Cut thermal injuries with education, inspections
There is no doubt that laparoscopic surgery is a growing component of day surgery programs. In fact, an informal study performed by the Society of Laparoendoscopic Surgeons in Miami projects that laparoscopy will account for an estimated 40% of urology procedures, 50% of general surgery procedures, and 70% of gynecology procedures performed in the United States by the year 2000.1
Of all the surgeons performing laparoscopic procedures, 86% report that they use monopolar electrosurgery for cutting and coagulation during the surgery.2
Along with the increased use of electrosurgical tools during laparoscopic surgery comes an increased risk of thermal injuries to patients, says D. Stephen Robins, MD, president of Communicore, a Friday Harbor, WA-based medical communications company that promotes the use of technology.
The medical malpractice risk is significant. At a 1995 meeting of the Society of Laparoendoscopic Surgeons, 13% of the members surveyed said that they currently had one or more malpractice cases in litigation.2 Because of the serious complications that are a result of thermal injury such as bowel perforation, peritonitis, or hemorrhage, the jury awards in malpractice cases have been high, ranging from several hundred thousand dollars to $2 million. As a result, some insurers have raised malpractice rates by 15% to 20% for surgeons who use electrosurgical techniques.3 Some attorneys say that surgeons, surgery centers, and hospitals may be targeted not only for the surgical errors but also for choosing equipment that allows stray current to injure a patient.4
Robins’ organization put together a Consortium on Electrosurgical Safety During Laparoscopy that included patients who received thermal injuries during laparoscopic surgery, physicians, attorneys, insurers, and nurses. "Whenever you have a problem that can only be solved by a change of behavior, it is important to include all groups that are affected by the issues," Robins says.
Physicians haven’t received safety training
A key result of the consortium’s efforts is a list of principles and guidelines to help ensure patient safety. (See electrosurgical safety guidelines, inserted in this issue.) The guidelines address several issues, but the lack of training in electrosurgical safety for physicians was a surprise to him, says Robins.
"Potential dangers in electrosurgery are not well-recognized by surgeons because they haven’t received training in laparoscopic electrosurgery," he says.
It is important for surgeons to learn how electricity is conducted and which voltage levels are appropriate for laparoscopic surgery, says Andrew I. Brill, MD, professor of obstetrics and gynecology and director of gynecologic endoscopy at the University of Illinois at Chicago.
Managers should develop and implement protocols that address not only visual inspection but also the voltage output of the equipment, Robins says. Making sure that regular inspections of the equipment are performed by the nursing staff as well as biomedical personnel is critical, as is purchasing equipment with appropriate safety features, he adds.
"Manufacturers can be very helpful in developing inspection guidelines, but it is up to the surgery program manager to make sure the equipment is regularly checked," Robins says.
Three types of injuries
It is important for day surgery program managers to be aware of the types of injuries that can occur and what they can do to prevent them. Thermal injuries that can occur during laparoscopic electrosurgery fall into these three categories:
o Direct coupling.
Also referred to as "pilot error," direct coupling occurs when the active electrode touches or arcs to another metal instrument. The electricity then travels through the second instrument and possibly to nearby tissue.
o Capacitive coupling.
Stray electrical current can travel through the insulation of an active electrode to any surrounding conductor, such as a metal trocar sheath. If the conductor (i.e. the trocar sheath) is not touching the abdominal wall, the electric current cannot reach the return electrode and will cause a thermal burn. Conductive material is not limited to metal, Brill points out. Blood also can conduct electricity, so if there is blood in the surgical field, the electric current can travel to another area, he explains.
o Insulation failure.
Constant sterilization and use of the equipment can cause the insulation that covers the shaft of the electrode to erode. The most dangerous cracks in insulation are the smaller, almost microscopic breaks, says Brill. These small cracks concentrate the current and are more likely to create significant injuries, he explains.
Remote electrode monitoring (REM), the use of a split conductive surface patient return electrode that measures impedance between patient tissue, and the return electrode can reduce the risk of capacitive coupling. However, the best technological solution is active electrode monitoring (AEM), says Brill.
AEM is a technology that uses a combination of extra electrical shielding and an electronic current monitor to prevent burns due to insulation breakdown and capacitive coupling. The shielding is conductive and is connected directly to the return electrode of the electrosurgical unit, which allows the current to flow harmlessly back to the return electrode. If the amount of stray energy reaches a dangerous level, the current is shut off and an alarm sounds.
Northside Hospital in Atlanta began using active electrode monitoring in operating rooms that were designated specifically for laparoscopic procedures a few years ago.
"Now, AEM is the standard of care for all of our electrosurgical procedures, including our newly opened day surgery center," says Vicki Barnett RN, MSN, CNOR, director of surgical services.
There are capital and disposable costs associated with the technology, but the extra cost per case is covered by the payers her facility contracts with, says Barnett. The equipment was purchased from ElectroScope, a Boulder, CO-based company that is currently the only manufacturer of AEM laparoscopic equipment. While purchasing prices can vary among surgery centers depending on the specific agreements, an AEM system costs approximately $6,285, says Eileen Banman, sales/marketing coordinator for ElectroScope. This system includes a monitoring unit, cables, electrode shields for use with unshielded 5-mm electrodes, and 5-mm shielded electrodes with integrated shielding within the insulation.
"I am a supporter of AEM because whatever initial costs are incurred are small when you consider the cost of unintentionally burning a patient during surgery," she says.
References
1. Wetter PA. Trends study. Presented at Society of Laparoendoscopic Surgeons Annual Meeting. Seattle; June 1994.
2. Tucker RD. Laparoscopic electrosurgical injuries: Survey results and their implications. Surg Laparosc Endosc 1995; 5:311-317.
3. Harrell GJ, Kopps DR. Minimizing patient risk during laparoscopic electrosurgery. AORN J 1998; 67:1,194-1,205.
4. Laparoscopy seen as hotbed for malpractice.’ Laparoscopic Surgery Update 1994; 2:121-123.
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