Re: Safe use of electrosurgery in gynaecological laparoscopic surgery

Abstract

Dear Editor, We would like to thank El-Sayed et al. for their review on safe use of electrosurgery in gynaecological laparoscopy. We agree that complications can be avoided by understanding the underlying mechanisms. We share a case of electrosurgical burn and endorse their call for training surgeons in the mechanisms of electrosurgical complications and safety measures. A 36-year-old woman underwent an elective laparoscopic salpingectomy for hydrosalpinx and treatment of endometriosis. A Harmonic scalpel was used for adhesiolysis and salpingectomy followed by Helica to treat endometriosis. Monopolar or bipolar diathermy were not needed, but a diathermy pad was in place. Her arms were wrapped by her sides and a holster was used. At no time were the devices kept on or across the patient’s chest. On completion of surgery, the recovery nurse reported a superficial burn to patient’s right palm (Figure 1). The patient was debriefed, and duty of candour was undertaken. She was told that the superficial burn was likely to be due to the electrosurgical energy used. The burn was dressed, painkillers given and the hand reviewed by an orthopaedic surgeon. Antibiotics were prescribed and hand exercises suggested. After further review, she declined the option of a skin graft. Her hand made a full functional recovery and the investigation report was shared. The theatre team were informed, and the instruments examined. The service log for both instruments were reviewed. Medical physics and the company representative were contacted to review the instruments and settings used and refresh staff training. The cause of the burn was thought to be due to insulation failure and capacitive coupling causing an alternate site burn. The harmonic scalpel uses ultrasonic energy to achieve protein denaturation. It allows simultaneous cutting and coagulation to control bleeding and minimise thermal spread. As no electrical current is used, it eliminates the risk of burns. This vessel sealing device can fuse layers with minimal levels of thermal dispersion, burning and tissue friction, thereby reducing the risk of accidental burns. Similarly, the Helica thermal coagulator (HTC) has been shown to be safe. It uses a combination of low volume helium gas and very low electrical power (2–8 watts) to allow precise cauterisation to an area of tissue in a highly controlled and non-contact mode. It is applied 3–5 mm away from tissue, and coagulation is activated at this distance, where temperatures up to 800°C are achieved. As coagulation occurs in a helium environment, there is no surgical smoke or carbonisation. The depth of penetration is easily controlled by the power setting and the distance of the probe from the tissue. This case highlights the need for formal training for everyone involved in laparoscopic surgery to be fully aware of all energy devices used. Harmonic scalpel and Helica are Figure 1. Photograph showing the superficial burn after laparoscopic surgery.