Electrosurgery
The Electrosurgical Unit - Surgery with Electricity
Introduction
Electrosurgery
Definition and Usage
• Electric current used to cut and/or coagulate tissue
• Used to cut fat, fascia, muscle, and internal organs
• Part of surgeon’s routine armamentarium
• Often referred to as the “Bovie”
Monopolar vs Bipolar
Monopolar Current

• Most frequently used type of cautery
• Requires a grounding pad
• Pencil-style handpiece is used
• May be activated with a foot control or hand switch
Bipolar Current
Used for minor procedures; plastic procedures; delicate procedures such as ophthalmic and neurosurgery
• Does not require a grounding pad
• Various types of forceps are used (one tip is the active electrode and the opposing tip is inactive)
• Foot pedal is used to activate
Flow of Current
Monopolar
current flows from the
1. Generator or electrosurgical unit (ESU) to the
2. Active electrode (cautery tip) through the
3. Patient’s tissue to the
4. Dispersive electrode (grounding pad) and back to the
5. ESU
Bipolar current flows from the
1. Generator or electrosurgical unit (ESU) to the
2. Active tip of the forceps through the
3. Patient’s tissue to the
4. Opposing forceps tip and back to the
5. ESU
Types of Monopolar Current
Coagulate
• Coagulate capillary and other small bleeding vessels
Cut
• Cut adipose tissue, fascia, internal organs
Blend
• Combination of cutting and coagulating current
• Not a strong coagulating current
• Effective on capillary bleeding
Monopolar Handpiece
• Handpiece (with cord attached) and tip are single-use disposable items
• Distal end of cord is passed to the circulator to be connected to the generator
• Coagulating current is activated with the distal handpiece button
• Cutting current is activated with the proximal handpiece button

Tip of handpiece is
• Removable to facilitate use of various styles (blade, needle, loop, etc)
• Considered a “sharp” and must be handled and disposed as such
• A countable item in some facilities
Types of tips
• Blade - most frequently used; available in regular and long (for use in deep body cavities) lengths
• Ball - ball shape on end of tip; frequently used in throat procedures such as T&A
• Needle - ends in a sharp point; used in minor procedures, plastic, and delicate procedures
Cleaning of Tip
• To keep charred tissue from building up on cautery tip preventing effective flow of current
• Clean the tip using moist sponge or cautery scrapper
– Cautery scrapper: small square abrasive pad with adhesive backing placed on sterile field
• Knife blade NOT recommended, but is often used
Grounding Pad and Placement
• Technical names - inactive or dispersive electrode
• Single-use disposable item
• Available in various sizes ranging from adult to infant
• Prelubricated with conducting gel
• Position patient; then place the pad
• Place pad as close as possible to the operative site
• Do not remove and reposition pad
– Loss of conducting gel
– New pad must be placed
• Pad should cover as large of area as possible
• Extremity - place on area of largest circumference
• Do not place on area with excessive scar tissue
• Do not place over area with excessive hair
– May have to shave the area
• Do not place over bony prominences
• Do not place over or near metal implants
• Do not allow skin prep fluids to pool around or under the pad
• Place on clean, dry skin
• Pad must uniformly adhere to patient’s skin
– No tunneling effect or air pockets
– Edges cannot curl up
• No part of the patient’s body can touch a metal surface such as OR table
– Electric current is attracted to metal
– Current will seek the path of least resistance to complete the circuit
– Body part touching metal will be severely burned
• Awake patient
– Warn patient of placement due to cold and sticky nature of conducting gel so that the patient is not startled
Principles Associated with
Cauterizing Tissue
• ESU produces “buzzing” sound when activated
• Surgeon may ask the assistant to “buzz” a clamp or forceps to coagulate tissue within
– Surgeon holds tissue or vessel with forceps or clamp
– Assistant touches instrument with electrocautery (“Bovie”) tip
– Current travels down instrument to cauterize tissue or vessel
Precautions when “buzzing”
• Do not activate cautery prior to application to instrument to avoid “arcing” of current
• Place cautery tip below fingers of surgeon
– Current can penetrate surgical gloves and cause pin point 3rd degree burn
• Be sure that the instrument grasping the tissue is not touching other tissue
• Be sure that the instrument grasping the tissue is not touching other metal instruments such as a retractor








Documentation
Documentation
Circulator records all information on patient’s intraoperative record
• Location of grounding pad
• Condition of patient’s skin pre- and postoperatively
• Power settings for cutting and coagulating currents
• ESU hospital identification number
Safety Principles

• Initial skin incision is be made with the scalpel
– Bovie will char and scar the skin
• Keep handpiece protected when not in use to prevent accidental activation
– Place in plastic protective holster that can be attached to the drapes
– Keep out of team member’s way to avoid leaning on it

General safety rule
• Start with lowest power settings of current that accomplish the job
• Adjust the current at the surgeon’s request

Clue to equipment malfunction
• Surgeon has repeated request for more power
Avoid inhaling plume (smoke)
• Not yet proven; could be harmful
• Could contain bits of vaporized tissue that could be mutagenic and/or carcinogenic
• Plume is irritating to the respiratory tract
• Oxygen and Nitrous Oxide Used
– Do not use cautery in the mouth, around the head, or in pleural cavity in the presence of oxygen and nitrous oxide
– Nitrous oxide supports combustion
• Metal jewelry removed from patient
• Only moist sponges used in presence of ESU
• ECG Electrodes
– Place electrodes as far away from operative site as possible
– Place grounding pad as far away from ECG electrodes as possible
– Electrical current can be attracted to ECG electrodes and cause severe burns
• ESU can disrupt the operation of implanted cardiac pacemaker
• Alcohol used for skin prep
– Alcohol must be allowed to dry before draping the patient
– If not allowed to dry, fumes can build up under the drapes and possibly ignite when cautery is used
Reasons for Malfunction of ESU

• Improper placement of grounding pad
• Less that full contact of grounding pad with skin surface
• ESU machine malfunction
• Frayed cord