Electrosurgery

Abstract: Background: Electrosurgery is one of the most commonly used energy systems in laparoscopic surgery. Two major categories of potential complications related to electrosurgery in laparoscopy are mechanical trauma and electrothermal injury. The latter can result from unrecognized energy transfer in the operational field or, less commonly, to unnoticed stray current outside the laparoscopic field of view. Stray current can result from insulation failure, direct coupling, or capacitive coupling. Methods: We reviewed the literature concerning essential biophysics of electrosurgery, including electrosurgical waveform differentiation, tissue effect, and variables that determine tissue effect. The incidence of electrosurgical injuries and possible mechanisms responsible for the injuries are discussed. Different types of injuries may result in different clinical manifestations and histopathological findings. Gross and microscopic pathological check-ups of the injury sites may distinguish between different mechanisms, and thus provide further clues postoperatively. Results: Several recommended practices are proposed to avoid electrosurgical injury laparoscopically. To achieve electrosurgical safety and to prevent electrosurgical injuries, the surgical team should have a good understanding of the biophysics of electrosurgery, the basis of equipment and general tissue effects, as well as the surgeon’s spatial orientation and hand-eye coordination. Some intraoperative adjuvant procedures and newly developed safety devices have become available may aid to improve electrosurgical safety. Conclusions: Knowledge of the biophysics of electrosurgery and the mechanisms of electrosurgical injury is important in recognizing potential complications of electrosurgery in laparoscopy. Procedures for prevention, intraoperative adjuvant maneuvers, early recognition of the injury with in-time salvage treatment, and alertness to postoperative warning signs can help reduce such complications.

Abstract: This study compares the histologic effects of scalpel, CO2 laser, electrosurgery, and constant-voltage electrosurgery incisions on the mucosal tissue of swine. Tissue studies comparing the CO2 laser with the scalpel and electrosurgery have been done. However, a gross and histologic comparison of the effects of all three techniques on oral mucosal tissue has not been reported. A swine model of both tongue and buccal mucosa was used to compare the scalpel, CO2 laser, electrosurgery unit, and constant-voltage electrosurgery unit in an effort to assess their value in oral surgery. Tissue samples of tongue and buccal mucosal incisions and excisions were histologically examined at 0, 3, 7, 14, 28, and 42 days after surgery to evaluate tissue damage and wound healing properties induced by the four instruments. The instruments were also evaluated for performance and ease of use. On subjective evaluation of ease of use, constant-voltage electrosurgery scored highest (p < 0.05) on a scale of 0 to 4, followed by the CO2 laser. Speed of incisions and excisions, measured in seconds, was fastest with the scalpel (p < 0.001) and electrosurgery unit (p < 0.05). The amount of bleeding, as evaluated on a scale of 0 to 4, was least for electrosurgery (p < 0.001) and CO2 laser (p < 0.001). Histologic damage, as expected, was least with a scalpel. The extent of epithelial damage lateral to the wound edge and the extent of collagen denaturation were the lowest with the scalpel (p < 0.001), followed by constant-voltage electrosurgery. The wounds created by all four instruments displayed intact epithelium by 4 weeks, and granulation tissue peaked at 4 weeks with all methods except constant-voltage electrosurgery, where granulation tissue was still prevalent at week 6. Constant-voltage electrosurgery and the CO2 laser provided the best combination of ease of use, hemostasis, and lack of tissue injury among the instruments compared. Incisions and excisions made with constant-voltage electrosurgery required less time than those made with the laser, but constant-voltage electrosurgery wounds also had significantly more granulation tissue in later weeks of the study, suggesting that wound healing may be delayed.

Abstract: Background and aims. The minimally invasive technique of transanal endoscopic microsurgery (TEM) combines the benefits of local resections, a low complication rate and high patient comfort, with low recurrence rate and excellent survival rate after radical surgery (RS). The use of an ultrasonically activated scalpel rather than electrosurgery further improves the results of TEM. Patients and methods. A retrospective study was performed of 182 operations on 162 patients with early rectal carcinoma (pT1, G1/2) or adenoma to compare the outcome following four different kinds of surgical resection techniques: RS (anterior or abdominoperineal resection; n=27), conventional transanal resection using Park's retractor (TP; n=76), transanal endoscopic microsurgery (TEM) with electrosurgery (TEM-ES; n=45), and TEM with UltraCision (TEM-UC; n=34). One-third of the patients with RS (33%) received either a colostomy or a protective loop-ileostomy. Results. Operation time with TEM-UC was significantly shorter than with TEM-ES or RS. Hospitalization was significantly longer with RS than for TEM or TP. Complication rate with TEM was significantly lower than with RS. Recurrence rate with RS and TEM was significantly lower than with TP, with a trend to TEM-UC being better than TEM-ES. Mortality rate was 3.7% with RS and 0 with TP and TEM. The 2-year survival rate was 96.3% with RS and 100% each with TP and TEM. Conclusion. TEM using UC seems to be the technique of choice. TP leads to an unacceptable recurrence rate, and RS results in a higher incidence of complication and impairment of life quality.