Electrosurgery: short-circuit between education and practice

Environmental Sustainability Initiatives in the Operating Room: A Scoping Review

The global healthcare industry has a substantial environmental footprint and therefore has a responsibility to decrease its impact. Changes to increase sustainability will only occur if healthcare providers (HCPs) and decision-makers understand and incorporate environmentally conscious practices in the operating room (OR). This scoping review aimed to assess hospital initiatives undertaken to support environmental sustainability in the OR, with a focus on HCP and hospital decision-maker beliefs and perceptions related to sustainability. A scoping review was conducted using Embase and PubMed. Searches were performed to identify relevant studies published between January 2011 and November 2022. A total of 163 publications were included: 10 systematic literature reviews and 153 original research articles. Most studies reported department-wide sustainability measures (waste reduction, staff education, etc), which were evaluated by the reduction in generated waste and energy, emission of greenhouse gasses, and costs. Despite up to 97% of HCPs noting willingness to improve sustainability within practices, up to 80.9% of HCPs stated that they lacked the necessary training and information. In conclusion, this research highlights a recent increase in interest about sustainability initiatives in the OR and that HCPs and surgical staff are not only willing to participate but also have suggestions on how to minimize the environmental impact of the OR.

Minimally Invasive Beaded Electrosurgical Dissectors, Basic Science, and Pilot Studies

Background

Minimally invasive beaded electrosurgical dissectors ("BEED devices") provide simultaneous sharp dissection, blunt dissection, and electrosurgical coagulation while performing 100 cm2 porcine tissue plane dissections in 0.8 to 3 min with minimal bleeding and no perforations.

Objectives

The aim of the study was to report the basic science and potential clinical applications and to video document the speed and quality of planar dissections in in vivo and ex vivo porcine models with thermal damage quantified by thermal and histopathologic measurements. Additionally, in vivo porcine specimens were followed for 90 days to show whether adverse events occurred on a gross or macroscopic basis, as evidenced by photography, videography, physical examination, and dual ultrasonography.

Methods

Ex vivo porcine models were subjected to 20, 30, and 50 W in single-stroke passages with BEED dissectors (granted FDA 510(k) clearance (K233002)) with multichannel thermocouple, 3 s delay recordation combined with matching hematoxylin and eosin (H&E) histopathology. In vivo porcine models were subjected to eight 10 × 10 cm dissections in each of 2 subjects at 20, 30, and 50 W and evaluated periodically until 90 days, wherein histopathology for H&E, collagen, and elastin was taken plus standard and Doppler ultrasounds prior to euthanasia.

Results

Five to 8 mm width dissectors were passed at 1 to 2 cm/s in ex vivo models (1-10 cm/s in vivo models) with an average temperature rise of 5°C at 50 W. Clinically evidenced seromas occurred in the undressed, unprotected wounds, and resolved well prior to 90 days, as documented by ultrasounds and histopathology.

Conclusions

In vivo and ex vivo models demonstrated thermal values that were below levels known to damage subcutaneous adipose tissue or skin. Tissue histopathology confirmed healing parameters while Doppler ultrasound demonstrated normal blood flow in posttreatment tissues.

Level of Evidence 4

Surgeons know that they don't know about the safe use of surgical energy: an international study reveals that the knowledge gap persists

INTRODUCTION

The rate of electrosurgery complications is 0.1-2.1%. More than 10 years ago, SAGES pioneered a well-structured educational program (FUSE) aimed to teach about the safe use of electrosurgery. This inspired the development of similar training programs around the globe. Still, the knowledge gap persists among surgeons, possibly due to the lack of judgment.

AIM

To investigate factors affecting the level of expertise in electrosurgical safety and their correlation with self-assessment scores among surgeons and surgical residents.

MATERIALS AND METHODS

We conducted an online survey consisting of 15 questions that could be thematically broken down into 5 blocks. We analyzed how the objective scores were correlated with the self-assessment scores, professional experience, past participation in training programs, and work at a teaching hospital.

RESULTS

A total of 145 specialists took part in the survey, including 111 general surgeons and 34 s-year surgical residents from Russia, Belarus, Ukraine, and Kirgizia. Only 9 (8.1%) surgeons scored "excellent," 32 (28.8%) scored "good," and 56 (50.4%) scored "fair." Of all surgical residents participating in the study, only 1 (2.9%) scored "excellent," 9 (26.5%) scored "good," and 11 (32.4%) scored "fair." The test was failed by 14 surgeons (12.6%) and 13 (38.2%) residents. The difference between the trainees and the surgeons was statistically significant. Our multivariate logistic model identified 3 significant factors predisposing to successful performance on the test: past training in the safe use of electrosurgery, professional experience, and work at a teaching hospital. Of all study participants, those with no past training in the safe use of electrosurgery, and non-teaching surgeons were the most realistic about their competencies.

CONCLUSION

We have identified alarming gaps in the knowledge of electrosurgical safety among surgeons. Faculty staff and experienced surgeons scored higher, but past training was the most influential factor in improving knowledge of electrosurgical safety.

[Safety in electrosurgery: results of the All-Russian survey]

OBJECTIVE

To assess the level of knowledge in electrosurgical safety among specialists in the Russian Federation.

MATERIAL AND METHODS

An Internet survey was devoted to the issues of electrosurgical safety. The questionnaire consisted of 15 questions in 5 items. Data were collected for 2 months. Data analysis included final assessment of respondents, correlation of results with their own assessment of knowledge and parameters of surgical experience, the fact of training and belonging to the department. Question design, survey and presentation of results were performed in accordance with the CHERRIES (Check list of Reporting Results of Internet E-Surveys) criteria for Internet surveys.

RESULTS

Survey enrolled 231 specialists. Excellent rating was given to 13 (5.6%) respondents, good - 66 (28.3%), satisfactory - 105 (45.1%) respondents. Forty-nine (21.03%) respondents did not overcome the passing score (7) and showed unsatisfactory knowledge of electrosurgical safety. Mean score among all participants was 8.6±2.6 (median 8 points, interquartile range [7-11]) or 53.3% of maximum value (15). In multivariate logistic model, significant factors were the completed course in electrosurgical safety (OR 2.26, 95% CI 1.30-3.97; p=0.004), experience of work (OR 1.03, 95% CI 1.01-1.05; p=0.011) and work in the department (OR 1.74, 95% CI 1.03-2.95; p=0.038). Respondents who did not take the course (positive significant correlation r=0.1629, p=0.02674) and non-departmental employees (r=0.1655, p=0.031) assess the level of knowledge more adequately with respect to real results. Respondents with completed course (r=0.1078, p=0.4659) and departmental staff (r=0.1411, p=0.2699) are prone to overestimate self-assessment (positive insignificant correlation of their own assessment and received points).

CONCLUSION

We found significant knowledge gaps in electrosurgical safety among various practitioners. The main causes are no mandatory specialized courses on electrosurgical safety and insufficient motivation of specialists for self-education due to false ideas about their own level of knowledge.

Comparative healing of swine skin following incisions with different surgical devices

Background

Electrosurgical technology is widely used in surgical dissection and hemostasis, but the generated heat creates thermal injury to adjacent tissues and delays wound healing. The plasma blade (PB) applies pulsed radiofrequency (RF) to generate electrical plasma along the edge of a thin, flat, insulated electrode, minimizing collateral tissue damage. This study aimed to evaluate wound healing in swine skin following incision with a new surgical system that applies low-temperature plasma (NTS-100), a foreign PB, conventional electrosurgery (ES), and a scalpel blade.

Methods

In vitro porcine skin and an in vivo porcine skin model were used in this study. Full-thickness skin incisions 3 cm in length were made on the dorsum of each animal for each of the 5 surgical procedures at 0, 21, 28, 35, and 42 days. The timing of the surgical procedures allowed for wound-healing data points at 1, 2, 3, and 6 weeks accordingly. Local operating temperature and blood loss were quantified. Wounds were harvested at designated time points, tested for wound tensile strength, and examined histologically for scar formation and tissue damage.

Results

Local operating temperature was reduced significantly with NTS-100 (cut mode 83.12±23.55 °C; coagulation mode 90.07±10.6 °C) compared with PB (cut mode 94.46±11.48 °C; coagulation mode 100.23±6.58 °C, P<0.05) and ES (cut mode 208.99±34.33 °C, P<0.01; coagulation mode 233.37±28.69 °C, P<0.01) in vitro. Acute thermal damage from NTS-100 was significantly less than ES incisions (cut mode: 247.345±42.274 versus 495.295±103.525 µm, P<0.01; coagulation mode: 351.419±127.948 versus 584.516±31.708 µm, P<0.05). Bleeding, histological scoring of injury, and wound strength were equivalent for the NTS-100 and PB incisions.

Conclusions

The local operating temperature of NTS-100 was lower than PB, and NTS-100 had similarly reliable safety and efficacy.

Knowledge Assessment among Surgeons about Energy Devices safe use: A Multicenter Cross Sectional Study

Objective: To assess General Surgery trainee’s knowledge about safe use of energy devices in two tertiary hospitals in Riyadh, Saudi Arabia Background: Electro surgery is the use of high-frequency electrical energy to achieve cutting, and coagulation. This method has become ubiquitous worldwide for the purpose of achieving rapid hemostasis and rapid dissection of tissues Methods:   Participants completed a 35-item multiple choice question examination, testing critical knowledge of ES. The examination was developed according to the objectives and blueprints of SAGES’ Fundamental Use of Surgical Energy curriculum. Sections of the examination included: principles of ES, ES-related adverse events, monopolar and bipolar devices, and pediatric considerations and interference with implantable devices.’’ Scores were compared between juniors and seniors participants. Results: A total of 51 general surgical trainees from two academic hospitals completed the assessment. 15.69% of the participants correctly answered 30 questions out of 35 questions, 39.22% of the participants responded correctly to 20 questions out of 35 answers, and 45.09 who responded correctly to less than 20 questions. It was found that 52.2% of the individuals with a low level of understanding were junior residents as opposed to 87.5% of the participants with the highest level of understanding were senior residents with a significant P-value of 0.04. Conclusions: majority of general surgery residents enrolled in the Saudi Arabian board of surgery lack adequate knowledge about the safe and efficient use of surgical energy devices. The level of understanding is lower among the junior residents than seniors.

Application of multi-component fluid model in studies of the origin of skin burns during electrosurgical procedures

This paper reports on safety challenges regarding spark created when the applied electric field exceeds the dielectric breakdown strength as a source of complication during electrosurgery. Despite the unquestionable benefits of electrosurgery, such as minimal chances of infection and fast recovery time, the interaction of the electrosurgical tool with the tissue may result in tissue damage and force feedback to the tool. Some risks of complications often depend on a surgeon's knowledge of instruments and safety aspects of technical equipment that can be eliminated by clarifying the causation and conditions of their development. Current trends in electrosurgery include computational algorithms and methods to control the effect of delivered energy to the patient. For this study, calculations were performed by using the COMSOL simulation package based on a multi-component plasma fluid model. The emphasis is put on conditions that lead to the breakdown of the dielectric medium. It was found that breakdown occurs most easily when both electrodes are cylindrical. For configurations with one or two spherical electrodes, breakdown voltages are higher up to 25% and 48%, respectively. With decreasing the cathode radius, the breakdown voltage may decrease even to 41%. On the other hand, the temperature increase lowers the breakdown voltage. Also, electrical asymmetries appear to be a response to the non-symmetry of the electric field between the electrodes causing differences in the breakdown voltage between 36% and 70%. The results presented here could be very useful for the design of surgical devices to prevent potential complications of electrosurgical procedures.