Electrosurgery in Otolaryngology???Head and Neck Surgery: Principles, Advances, and Complications

Adverse events related to suction electrocautery devices in adenotonsillectomy: Analysis of the MAUDE database

OBJECTIVE

To identify adverse events (AEs) related to suction electrocautery use during adenotonsillectomy.

METHODS

The US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was searched using the terms "suction cautery," "suction electrocautery," "suction Bovie," and "suction coagulator" from January 2014 to December 2023.

RESULTS

165 AE reports were gathered from the MAUDE database medical device reports (MDRs). 36 met inclusion criteria. Patient injuries were found in 22 (61.1 %) reports and device malfunction events were found in 14 (38.9 %) reports. All patient injuries were thermal burns (N = 22, 100 %). Location of burn injuries included the lip (N = 6, 27.3 %), oral commissure (N = 5, 22.7 %), and tongue (N = 4, 18.2 %). The most common cause of an AE was inadequate device insulation (N = 7, 19.4 %).

CONCLUSION

The suction electrocautery apparatus may malfunction and cause patient burn injuries. Device failures mainly result from inadequate device insulation, coagulation problems, and detachment of device components. Surgeons must be aware of these potential complications and counsel parents and patients regarding AEs.

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

Treatment of Warthin's Tumors of the Parotid Gland With Radiofrequency Ablation: A Systematic Review of the Current Literature

Objective: Warthin's tumors of the parotid gland can be safely observed. Definitive treatment usually requires parotidectomy under general anesthesia. The decision to operate on Warthin's tumors of the parotid gland can be complicated in patients who wish to avoid risks of surgery and general anesthesia. This systematic review explores the potential of radiofrequency ablation (RFA) as a minimally invasive alternative. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model was used to collect 3 relevant studies that focused on RFA treatment for Warthin's tumors. The cumulative averages for tumor size and cosmetic scores were then quantified for patients with Warthin's tumors who underwent RFA therapy. The PRISMA systematic review method was employed to the PubMed and EMBASE databases. The comprehensive search term "Warthin Tumor Treatment" yielded 1299 articles from the years 1955 to 2023, 3 of which met inclusion criteria and were then selected. Results: The 3 quantitative studies collectively assessed 37 patients with Warthin's tumors treated with RFA. Patients experienced an average tumor size reduction of 85.03% at 12 months post-RFA. There were minimal complications associated with RFA in these patients. Conclusion: This study suggests that RFA is an alternative to parotidectomy for the symptomatic treatment of Warthin's tumors. RFA procedures demonstrated substantial tumor size reduction with few complications. However, further meta-analysis and comparison with alternative treatments is warranted to establish RFA's role in treatment of Warthin's tumors. The study is limited by its reliance on only 2 databases and a lack of comprehensive examination of different RFA settings.

Recurrent Laryngeal Nerve Intraoperative Neuromonitoring Indications in Non-Thyroid and Non-Parathyroid Surgery

Introperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is a well-established technique to aid in thyroid/parathyroid surgery. However, there is little evidence to support its use in non-thyroid or non-parathyroid surgery. The aim of this paper was to review the current evidence regarding the use of IONM in non-thyroid/non-parathyroid surgery in the head and neck and thorax. A literature search was performed from their inception up to January 2024, including the term "recurrent laryngeal nerve monitoring". IONM in non-thyroid/non-parathyroid surgery has mainly been previously described in oesophageal surgery and in tracheal resections. However, there is little published evidence on the role of IONM with other resections in the vicinity of the RLN. Current evidence is low-level for the use of RLN IONM in non-thyroid/non-parathyroid surgery. However, clinicians should consider its use in surgery for pathologies where the RLN is exposed and could be injured.

Risk of Monopolar Electrosurgery in Cochlear Implant Recipients is Nominal: Evidence to Guide Clinical Practice

OBJECTIVE

Comprehensively assess the prevalence of monopolar electrosurgery-related device complications among cochlear implant (CI) recipients.

STUDY DESIGN

Multifaceted retrospective review and survey.

SETTING

Tertiary medical center.

METHODS

Multifaceted approach including: (i) review of the current literature; (ii) historical review of institutional data from an academic, tertiary CI center; (iii) review of industry data provided by 3 Food and Drug Administration-approved CI manufacturers; and (iv) survey of high-volume CI centers.

RESULTS

Literature review identified 9 human studies, detailing 84 devices with 199 episodes of device-cautery exposure. From studies reporting on patients records, no implant showed evidence of damage after exposure. One cadaveric study using dental cautery reported 1 episode of device damage. Review of institutional records did not identify any CI damage in 84 instances of exposure. Data from the 3 major implant manufacturers showed a single report of damage that could be reasonably linked to monopolar electrosurgery, out of a possible 689,426 CIs. Last, a survey of 8 high-volume CI centers did not identify any adverse events associated with monopolar cautery.

CONCLUSION

These data estimate the risk of adverse device-related events or tissue injury to be extraordinarily low. Short of operating in immediate proximity to the CI (ie, the ipsilateral temporoparietal scalp), these data indicate that monopolar electrosurgery can be used in the body and the head-and-neck of CI recipients with nominal risk. These findings may guide decision-making in cases that are optimally or preferably performed with monopolar electrocautery and can be used to counsel CI patients following inadvertent exposures.

Repairing the Nose after Failed Minimally Invasive Procedures

Minimally invasive nasal procedures can be aimed at treating both functional and cosmetic problems. These procedures include lateral nasal wall implants, dermal fillers, thread lifting, and radiofrequency ablation. Though increasingly popular, nasal surgeons have limited data to draw from when faced with operating in a nose that has been altered by these techniques. In this article, best practice recommendations are described based on the available data for each of the techniques.

Implantable Electronic Cardiovascular Device Complications Related to Electrocautery During Ophthalmology Surgery: A Systematic Review

PURPOSE

Implantable electronic cardiovascular device such as cardiac pacemakers and implantable defibrillators are common life-saving devices. Device-related complications can arise when undergoing surgical interventions with electrosurgical tools due to electromagnetic interference, based on electrocautery type, implantable electronic cardiovascular device type, electrocautery location, and a number of other factors. The risk of device-related complications due to electrocautery in oculoplastic surgery has not been established. This systematic literature review assesses prevalence, risk factors, and outcomes of electrocautery-related device complications in oculoplastic surgery.

METHODS

Systematic literature review followed Preferred Reporting Items for Systematic and Meta-Analysis guidelines and used the search terms "pacemaker," "implantable cardioverter defibrillator," "electrocautery," "cautery," and "electrosurgery" through June 2022. Inclusion criteria were full-text articles, discussing ocular, oculoplastic, or other facial surgery. Exclusion criteria were non-English language or surgery focused on other parts of the body. Full-text manuscripts of identified articles were reviewed and relevant data were extracted.

RESULTS

Twelve studies met inclusion criteria. Two studies were level I and II evidence, while 10 studies were level III or IV. There were no reports of electromagnetic interference with bipolar cautery use. With monopolar cautery use, cases of electromagnetic interference were reported, but without related significant morbidity or mortality. Safety recommendations to minimize electrical flow through the implantable electronic cardiovascular device are described.

CONCLUSIONS

There were no reports of implantable electronic cardiovascular device-related complications from bipolar or thermocautery use in ophthalmic or oculoplastic surgeries. Monopolar have been associated with electromagnetic interference, but additional preoperative and perioperative measures can be taken to mitigate this risk.

Preliminary dynamic observation of wound healing after low-temperature plasma radiofrequency ablation for laryngeal leukoplakia

BACKGROUND

Low-temperature plasma ablation (LTPA) is an emerging technique for laryngeal leukoplakia (LL).

OBJECTIVE

To initially observe the healing process of trauma after LTPA for LL.

MATERIALS AND METHODS

Seventeen patients who underwent LTPA for LL were collected, and the degrees of wound healing were analyzed.

RESULTS

Only 1 patient in who dysbiosis of the pharyngeal flora was induced by self-administered hormone nebulization treatment during the follow-up period. In the remaining patients, the wound healing was characterized by a crater-shaped defect on the vocal folds surface with pseudo-membranes, congestion, and mild edema on postoperative day 1. These symptoms became worse on postoperative day 7. On postoperative day 15, the pseudo-membrane was fully formed and some patients had granulomatous swelling of the vocal cords. These symptoms became better and better on postoperative day 30 and day 45. On postoperative day 60, the mucosa of the vocal folds had essentially returned to normal. On postoperative day 90, the vocal folds morphology and function had recovered well.

CONCLUSION

It takes 2-3 months for the wound to heal completely after LTPA for LL.

SIGNIFICANCE

A proper understanding of the wound healing process can reduce unnecessary surgical and pharmacologic interventions and avoid excessive treatment.

Comparing the safety and effectiveness of dedicated radiofrequency transseptal wires to electrified metal guidewires

Background

Application of electrocautery to a metal guidewire is used by some operators to perform transseptal puncture (TSP). Commercially available dedicated radiofrequency (RF) guidewires may represent a better alternative. This study compares the safety and effectiveness of electrified guidewires to a dedicated RF wire.

Methods

TSP was performed on freshly excised porcine hearts using an electrified 0.014″ or 0.032″ guidewire under various power settings and was compared to TSP using a dedicated RF wire with 5 W power (0.035″ VersaCross RF System, Baylis Medical). The primary endpoint was the number of attempts required to achieve TSP. Secondary endpoints included the rate of TSP failure, TSP consistency, the effect of the distance between the tip of the guidewire and the tip of the dilator, and effect of RF power output level. Qualitative secondary endpoints included tissue puncture defect appearance, thermal damage to the TSP guidewire or dilator, and tissue temperature using thermal imaging.

Results

The RF wire required on average 1.10 ± 0.47 attempts to cross the septum. The 0.014″ electrified guidewire required an overall mean of 2.17 ± 2.36 attempts (2.0 times as many as the RF wire; p < .01), and the 0.032″ electrified guidewire required an overall mean of 3.90 ± 2.93 attempts (3.5 times as many as the RF wire; p < .01). Electrified guidewires had a higher rate of TSP failure, and caused larger defects and more tissue charring than the RF wire. Thermal analysis showed higher temperatures and a larger area of tissue heating with electrified guidewires than the RF wire.

Conclusion

Fewer RF applications were required to achieve TSP using a dedicated RF wire compared to an electrified guidewire. Smaller defects and lower tissue temperatures were also observed using the RF wire. Electrified guidewires required greater energy delivery and were associated with equipment damage and tissue charring, which may present a risk of thrombus, thermal injury, or scarring.

Electrosurgical unit: Iatrogenic injuries and medico-legal aspect. Italian legal rules, experience and article review

BACKGROUND

The use of the electrosurgical unit (ESU) is well-established in the surgical practice. The Authors, to better understand the genesis of injuries connected to the use of electrosurgical instruments, conducted an in-depth literature review pertaining to this topic.

MATERIALS AND METHOD

Using the most important medical databases, a research of experimental studies in the last 20 years was conducted.

RESULTS

The analysis of the mechanisms responsible for the lesions showed that high energy devices remain as the most common cause of injury. Adverse events are mainly given by thermal injuries; cases of electromagnetic interference are also described in patients with pacemakers or sacral nerve stimulator and spinal stimulators as well as cases of fire of the endotracheal tube in the course of tracheostomy for the use of the electrosurgical unit in an environment with a high concentration of oxygen or anesthetic gases. Also reported in the literature are individual cases of fires caused by sparks from the electrosurgical handpiece also for the use of disinfectants and/or in relation to surgical drapes.

CONCLUSION

In order to clearly define the medical-legal aspects, focusing on the professional responsibility of the surgical and nursing staff, the authors' attention was brought to the need for an effective prevention plan that highlights not only the importance of an accurate procedural knowledge in order to safety use the electrosurgical instruments, but also the need for a system that monitors any complications or adverse events resulting from the use of such instruments.

LigaSure versus the standard technique (Hem-o-lok clips) for robot-assisted radical prostatectomy: a propensity score-matched study

The aim of the study is to compare the utility and efficacy of the LigaSure system and standard surgical clips for robot-assisted radical prostatectomy. The medical records of 473 patients who underwent robot-assisted radical prostatectomy between May 2011 and 2018 were retrospectively reviewed and analyzed. The patients were divided into the LigaSure (n = 125) and Hem-o-lok (n = 348) groups, based on the device used to ligate the vascular pedicle. Owing to differences in the patient characteristics, a 1:2 propensity score matching was performed. In the final matched cohort, 375 patients were included for analysis. The median initial prostate-specific antigen level was not significantly different between the two groups. The median surgical and console times were significantly shorter for the LigaSure group than for the Hem-o-lok group (p < 0.001 and 0.003, respectively). The number of specimens with positive surgical margins was significantly lower in the LigaSure group than in the Hem-o-lok group (24.8 vs 40.8%, p = 0.002). The number of specimens with positive surgical margins for pathological stage T2 cases was also significantly lower in the LigaSure group than in the Hem-o-lok group (17.0 vs 37.5%, p < 0.001). However, non-focal positive surgical margins and biochemical recurrence-free survival rates at 1 year postoperatively were not significantly different (11.2 vs 18.4%, p = 0.075 and 91.2 vs 92.8%, p = 0.565, respectively). The LigaSure system was associated with fewer positive surgical margins and shorter operation time, indicating that it could be a useful alternative to Hem-o-lok clips for controlling the prostatic pedicle in robot-assisted radical prostatectomy, despite its high costs.

The utility of electrocautery for suture passage through bone: A biomechanical study

Electrosurgical devices are routinely employed during surgery. The use of a Bovie Electrosurgical Unit (ESU) to facilitate the passage of a suture needle through bone has not been studied in the literature. This study aimed to identify force reduction with the application of Bovie ESU to the suture needle through the bone. Peak and the average axial force required for a suture needle to penetrate cadaveric proximal humeri were measured using a custom setup. Twenty-four trials were conducted without electricity, and 72 trials were conducted with a Bovie ESU applying current. Needle size and Bovie ESU power settings were varied. t Tests and analysis of variance were used with p ≤ 0.05 denoting statistical significance. The application of electricity reduced the peak and average axial force needed for a needle to pierce bone, regardless of the Bovie ESU power setting (p < 0.001). The average peak force with the Bovie ESU was 65.7 N, compared with 126.0 N without (p < 0.001), a 47.9% reduction. The average axial force with the Bovie ESU was 38.2 N compared with 81.8 N without (p < 0.001), a 53.3% reduction. There was no significant difference in peak or average axial forces between power settings. At 30 and 90 W of power, larger needle size was associated with significantly lower peak (p = 0.001 and p < 0.001, respectively) and axial (p = 0.002 and p = 0.004, respectively) force. The Bovie ESU reduces the axial force required to pass a suture needle through bone. The use of this technique may allow for the avoidance of drilling for soft tissue repair. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:954-960, 2020.

Waveform Dependent Electrosurgical Effects on Soft Hydrated Tissues

Electrosurgical procedures are ubiquitously used in surgery. The commonly used power modes, including the coagulation and blend modes, utilize non-sinusoidal or modulated current waveforms. For the same power setting, the coagulation, blend and pure cutting modes have different heating and thermal damage outcomes due to the frequency dependence of electrical conductivity of soft hydrated tissues. In this paper, we propose a multi-physics model of soft tissues to account for the effects of multi-frequency electrosurgical power modes within the framework of a continuum thermomechanical model based on mixture theory. Electrical and frequency spectrum results from different power modes at low and high power settings are presented. Model predictions are compared with in vivo electrosurgical heating experiments on porcine liver tissue. The accuracy of the model in predicting experimentally observed temperature profiles is found to be overall greater when frequency-dependence is included. An Arrhenius type model indicates that more tissue damage is correlated with larger duty cycles in multi-frequency modes.

Real-time oncological guidance using diffuse reflectance spectroscopy in electrosurgery: the effect of coagulation on tissue discrimination

In breast surgery, a lack of knowledge about what is below the tissue surface may lead to positive tumor margins and iatrogenic damage. Diffuse reflectance spectroscopy (DRS) is a spectroscopic technique that can distinguish between healthy and tumor tissue making it a suitable technology for intraoperative guidance. However, because tumor surgeries are often performed with an electrosurgical knife, the effect of a coagulated tissue layer on DRS measurements must be taken into account. It is evaluated whether real-time DRS measurements obtained with a photonic electrosurgical knife could provide useful information of tissue properties also when tissue is coagulated and cut. The size of the coagulated area is determined and the effect of its presence on DR spectra is studied using ex vivo porcine adipose and muscle tissue. A coagulated tissue layer with a depth of 0.1 to 0.4 mm is observed after coagulating muscle with an electrosurgical knife. The results show that the effect of coagulating adipose tissue is negligible. Using the fat/water ratio's calculated from the measured spectra of the photonic electrosurgical knife, it was possible to determine the distance from the instrument tip to a tissue transition during cutting. In conclusion, the photonic electrosurgical knife can determine tissue properties of coagulated and cut tissue and has, therefore, the potential to provide real-time feedback about the presence of breast tumor margins during cutting, helping surgeons to establish negative margins and improve patient outcome.

Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy

Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.

Risks and prevention of surgical fires : A systematic review

Surgically induced fire is a life-threatening hazard; this topic has received little attention, although only 3 factors, the so-called fire triad, are needed for surgical fires to occur: an oxidizer, fuel and an ignition source. This systematic review aims to determine the impact of each component and to delegate every staff member an area of responsibility, thus ensuring patient health through prevention or protection. The trial was registered in Prospero CRD42018082656. A database search of eligible, preferably evidence-based studies was conducted. The Robins-I tool for assessing the risk of bias revealed a moderate risk of bias. Due to insufficient data, the main findings of these studies could not be summarized through a quantitative synthesis; therefore, a qualitative synthesis is outlined. The results are summarized according to the roles of the fire triad and discussed. (1) Role of the oxidizer: oxygen is the key component of the triad. Safe oxygen delivery is important. An oxygen-enriched environment (ORE) is caused by draping and is preferably prevented by suctioning. Fuel characteristics are affected by varying oxygen concentrations. (2) Role of the ignition source: electrocauterization is the most common ignition source, followed by lasers. Less common ignition sources include fiberoptic cables and preparative solutions, petrol or acetone. (3) Role of the fuel: surgical drapes are one of the most common fuels for surgical fires followed by the patient's hair and skin. Skin preparation solutions are among the less common fuels. Many fire-resistant materials have been tested that do not remain fire resistant in ORE. It was concluded that the main problem is defining the real extent of this hazard. Exact numbers and exact condition protocols are needed; therefore, standardized registration of every fire and future studies with much evidence are needed. Immediate prevention consists of close attention to patient safety to prevent surgical fires from happening.

Radioanatomic Study of the Greater Palatine Canal Relevant to Endoscopic Endonasal Surgical Landmarks

Objective A radioanatomic study of surgically relevant variations in the greater palatine canal (GPC) on computed tomography (CT) was performed to determine susceptibility during endoscopic endonasal procedures. Study Design Blinded radioanatomic analysis. Setting Tertiary university hospital. Subjects and Methods Fifty consecutive paranasal CT scans (100 sides) were analyzed. Measurements were standardized to landmarks such as the inferior turbinate (IT) and floor of the nasal cavity (FNC) to assess variability and vulnerability of the nerve. Measurements included (1) incidence of maxillary sinus pneumatization posterior to the GPC, (2) distance from the posterior wall of the maxillary sinus to the GPC at the IT and FNC, (3) width of bone containing the GPC, (4) incidence of medial GPC dehiscence, and (5) angle of the GPC extending from the IT to FNC. Results Ninety-one percent of maxillary sinuses were pneumatized posterior to the GPC. The distance from the posterior wall of the maxillary sinus to the GPC was 2.8 ± 1.7 mm (range, -2.3 to 5.9) at the posterior attachment of the IT and 4.1 ± 3.1 mm (range, -6.3 to 11.9) at the FNC. The width of bone containing the GPC was 3.3 ± 1.3 mm (range, 1-8.9), and the medial bony GPC was dehiscent in 38% of cases. In the sagittal plane, the angle of the GPC between the IT and the FNC was 31.9 ± 6.9 degrees (range, 10.8-45). Conclusion The GPC has considerable anatomic variability relative to important surgical landmarks in endoscopic procedures. Preoperative review of CTs to assess vulnerability may prevent postoperative complications.

Electrosurgery use in circumcision in children: Is it safe?

Circumcision is one of the most common procedures performed worldwide. Bleeding is one of the most common complications following male circumcision, and to decrease the risk of bleeding, electrosurgery may be utilized. However, the use of diathermy on the penis is controversial, and there are reported complications due to the use of electrosurgery for circumcision. The aim of this review is to evaluate the utilization and relative safety of monopolar and bipolar electrosurgery for circumcision in children.

A Century of Surgical Innovation at a Boston Hospital

BACKGROUND

Innovation has been a central focus of the Department of Surgery at the Brigham and Women's Hospital since its very inception. Here we review examples of innovations originating in this Department and analyze factors that have been critical to successful innovation. Finally, we discuss challenges to sustainability of innovation in this Department.

METHODS

Narrative review of the literature, interviews, and personal observations.

RESULTS

Examples of innovations reviewed here were each dependent on three critical elements: 1) multidisciplinary collaboration among surgical innovators and individuals outside of surgery who offered complementary skills and expertise, 2) a rich institutional environment that sustained a diverse complement of innovators working in close proximity, and 3) Department Chairmen who facilitated the work of innovators and promoted their contributions, rather than seeking personal prestige or financial gain. Contemporary challenges to sustainability of innovation include the prevailing emphasis on clinical efficiency and on cost containment.

CONCLUSION

We have identified factors critical to successful innovation in a Department of Surgery. The relevance of these factors is unlikely to be diminished, even in the changing landscape of modern medicine.

Does Increased Electrocautery during Adenoidectomy Lead to Neck Pain?

OBJECTIVES: The objective was to assess the impact of electrocautery on complications in adenoidectomy. We sought to quantify cautery-related temperature changes in prevertebral fascia that may occur during the procedure, retrospectively evaluate the incidence of cautery-related complications, and prospectively assess the role of cautery in postoperative neck pain.

METHODS: Three consecutive related trials were performed. Initially, adenoidectomy was performed on 20 fresh cadavers, using a thermister to evaluate temperature changes in the prevertebral fascia after electrocautery (30 watts over a 30-second period). Next, retrospective analysis of adenoidectomy complications in 1206 children over a 5-year period was performed. Based on these findings, a prospective study of the incidence of neck pain following adenoidectomy was performed in a cohort of 276 children. Adenoidectomy technique, wattage, and duration of electro-cautery were recorded for each child. Children with significant neck pain were evaluated with MRI.

RESULTS: Peak thermister readings averaged 74°C, for a mean change of 51.8°C. Complications observed in retrospective analysis included neck pain (3), Grisel's syndrome (1), prolonged velopharyngeal insufficiency (1), retropharyngeal edema (1), and severe nasopharyngeal stenosis (1). The incidence of neck pain in the prospective study was 12% (33 pts), and was independent of adenoidectomy technique, cautery wattage, or duration of cautery use. MRIs revealed edema without abscess.

CONCLUSIONS: Cautery can result in substantial temperature changes in the surgical adenoid bed. Despite this, the incidence of complications, specifically neck pain, associated with adenoidectomy is low, although underreported. Complications appear to be independent of adenoidectomy technique and cautery use.

Dual-sided electrosurgery handpiece for simultaneous tissue cutting and coagulation: first report on a conceptual design validated by an animal experiment

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.

Harmonic Scalpel and Electrothermal Bipolar Vessel Sealing System in Head and Neck Surgery

Objectives:

Define and compare the thermal nerve injury caused by 3 different vessel sealing and dissection devices: the harmonic scalpel (HS), the electrothermal bipolar vessel sealing system (EBVS), and the bipolar electrosurgery unit (BE).

Methods:

First we recorded the heating variations in pig tissue caused by a BE unit, HS, and EBVS after an activation for 5, 10, and 15 seconds at minimum and at maximum power. In the second part, we evaluated the histological damage caused by HS and EBVS on 20 in vivo human nerves, 10 per device. The 2 scalpels were placed and activated at 3 different distances from the nerve (1, 3, and 5 mm). The extension and the degree of the nerve lesion was then calculated.

Results:

The instrument determining the highest rise in temperature was the BE unit, followed by HS and then EBVS. Comparison between the extension and degree of nerve injury caused by the 2 scalpels showed no statistically significant differences. Based on these evaluations, we established a relative safety limit at 3 mm and an absolute safety limit at 5 mm for both scalpels.

Conclusions:

Our data suggest EBVS and HS can be considered valid and safe devices for ENT surgery.

Research of electrosurgical ablation with antiadhesive functionalization on thermal and histopathological effects of brain tissues in vivo

Thermal injury and tissue sticking are two major concerns in the electrosurgery. In the present study, the effect of lateral thermal injury caused by different electrosurgical electrodes on wound healing was investigated. An electrosurgical unit equipped with untreated (SS) and titanium oxide layer-coated (TiO2-coated) stainless steel needle-type electrodes was used to create lesions on the rat brain tissue. TiO2 layers were produced by radiofrequency plasma and magnetron sputtering in the form of amorphous (TO-SS-1), anatase (TO-SS-2), and rutile (TO-SS-3) phase. Animals were sacrificed for evaluations at 0, 2, 7, and 28 days postoperatively. TO-SS-3 electrodes generated lower levels of sticking tissue, and the thermographs showed that the recorded highest temperature in brain tissue from the TO-SS-3 electrode was significantly lower than in the SS electrode. The total injury area of brain tissue caused by TO-SS-1 and TO-SS-3 electrodes was significantly lower than that caused by SS electrodes at each time point. The results of the present study reveal that the plating of electrodes with a TiO2 film with rutile phases is an efficient method for improving the performance of electrosurgical units and should benefit wound healing.

Six years of evidence-based adult dissection tonsillectomy with ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection

OBJECTIVE

To conduct an adequately powered, prospective, randomised, controlled trial comparing adult dissection tonsillectomy using either ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection.

METHODS

Three hundred patients were randomised into four tonsillectomy technique groups. The operative time, intra-operative bleeding, post-operative pain, tonsillar fossa healing, return to full diet, return to work and post-operative complications were recorded.

RESULTS

The bipolar radiofrequency group had a shorter mean operative time. The mean intra-operative blood loss during bipolar radiofrequency tonsillectomy was significantly less compared with cold dissection and ultrasonic scalpel tonsillectomy. Pain scores were significantly higher after bipolar electrocautery tonsillectomy. Patients undergoing bipolar electrocautery tonsillectomy required significantly more days to return to full diet and work. The bipolar electrocautery group showed significantly reduced tonsillar fossa healing during the first and second post-operative weeks.

CONCLUSION

In this adult series, bipolar radiofrequency tonsillectomy was superior to ultrasonic, bipolar electrocautery and cold dissection tonsillectomies. This method combines the advantages of 'hot' and 'cold' tonsillectomy.

Robotic-assisted radical prostatectomy after the first decade: surgical evolution or new paradigm

Early studies indicate that robotic-assisted radical prostatectomy (RARP) has promising short-term outcomes; however, RARP is beyond its infancy, and the long-term report cards are now beginning. The important paradigm shift introduced by RARP is the reevaluation of the entire open radical prostatectomy experience in surgical technique by minimizing blood loss and complications, maximizing cancer free outcomes, and a renewed assault in preserving quality of life outcomes by many novel mechanisms. RARP provides a new technical “canvas” for surgical masters to create upon, and in ten years, has reinvigorated a 100-year-old “gold standard” surgery.

The comparison of thermal tissue injuries caused by ultrasonic scalpel and electrocautery use in rabbit tongue tissue

The aim of this study compares to the increase in tissue temperature and the thermal histological effects of ultrasonic scalpel, bipolar and unipolar electrosurgery incisions in the tongue tissue of rabbits. This study evaluates the histopathological changes related to thermal change and the maximum temperature values in the peripheral tissue brought about by the incisions carried out by the three methods in a comparative way. To assess thermal tissue damage induced by the three instruments, maximum tissue temperatures were measured during the surgical procedure and tongue tissue samples were examined histopathologically following the surgery. The mean maximum temperature values of the groups were 93.93±2.76 Cº for the unipolar electrocautery group, whereas 85.07±5.95 Cº for the bipolar electrocautery group, and 108.23±7.64 Cº for the ultrasonic scalpel group. There was a statistically significant relationship between the increase in maximum temperature values and the separation among tissue layers, edema, congestion, necrosis, hemorrhage, destruction in blood vessel walls and fibrin accumulation, and between the existence of fibrin thrombus and tissue damage depth (p<0.05). It was concluded that the bipolar electrocautery use gives way to less temperature increase in the tissues and less thermal tissue damage in comparison to the other methods.

The application of regional hypothermia using transrectal cooling during radical prostatectomy: mitigation of surgical inflammatory damage to preserve continence

Preservation of continence and sexual function continues to be a formidable quality-of-life issue regarding outcomes after radical prostatectomy. There is little argument that physical preservation of the nerves and sphincters is a critical component to achieving success in these domains. Previously demonstrated factors such as advancing age, deteriorating physical health status, and subnormal baseline potency negatively impact outcomes. Our hypothesis, however, has been that inflammatory response to surgery has a large impact on surgical outcomes of prostatectomy. Trauma-induced inflammation could account for variation in recovery despite nearly identical surgery on many patients, especially in high-volume surgeons. In other words, we suggest and maintain that younger and healthier patients tolerate and/or recover better from the trauma/inflammation of surgery. Those who do not recover as well may have altered inflammatory response to injury. A common response to decrease inflammation in response to physical injury would be as simple as to cool the injury with ice. Previous neurologic studies have suggested that using ice during surgical intervention can reduce the inflammatory damage. Therefore, we applied this concept that preemptive hypothermia could reduce inflammation to the robot-assisted prostatectomy procedure to potentially lead to improved continence and potency outcomes. In 2009, we introduced the concept of regional hypothermia via an endorectal cooling balloon during robot-assisted radical prostatectomy (RARP). We have published our single institution data demonstrating a significant reduction of overall incontinence. Defining continence as zero-pads, our overall 1-year incontinence has been reduced by 70% (from 13% to 4%). Severe incontinence, defined as two or more pads, was likewise reduced by 70% (from 2.9% to 0.9%). Regional hypothermia used during the time of surgery represents a novel strategy for minimizing inflammation and subsequent muscle and nerve damage in RARP.

Patient safety in the operating room: II. Intraoperative and postoperative

BACKGROUND

The perioperative environment can be hazardous to patients and providers alike. Although many risks are best addressed preoperatively, some hazards require constant attention by the surgeon, anesthesiologist, and staff in the operating room. In a previous article, the authors discussed preoperative aspects of patient safety. In this article, the authors review intraoperative and postoperative risks and techniques to decrease these risks.

METHODS

The authors reviewed the literature regarding operating room safety, both primary research and secondary reviews, via multiple PubMed queries and literature searches. Topics most relevant to inpatient plastic surgery were included in the final analysis and summarized, as a full review of each topic is beyond the scope of this article.

RESULTS

Several intraoperative and postoperative risks were identified, in addition to methods designed to decrease the incidence of those risks, complications, and other adverse events among plastic surgeons and their patients.

CONCLUSIONS

In this article covering intraoperative and postoperative hazards, the authors build upon a previous article addressing preoperative risks to patients during inpatient plastic surgery. Although neither article covers an exhaustive list of potential risks, the goal is to provide the modern plastic surgeon with the means to prevent common adverse events, as well as the tools to research new hazards.

Implementing AORN recommended practices for electrosurgery

Technology is constantly changing, and it is important for perioperative nurses to stay current on new products and technologies in the perioperative setting. AORN's "Recommended practices for electrosurgery" addresses safety standards that all perioperative personnel should follow to minimize risks to both patients and staff members during the use of electrosurgical devices. Recommendations include how to select electrosurgical units and accessories for purchase, how to minimize the potential for patient and staff member injuries, what precautions to take during minimally invasive surgery, and how to avoid surgical smoke hazards. The recommendations also address education/competency, documentation, policies and procedures, and quality assurance/performance improvement. Perioperative nurses should consider the use of checklists and safety posters to remind staff members of the dangers of electrosurgery and the steps to take to minimize the risks for injury.

Safe use of bipolar radiofrequency induced thermotherapy (RFITT) for nasal surgery in patients with cochlear implants

Treatment of nasal turbinate hypertrophy with bipolar radiofrequency-induced thermotherapy (RFITT) is a common indication in patients affected by chronic vasomotor rhinitis. Nonetheless, there are no reports about the safety of such a surgical procedure in cochlear implant (CI) users, due to concerns that the spread of electrical current and heat could damage the CI inner component. We report two cases of CI recipients successfully and safely undergoing RFITT performed by means of the Olympus® Celon-ProBreath bipolar coagulation electrode.

Multilevel radiofrequency ablation for snoring and OSAHS patients therapy: long-term outcomes

Our objective is to evaluate the outcomes of the Radio-Frequency (RF) energy for tissue thermo-ablation therapy in sleep-disordered breathing patients and retrospective evaluation of the RF therapy after a 5-year follow-up period, in terms of snoring and apnea reduction. From June 1999 to June 2009, we enrolled patients suffering from simple snoring and patients with obstructive apnea hypopnoea syndrome (OSAHS). A visual analog scale (VAS) questionnaire was used to evaluate the level of snoring and was filled out in short- and long-term periods, whereas in OSAHS patients an unattended polysomnography was performed before and after a minimum of 6 months from the last RF therapy treatment session. The presence of post-operative pain was assessed by means of a specific VAS. Results stated that 187/250 patients finished the RF therapy. In the simple snoring group, mean snoring VAS decreased from 7.48 to 3.7 (P < 0.0001). In the post-operative snoring group, mean snoring VAS decreased from 7.6 to 3.6 (P < 0.0001). In the mild-to-moderate grade OSAHS group, AHI decreased from a mean value of 18.1 to a mean value of 12.9 (P < 0.0001). Furthermore, we recorded a mean post-operative pain VAS of one in each group of patients. Our results suggest an important role of RF therapy in the improvement of snoring solution, but not for a significant AHI reduction. Level of evidence 2c.

Histopathological and ultrastructural effects of cutting radiofrequency energy on palatal soft tissues: a prospective study

Radiofrequency (RF) surgery has gained popularity as a safe and effective method for treating patients with snoring and mild obstructive sleep apnoea (OSA). Both interstitial and cutting radiofrequency energy may be used for multi-segmental management of the upper airway. Little is known about the effect of cutting radiofrequency energy on human soft palate. Excessive collateral injury may have an impact on tissue healing and functional outcomes. A histological analysis of specimens of human soft palate and uvula following resection with cutting RF energy was performed. In addition, ultrastructural analysis using scanning electron microscopy of excision margins was performed and compared with CO(2) LASER. Twelve patients were included. In ten patients, specimens of redundant uvula and faucial pillars were collected and underwent formal histological analysis. The maximum depth of tissue injury was 1 mm in two specimens and overall average depth of injury was 0.15 mm. Injury depth was independent of tissue subtype at the resection margin. Ultrastructural analysis demonstrated accurate incision when compared to CO(2) LASER. Cutting RF energy causes minimal collateral injury to the soft palate during resection for the treatment of snoring and mild OSA. A detailed knowledge of local effects on resection specimens allows accurate inference of in vivo tissue injury at the resection margin and may enable more precise prediction of healing patterns and repair.

Diathermy in perioperative practice

Diathermy has revolutionised modern surgery and is an important tool for efficient and safe surgical practice. It has evolved to become the modern day scalpel, being used for cutting and coagulating tissues. This article addresses the functioning and safe use of diathermy in the perioperative setting. The various precautionary checks before surgery, which are prerequisite for safe usage, are highlighted along with the necessary safety drills during and after operation. A specific note is included about the use of electrical equipment in specialised surgeries like cardiac and laparoscopic surgery. The issues regarding the maintenance and repair of equipment are acknowledged and finally, the anticipation for a future with precise and safer cutting and coagulation devices is addressed.

Radiophonosurgery of vocal fold nodules

PURPOSE OF REVIEW

To describe the current support in the literature for radiophonosurgery in cases of vocal fold nodules.

RECENT FINDINGS

Radiophonosurgery is a recent innovation in the field of laryngeal surgery. It is emerging as a reliable and practical method for treating benign superficial vocal fold lesions that is increasingly becoming popular. It induces an excellent subjective and objective improvement in voice parameters. Histologically, it produces unremarkable lateral thermal damage and char penetration, which is quite crucial in a functional surgery such as in phonosurgery. Well designed probes are still lacking in the market.

SUMMARY

Radiophonosurgery provides a new approach for patients with vocal fold nodules. It combines the advantages of both cold knife and laser phonosurgery and is easy, well tolerated, precise and effective with excellent tactile and hemostatic properties.

Principles and initial experience of a new device for dissection and hemostasis

Electrosurgery is a commonly used technology in laparoscopy. Electrosurgical devices are being used in many medical subdisciplines in order to coagulate, cut, and ablate tissue and to produce hemostasis. The latest advance in electrosurgery is the introduction of novel simultaneous hemostatic sealing and cutting bipolar devices that minimize force by delivering energy as high current and low voltage output. One of these systems is the Gyrus Plasma Trissector (GPT), (Gyrus Group PLC, Gyrus International, Ltd.UK), a novel radiofrequency (RF) system based on bipolar technology, which consists of a proprietary PlasmaKinetic (PK) generator and specific instruments, designed as a system. The instrument consists of a 17 mm long gold-coated curved jaw with a ceramic insulated cutting element. The PK system uses high-powered pulsed bipolar energy to produce a plasmakinetic field around the working elements and is designed to operate at temperatures that allow effective tissue dissection but result in minimal collateral damage and adherence to tissue. The GPT was used with the Gyrus G400 WorkStation generator in laparoscopic radical prostatectomies (LRP). Our initial experience with this novel bipolar device demonstrates it to be safe and effective in dissection and hemostasis. The GPT permits us to act quickly when bloody fields are present, improves coagulation, reduces or eliminates sticking, seals large vessels such as dorsal vein complex (DVC) and allows secure grasping and dissecting of tissue. The urologist is familiar with electrosurgery, as we have become comfortable using GPT to dissect, cut, and coagulate tissue. We feel that the GPT can be used in a variety of laparoscopic procedures in urology.