions regarding the treatment performance. CONCLUSIONS Some basic knowledge on used energetic treatments and settings and a proper use of terminology may enhance the practitioner's insight in allowable actions to take, improve the interpretation and diagnosis of histological and mechanical tissue changes, and decrease the probability of iatrogenic mishaps.
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Affiliation(s)
- N J van de Berg
- Department of Biomechanical Engineering, Delft University of Technology, 3mE, Mekelweg 2, 2628 CD Delft, The Netherlands.
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Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS 2012; 16:130-9. [PMID: 22906341 PMCID: PMC3407433 DOI: 10.4293/108680812x13291597716348] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This report stresses that a thorough knowledge of electrosurgical fundamentals by the entire operative team is essential for patient safety and recognizing potential complications. Background: Electrosurgical units are the most common type of electrical equipment in the operating room. A basic understanding of electricity is needed to safely apply electrosurgical technology for patient care. Methods: We reviewed the literature concerning the essential biophysics, the incidence of electrosurgical injuries, and the possible mechanisms for injury. Various safety guidelines pertaining to avoidance of injuries were also reviewed. Results: Electrothermal injury may result from direct application, insulation failure, direct coupling, capacitive coupling, and so forth. Conclusion: A thorough knowledge of the fundamentals of electrosurgery by the entire team in the operating room is essential for patient safety and for recognizing potential complications. Newer hemostatic technologies can be used to decrease the incidence of complications.
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Affiliation(s)
- Ibrahim Alkatout
- Department of Obstetrics and Gynaecology, University Hospitals Schleswig-Holstein, Campus Kiel, Germany
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Mendez-Probst CE, Vilos G, Fuller A, Fernandez A, Borg P, Galloway D, Pautler SE. Stray Electrical Currents in Laparoscopic Instruments Used in da Vinci® Robot-Assisted Surgery: An In Vitro Study. J Endourol 2011; 25:1513-7. [DOI: 10.1089/end.2010.0706] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Carlos E. Mendez-Probst
- Division of Urology, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
| | - George Vilos
- Department of Obstetrics and Gynaecology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Andrew Fuller
- Division of Urology, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
| | - Alfonso Fernandez
- Division of Urology, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
| | - Paul Borg
- Department of Biomedical Engineering, St Joseph's Hospital, London, Ontario, Canada
| | - David Galloway
- Department of Biomedical Engineering, St Joseph's Hospital, London, Ontario, Canada
| | - Stephen E. Pautler
- Division of Urology, Department of Surgery, The University of Western Ontario, London, Ontario, Canada
- Division of Surgical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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Cox C, Yao J. Electrocautery use in hand surgery: history, physics, and appropriate usage. J Hand Surg Am 2010; 35:489-90. [PMID: 19942358 DOI: 10.1016/j.jhsa.2009.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 09/25/2009] [Indexed: 02/02/2023]
Affiliation(s)
- Christopher Cox
- Department of Orthopaedic Surgery, Stanford University, Stanford and Redwood City, CA 94063, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the evolutionary changes that have taken place in the area of electrosurgery. The distinct differences between devices along with disadvantages and ways of minimizing hazards will be analyzed. RECENT FINDINGS Since the first surgical application of electricity in the 1880s, the use of radiofrequency current in surgery has grown. Although monopolar and bipolar energy form the backbone of electrosurgery, various modifications have been made to both the electrosurgical generators and the hand instruments. Much of the driving force behind these modifications has been the goal of minimizing possible complications while improving surgical efficiency. Recently, the ability to obtain vessel sealing has dramatically impacted clinical practice in open, laparoscopic, and vaginal surgery. SUMMARY Current evidence demonstrates the effectiveness and safety of electrosurgical devices in gynecologic surgery. Technology has evolved to allow vessel sealing capability through various instruments. Critical to the successful use of these advanced electrosurgical devices is a thorough understanding of their individual differences and nuances in order to obtain the desired tissue effects. Further studies are needed to determine the most appropriate applications and surgical procedures for these devices.
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[Nadroparin-induced skin necrosis then thrombocytosis in intensive care unit: difficulty in diagnosis]. ACTA ACUST UNITED AC 2007; 26:791-4. [PMID: 17658717 DOI: 10.1016/j.annfar.2007.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Accepted: 05/02/2007] [Indexed: 11/21/2022]
Abstract
Skin necrosis is a rare complication in intensive care unit. A case-report of nadroparine-induced skin necrosis and thrombocytosis in a patient with traumatic paraplegia is reported. This case emphasised the difficulty in diagnosis despite absence of thrombopenia. A skin necrosis could suggest the diagnosis and a substitutive therapy must be administrated after heparin therapy withdrawal. A thrombocytosis is a little reported complication of low-molecular-weight heparins without complication.
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Abstract
The ongoing desire to improve hemostasis and efficiency during surgery is manifested in the rapid development of electrosurgical technology. These changes have brought about a wide variety of devices available to the practicing surgeon during both open and endoscopic cases. Depending on the instrument chosen, various clinical effects ranging from simple coagulation to the sealing of large vascular bundles are obtained. However potential pitfalls or complications also exist. A thorough understanding of the pros and cons of these technological advancements can improve the operative experience for both surgeon and patient.
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Affiliation(s)
- K Wang
- Department of Obstetrics and Gynecology, University of Michigan Medical Center, Women's Hospital, Ann Arbor 48109, USA
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Abstract
The purpose of this report is to increase awareness of intraoperative burns during standard procedures, to discuss their possible causes and warning signs and to provide recommendations for prevention and procedures to follow after their occurrence. A total of 19 patients associated with intraoperative burn accidents were treated surgically and analyzed after a mean follow-up of 5 +/- 3.5 months. Review included retrospective patient chart analysis, clinical examination, and technical device and equipment testing. A total of 15 patients recently underwent cardiac surgery, and 4 pediatric patients recovered after standard surgical procedures. A total of 15 patients had superficial and 4 presented with deep dermal or full-thickness burns. The average injured TBSA was 2.1 +/- 1% (range, 0.5-4%). Delay between primary surgery and consultation of plastic surgeons was 4.5 +/- 3.4 days. A total of 44% required surgery, including débridment, skin grafting or musculocutaneous gluteus maximus flaps, and the remaining patients were treated conservatively. Successful durable soft-tissue coverage of the burn region was achieved in 18 patients, and 1 patient died after a course of pneumonia. Technical analysis demonstrated one malfunctioning electrosurgical device, one incorrect positioned neutral electrode, three incidents occurred after moisture under the negative electrode, eight burns occurred during surgery while fluid or blood created alternate current pathways, five accidents were chemical burns after skin preparation with Betadine solution, and in one case, the cause was not clear. The surgical team should pay more attention to the probability of burns during surgery. Early patient examination and immediate involvement of plastic and burn surgeons may prevent further complications or ease handling after the occurrence.
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Affiliation(s)
- Erhan Demir
- Department of Plastic and Hand Surgery, Burn Center, University Hospital RWTH Aachen, Aachen, Germany
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Abstract
An unhurried, deft, economical technique allied to efficient use of available resources, surgical instruments and support staff is the hallmark of a 'good' surgeon. To achieve this sense of fluency, surgeons need to be familiar with the tools of their profession so that these can be employed appropriately for the task at hand. The range of instruments available in obstetrics and gynaecology is no less wide or complex than in any other branch of surgery, but formal teaching in the full range of surgical hardware is frequently lacking and an individual's exposure is generally limited to the instruments used in his or her own training hospital. This chapter sets out to describe key technical areas with which surgeons need to be familiar.
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Affiliation(s)
- S Singh
- Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK.
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Mohs Micrographic Surgery in a Patient with a Deep Brain Stimulator. Dermatol Surg 2004. [DOI: 10.1097/00042728-200407000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Martinelli PT, Schulze KE, Nelson BR. Mohs Micrographic Surgery in a Patient with a Deep Brain Stimulator: A Review of the Literature on Implantable Electrical Devices. Dermatol Surg 2004; 30:1021-30. [PMID: 15209793 DOI: 10.1111/j.1524-4725.2004.30308.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Implantable electrical devices are becoming increasingly common in the patient population presenting for Mohs micrographic surgery. In addition to understanding the potential intraoperative complications with implantable cardioverter-defibrillators and pacemakers, the Mohs surgeon needs to be aware of the relatively new treatment of movement disorders using implanted deep brain stimulators. OBJECTIVE We present only the second reported case of Mohs surgery in a patient with a deep brain stimulator. In an attempt to help minimize adverse events during a procedure, we review the more commonly encountered electrical devices as well as the newer deep brain stimulators. We provide guidelines for the avoidance of electromagnetic interference during an electrosurgical procedure. METHODS This 76-year-old patient with Parkinson's disease and an implanted deep brain stimulator underwent Mohs surgery for excision of a squamous cell carcinoma on the ear. In an attempt to minimize electromagnetic interference with his implanted device, hemostasis was obtained with the aid of a battery-operated heat-generating handheld electrocautery device. RESULTS The patient tolerated the procedure well without complications or reports of discomfort. CONCLUSION Patients with implanted electrical devices are subject to electromagnetic interference during an electrosurgical procedure. Care must be taken in this expanding patient population during a Mohs surgical procedure.
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Affiliation(s)
- Paul T Martinelli
- Department of Dermatology, Baylor College of Medicine, Houston, Texas 77030, USA.
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Parikh SN, Mehlman CT, Keith RW. A third-degree burn caused by a neurogenic motor-evoked potential monitoring electrode during spinal surgery: a case report. Spine (Phila Pa 1976) 2003; 28:E21-4. [PMID: 12544969 DOI: 10.1097/00007632-200301010-00028] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report is presented. OBJECTIVE To report a previously undescribed complication related to use of a neurogenic motor-evoked potential monitoring electrode and electrosurgery during spinal surgery. SUMMARY OF BACKGROUND DATA Although electrosurgery is one of the most commonly used technologies in the operating room, its electrophysical properties, including the potential for complications, are poorly understood by many surgeons. Complications related to the use of electrosurgical instruments, monitoring electrodes, and radiofrequency current are underreported in the literature. METHODS Clinical case analysis and investigation report were used. RESULTS A case of third-degree skin burn at the site of a neurogenic motor-evoked potential monitoring electrode during posterior spinal fusion surgery is described. CONCLUSIONS A burn resulting from a neurogenic motor-evoked potential monitoring electrode is rare. However, surgeons and electrophysiologists should be familiar with this potential complication in order to prevent it.
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Affiliation(s)
- Shital N Parikh
- Department of Pediatric Orthopedics, Children's Hospital Medical Center, Cincinnati, Ohio, USA
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