SUR 101
Explain the principles behind what could be the primary cause of these burns.
Use of a cautery while the patient is in contact with metal can cause burns
What specific factors contributed to what occurred in this situation?
Patient positioning issues. Patient was clearly not positioned correctly
What complications might result from the burn injury? Second, Third-, or fourth-degree burns resulting in skin grafting
What could the CST and other surgical team members do to help prevent this type of injury?
Communication is key. Check behind each other.
Computers and information technologies have become a vital source of importance to today’s workforce.
They are providing the user faster ways to research, increasing access to information, and improving patient safety by reducing human error.
The following sections address background information regarding the operation of electronic devices
Hardware is the overall term used to describe the physical components of any computing device and may include a central processing unit (CPU), keyboard, display screen or monitor, modem, and memory storage devices.
Once the power is turned on, the CPU goes through a start-up process, referred to as booting, to activate the device.
For security purposes, a log-in screen will open that may request the user’s name and password. For users sharing a device, the login screen can be accessed again for the new user to type in their name and password.
Once the user has logged on to the operating system, a desktop appears, the general background on which windows, dialog boxes, and icons appear.
Short-cut icons to programs can be placed on the desktop, and the screen background, or wallpaper, and the taskbar can be customized.
Computer software are programs that operate the computer system and its hardware components and the user’s programs, such as word processing, email, or internet access.
Most computer systems are factory equipped with software programs. When utilizing a computer, it is important to use software programs that can be used with the application the person is trying to interface, for example, home, work, or school.
In healthcare, software programs provide applications that allow access to EMRs and data systems.
An electronic medical record (EMR) is a digital version of the patient’s chart that contains their medical and treatment history.
EMRs allow clinicians to track data and monitor the overall quality of care within the practice or healthcare facility (HCF).
EMRs aren’t easily shared outside of the system but can be printed and shared with specialists or other healthcare providers (HCP) within the network. In contrast, an electronic health record (EHR) is designed to go beyond the standard data collected by a single practice and offers a much broader view of the patient’s care. EHR systems are built with the purpose to share information securely with other HCPs, including the patient, so the data reflects information from all involved in the care of the patient and is not limited to one practice or HCF.
Tidelands MyChart (EHR) for example allows the patients practicians to share date and notes and allows the [atients to access those notes.
Word processing is a term that means creating a document file.
There are many functions that can be used when creating a document.
Microsoft Word and Google Docs are popular word processing programs.
The functions may be displayed in toolbars either as words or symbols called icons that can be selected.
Educators and students have numerous programs available to prepare digital presentations that may incorporate informational slides, audio or video clips, and a myriad of statistical data models.
PowerPoint, part of Microsoft Office tools, Prezi, and Google Slides are examples of the software or web-based platforms that can create presentations.
The care of patients in the perioperative setting is coordinated using EHRs or EMRs because of mandates by the Centers for Medicare and Medicaid Services (CMS).
The circulator is tasked with inputting procedural information into the digital chart such as billing codes, inventory used, and the patient’s condition throughout the perioperative period.
Similar technology can also provide circulators and CSTs access to supply chain data, resulting in easier data management and improved efficiency in locating required items needed during the surgical procedure.
In technologically advanced ORs, surgeons can also access digitalized files, such as clinical data, lab work, and radiographs on boom-mounted screens or flat-panel monitors mounted on the walls.
This is extremely helpful as it minimizes the hazards of cords on the floor or having to place towers in less-than-ideal locations that may hinder visibility or movement in the OR.
Another benefit of advanced technology is that it can allow for real-time teleconferencing with another surgeon or expert, even offering telesurgery capabilities if needed.
Digitized information isn’t exclusive to the OR. Data can be shared in real time with other departments, such as radiology, pathology, materials management, and the PACU, without staff needing to leave the room.
This reduces the need for emails, phone calls, and text messaging to seek out information.
Digital charting decreases administrative tasks and helps to reduce human error.
Electronic coding is also substantially more efficient.
For example, recording a patient implantable device is much easier using software that can automatically identify the manufacturer and serial numbers without the circulator writing down and entering a ten-digit serial number.
The use of barcoding to track supply use and charges during surgery has become more commonplace in today’s HCFs.
For example, an automated bar-coding system can be accessed by entering the patient ID and scanning a code on a single supply item using an optical laser.
Integrated software then adds this information directly to the patient’s record, billing system, and in some cases, to materials management to prompt resupply.
Materials management staff or the CST may also use a barcode system when pulling cases.
Case carts are filled with items using automated preference cards. Once each item has been pulled, it is scanned before placing it into the cart and automatically deducted from the inventory.
Using RFID technology has proven to be an efficient method to automate data collection, reducing human effort and error.
It is similar to the method of scanning bar codes but instead of using laser sight, RFID uses radio-frequency waves to capture multiple “tags” simultaneously.
These tags contain microchips with the ability to access large amounts of information.
For example, if a patient experienced an emergency in the OR, scanning their wristband would give the surgical team immediate access to the patient’s medical conditions, history, and medical allergies.
RFID is especially useful in the OR when managing and tracking surgical sponges, medications, and specimens.
Sponges account for upwards of 70 percent of all retained surgical items.
Used alongside the manual sponge count, RFID tagging helps to confirm the accuracy of the initial count and the addition of sponges to the sterile field during the procedure.
It also helps to prevent any tagged sponges from being left in the surgical wound by placing a detection mat underneath the patient.
At the conclusion of the case, the mat is activated, and a wand is passed over the operative site to detect any missing sponges.
While effective for locating sponges, it is important to note that the RFID system should not be used to replace a manual count of sponges.
Electronically scheduling surgical procedures have been streamlined because of advancements in computer technology
Communication from the physician’s office instantly provides necessary patient and procedural information to all relevant departments in the HCF.
The information saved in most internal operating systems can be easily updated and dispersed or accessed by the designated department staff prior to surgery.
The devices used for scheduling have patient confidentiality at the forefront and can be located beneath a high counter or have encrypted screens when the device is at rest or in transit to prevent protected health information (PHI) from being accessed or shared by non-authorized users.
A surgeon’s preference card provides procedural specifications and the list of equipment, supplies, and surgical instrument trays that will be necessary for the procedure being scheduled.
In the past, surgeon’s preference cards were handwritten with notes scribbled in the margins, often becoming illegible.
Additionally, if the surgeon had privileges at more than one HCF, it was difficult to get copies of the cards or, if the surgeon moved, the cards would be left behind.
Currently, the majority of HCFs develop and save preference cards electronically, making it easier to update the cards and obtain an accurate copy when preparing for a surgical procedure.
Some software programs can also derive a preference card from EHR (electronic health records) data.
Operating system software has substantially reduced the paperwork of the sterile processing department. Most records related to sterilizing supplies and equipment can now be maintained electronically. Additionally, just as with the surgeon’s preference cards, the instrument list and count sheet used to assist with assembling instrument trays can be entered, saved, updated, and printed.
There are a variety of automated instrument tracking programs that HCFs use to improve quality processing and facility workflow. These systems can record and track instruments to prevent loss as well as to assist in locating them in an emergent situation. Using barcodes or RFID systems can also communicate the status of an item or instrument set and whether it is in use in an OR, in decontamination, has completed the sterile processing cycle, or is stored and ready for use.
Safety Data Sheets (SDS) are used to catalogue information on chemicals and solutions used in the HCF.
Copies of SDSs are required to be kept on file or electronically accessible to meet compliance with both federal and state regulatory standards.
They must be accessible to employees who need the instructions for safely handling and using the solutions. Though SDSs may be accessed electronically via the internet, it is still recommended to keep paper copies in the workplace.
All employees are held accountable to demonstrate how and where these sheets are accessed.
Recommendation: Identify the chemical that will be used and research ahead of time.
Ensuring the security and protection of patients’ healthcare data is critical.
The Health Insurance Portability and Accountability Act (HIPAA) ensures that this information remains private and secure.
HCPs should know that PHI is not limited to electronic transmission but also includes any oral or written communication.
For example, if a CST speaks about a procedure, they participated in that day in an elevator full of people, this can be a HIPAA violation if any PHI is mentioned.
PHI definitions and rules can vary among HCFs, but usually include the following:
Referrals
Patient profile
Billing records
Admission records
Prescription records
Discharge and follow-up appointments
HIPAA policies apply to all departments in an HCF, including parking lots or garages, and the employee’s home internet.
PHI must always be preserved. Whenever a surgical patient is admitted to the HCF, they sign and receive a copy of a privacy notice.
If for any reason the patient cannot sign, the reason must be documented and witnessed.
PHI is especially important for surgical personnel to understand.
Surgeon’s or OR team members who videotape a procedure or take and post images of one, are in violation of HIPAA if prior consent from the patient has not been received.
If consent is given, names should not be used and the face should be blanked.
PHI data may be compromised when stored on hard drives, especially with laptop computers and flash drives. For this reason, HCPs should refrain from storing patient data on these types of electronic devices. Advances in cloud technology and storage has significantly reduced the risk of privacy breaches of electronic devices.
To ensure patient safety, it is important to study the terminology and principles of electricity and examine its applications as they relate to the OR.
The principle that governs the behavior of tiny particles known as electrons is called the electron theory that helps to explain electricity and serves as the basis for the design of all electrical equipment.
All matter consists of atoms and all atoms are composed of small particles called protons, electrons, and neutrons.
The center of the atom is called the nucleus and contains protons that are positively charged electric particles, and neutrons that are neutral particles.
Electrons are negatively charged particles that travel around the nucleus in concentric paths called shells or orbits.
Electrons located closer to the nucleus demonstrate a stronger attraction to the nucleus,
Electrons moving in the outer orbits are less attracted.
If outer electrons are exposed to light, heat, or electric energy, they will speed up and leave the atom.
These outer electrons are referred to as free electrons.
Movement of free electrons that creates electrical current.
Electricity describes the free electrons moving or flowing from the outermost shell of one atom to another.
Materials that allow the flow of free electrons are called conductors.
Examples of conductors are silver, copper, aluminum, zinc, brass, iron, saltwater (saline), carbon, and some acids.
Copper is the most commonly used conductor because it is relatively economical.
Examples of devices that use copper wire as a conductor in the OR include surgical lamps, ESU, and power drills.
A conductor material, such as the filament in a lightbulb, has a high resistance to the flow of electricity.
Resistance refers to restricting the flow of the current.
The electricity must force its way through the resistance and the energy causes the conductor to glow or heat up.
When the load increases or decreases, the power source delivers more or less power.
Because water is a conductor of electricity, the amount of humidity in the air within an environment is important to consider.
High humidity often results in static charge leakage and low humidity results in the formation of sparks; therefore, humidity in the OR should be maintained between 20 percent and 60 percent.
Materials that inhibit the flow of electrons are called insulators.
Insulators are simply poor conductors.
Conductors, such as copper and other metals, are wrapped with an insulating material that does not conduct electricity to prevent electrons from leaking while the current flows to the device that it powers.
Examples of insulators in the OR are the rubber and plastic covers around electrical cords and hard plastic that cover electrical devices such as monitors, the ESU, or X-ray machines, and the plastic insulating sheaths of laparoscopic instruments.
An electric current is the flow of electric charge or the rate of flow of electrons
Current is measured in amperes (amps).
For example, an incandescent lightbulb illuminates because the electrons move through the conductor and the tungsten filament in the bulb. The filament heats up and brightens. The electrical current travels through conductors by movement of the free electrons that migrate from atom to atom inside the conductor.
The path that electricity travels from the energy source to a device and then back to the energy source is defined as a circuit
A simple electrical circuit is comprised of a source of power, conductor, load, and switch.
Measurement terms used for electricity include volts, voltage, current, amperes, and watts.
The term volt defines electrical potential.
Voltage is the potential energy of electrons or the electric charge at any given time between two points.
An electric system uses a battery or generator to create a force or voltage to move the electricity from one point to another. Typical home voltage in the United States is 110 V or 120 V.
Current is measured in amperes (amps).
Current is the flow of electric charge or the rate of flow of electrons.
For example, a single strand of copper wire is laid on a table; one end of the wire is negative, and the other is positive.
All free electrons in the wire will be attracted to the positive end and consequently flow in the same direction.
Free electrons will always be attracted from a point of excess electrons to a point that lacks them.
Amperage is the "rate" that current is flowing through the circuit or the number of electrons moving through the wire. Amperage is listed in units called amps (or amperes).
Watts is a unit of power that measures the rate of energy transfer. It is the rate at which electrical work is done when one ampere (A) of current flows through one volt (V).
Buying a light bulb: Wattage measures the amount of energy a light bulb uses. In the past, higher wattage meant brighter light. However, with modern energy-efficient bulbs, wattage primarily indicates energy consumption rather than brightness. The higher the wattage, the more energy is consumed.
In the OR, wall outlets are usually 110 volts (V), excluding the outlet for the mobile X-ray unit and some laser units that require 220 V.
Plugs used in surgery have three prongs.
Components of the three-prong plug are:
first prong (positive),
second prong (negative), and
third prong (ground).
Electrical current ultimately seeks to go to the earth or ground.
Buildings with steel frames provide a direct route for electrical current to travel to the ground.
Often, copper piping and wiring are utilized as additional pathways to the building frame then to the earth.
In electrical circuits, if a short occurs, the current will flow through the grounded third prong of the plug, reducing the risk of current passing through the surgical team or the patient.
Operating Room wall outlets
The ground prong also captures excess or leakage current not removed by the negative prong. The ground prong should never be cut or broken off to accommodate plugging into a non-grounded two-hole electrical outlet.
There are two types of electrical currents: direct current (DC) and alternating current (AC).
DC indicates current that flows in one direction from the negative pole to the positive pole.
Batteries are a common example of DC current. Batteries have a negative (-) terminal and a positive (+) terminal.
When the switch is closed, current flows from one terminal to the other.
Current ceases when the switch is open.
The four components of a DC circuit are:
source of electricity, for example, a battery;
conductor, for example, a wire from a source to a load;
control device, for example, a switch; and
load, for example, a bulb or heater.
AC describes the flow of current that reverses direction periodically.
A complete AC cycle occurs when the current moves in one direction and then reverses its course.
The number of cycles per second is called frequency and is indicated by the symbol f.
The most used power in the United States is 60-cycle AC, meaning there are 60 AC cycles per second.
AC is characterized by its ability to change the voltage.
AC can be delivered at a high voltage and then reduced to a lower voltage at the point of use.
Transformers are devices that reduce or increase the exiting voltage and only work with AC.
Power lines are a common example.
Utility companies deliver electricity through power lines at a very high voltage.
However, before the voltage can be safely used by a HCF, it must be reduced to a lower voltage using transformers.
All radio and television signals are electromagnetic waves.
An important concept to remember is that the number of wave cycles per second is called frequency.
The radio or television transmitter output is connected to the antenna system located at a distance from the transmitter.
The energy travels through a transmission line from the transmitter to the antenna.
Example: Surgical Wands that are used to scan patients for retained items use RF. Keeping track of instruments through the tracking system uses RF.
An example of a transmission line is the set of cables used for consumer television receiving antennas.
Depending on the frequency, the waves travel through the atmosphere or space.
Because of the use of many electrical devices and equipment in the OR, isolated power systems (IPS) are frequently used to monitor power overloads and prevent potential fires caused by faulty equipment or excess electrical current usage.
In many individual ORs, a panel on a ceiling boom or on the wall with a red and green light are visual signals of the status of the electrical circuitry in that room.
If the light turns red and an audible alarm sounds, the last piece of electrical equipment plugged into the wall outlet should be carefully unplugged.
The device may have an electrical short in its circuit or may have overloaded the electrical system in that room.
If the IPS light returns to green and the alarm ceases, the equipment should be removed from service and checked by the biomedical engineer before returning it for use.
Physicians have long recognized the benefits of using heat on wounds to accelerate blood clotting.
In 1926, a Harvard physicist, William T. Bovie, PhD, and Harvey Cushing, MD, considered the father of modern neurosurgery, developed the first electrosurgical generator.
Modern variations of the electrosurgical unit (ESU), also referred to as the Bovie machine, are routinely used in surgery to coagulate or cut tissue. The ESU is the device that provides the power for electric current to travel to the tissue
Electrosurgery is the application of AC through tissue to coagulate or cut tissue.
The term electrocautery is often used; however, this is incorrect because the electrocautery is a disposable, battery-operated (DC current) device that uses a heated wire to cauterize superficial bleeding vessels such as those of the conjunctiva of the eye.
Components of the ESU include the generator, optional foot pedal, cords, active electrode, and a patient return electrode or dispersive pad.
The ESU uses two modes to deliver the electrical current to the tissue called monopolar and bipolar.
Monopolar electrosurgery is more frequently used for coagulation but may also be used to cut tissue.
The generator can change the frequency levels, blending the coagulation and cutting functions to achieve a combined result.
Monopolar electrosurgery is used when relatively large surgical areas are involved.
The bipolar mode is used less frequently and is only used for coagulation, not cutting.
Bipolar electrosurgery is used for delicate surgical procedures, at sites where moisture is nearby, to prevent damage to delicate tissue and nerves, or in patients with implanted pacemakers or metal prostheses.
Monopolar ESUs
The monopolar mode consists of three main components called the generator, active electrode, and patient return electrode, also more commonly called a dispersive or grounding pad.
The active electrode, also called the electrosurgical pencil or Bovie pencil, is a sterile, pencil-shaped device with a removable metal tip that is disposable.
The generator is the main unit that provides the source of electrical current to the active electrode and completes the pathway for the returning current from the grounding pad.
Monopolar pathway:
Current travels from the generator to the active electrode, such as the ESU pencil or laparoscopic instrument with ESU cord attached.
The active electrode is activated by the surgeon to deliver the cutting or coagulating current to the tissue or vessel.
The electrical current then passes through the patient’s body to the grounding pad.
The current exits the patient’s body via the grounding pad and returns to the generator.
The surgeon activates the generator with a hand control located on the active electrode or with a foot pedal when laparoscopic instruments are used.
The main power or electrical cord is attached to the back of the ESU.
The electrical cord is plugged into a wall outlet in the OR. An electrical cord with a three-prong HCF-grade plug must be used.
An extension cord should not be used with the ESU or any other electrically powered equipment in the OR.
The power cords for the monopolar and bipolar foot pedals are attached to the back of the generator.
Also located on the back of the generator is the volume control for the audible tones.
When the active electrode is in use, the generator emits a high-pitched sound.
If the active electrode is inadvertently activated, the sound alerts the surgical team to stop the activation and prevent burning the drapes or the patient.
For safety reasons, the volume should never be completely turned off or down so low as to make it inaudible.
The control panel is located on the front of the generator and contains the on and off switch, plug-ins for the active electrode and grounding pad, power level adjustment controls, and blend (cutting/coagulating) adjustment controls.
Some generators are equipped to handle two active electrodes at the same time.
This feature is useful when multiple procedures are simultaneously performed on a patient.
The surgeon determines the power and blend settings and communicates the settings to the surgical team.
Some generators are capable of operating in both monopolar and bipolar mode.
When turned on, the generator performs a self-check prior to entering the “ready” mode.
The active electrode is packaged and sterilized by the manufacturer.
It includes the active electrode with a removable metal tip and a protective plastic holster.
The ESU pencil may also come with attached smoke evacuation tubing
. To prepare the ESU pencil for use, the CST should set the entire unit pencil with tip and holster aside on the back table for placement on the sterile field following the application of sterile drapes over the patient
After draping is completed, the sterile cord and holster are attached to the sterile drapes with a non-perforating plastic towel clip, hook-and-loop strips, or tabs attached to the drape to prevent it from falling off the field or below the table level.
The plug end of the cord from the ESU pencil is passed off the sterile field to the circulator for attachment to the generator.
Once connected, the power settings are adjusted by the circulator according to the surgeon’s preference.
When the ESU pencil is not in use, it should be placed in the holster to prevent inadvertent activation and ignition of drapes and to protect the tip from penetrating the drapes, possibly injuring the patient.
The ESU pencil is activated by the surgeon pressing on one of the appropriate buttons, cut or coag (coagulation).
Some ESU pencils have a third button that allows the surgeon to adjust the power setting up or down at the sterile field rather than having the circulator adjust the setting on the generator.
Argon plasma coagulation (APC) can be used to enhance the effectiveness of the electrosurgical current.
Argon gas is inert and incapable of combustion, allowing electric current to pass safely through the gas that is ignited into a plasma.
The energized argon plasma appears as a bright beam of light.
Because argon gas is heavier than air, the “beam” displaces the air, causing less tissue damage, which, in turn, produces less vaporized tissue plume than traditional electrosurgery.
APC may be used to cauterize large areas of tissue for debridement and debulking, and to achieve hemostasis.
Because electrical current still passes through the patient, a grounding pad specific for the argon beam coagulator must be placed on the patient.
Very helpful in laparoscopic procedures where tissue beds needs coagulation
Various types of tips are available for placement on the end of the ESU pencil.
They include blade-shaped, ball-tipped, wire loop, and needle tips.
Long extension tips are available for deep surgical wounds.
Tips may be partially insulated to prevent thermal damage to the surrounding tissue.
Some surgical procedures may call for the use of more than one type of tip; therefore the tips can be removed and replaced on the end of the pencil by the CST. (counted items)
The blade or tip of the pencil must be kept clean and free of charred tissue to allow the current to freely flow and work efficiently.
Sterile scratch pads are commercially available and consist of a small square with adhesive on the bottom for attachment to the drapes and a rough, sandpaper surface used for scraping the tip to remove charred debris .
The CST must make sure the scratch pad does not come loose and enter the surgical wound, becoming a retained foreign object.
Non-stick Teflon-coated ESU tips are available that allow charred tissue to be easily removed with a sponge.
All ESU tips are considered sharps and are included in the sharps count, removed from the ESU pencil, and disposed of in the sharps container in the OR following the procedure.
The flexible, disposable, nonsterile dispersive pad or patient return electrode is supplied in a protective package with a cord and sticky conductive gel on its surface
These are available in adult, pediatric, and neonatal patient sizes.
The gel supports the conductivity of the current from the patient back to the generator and allows the pad to stick uniformly to the patient without damaging the skin upon removal.
The dispersive pad is only required when the ESU is operated in monopolar mode.
The dispersive pad is removed by the circulator from its package and securely placed on the skin of the patient. The cord is then connected to the front panel of the generator. The entire surgical team must always be aware that an improperly placed dispersive pad can be the cause of a severe patient burn.
General safety and patient considerations include the following:
Dispersive pads can be cold when applied to the skin. If the patient is receiving general anesthesia, it is recommended to apply the dispersive pad after they are anesthetized. If the patient is receiving local anesthesia, warn the patient that the pad will feel cold during its application.
Apply the pad after positioning the patient to prevent wrinkling, gapping, or movement of the pad.
Apply the pad to a large, fleshy area, preferably over a muscle mass that is clean and dry. Avoid areas that may get wet during the procedure and cause the pad to slip.
Avoid placing the pad over a bony area or prominence that could contribute to an uneven placement.
If the patient is placed in the supine position, avoid placing the pad on the buttocks because uneven placement could occur, and the pad cannot be seen.
Do not apply the pad over a metal prosthesis. Doing so may cause the electrical current to travel through the metal and internally and externally burn the patient. Make sure the pad isn’t touching or near other sources of metal, such as the OR bed frame.
Handle the pad as little as possible.
Confirm the entire pad is making full contact with the skin and there is no wrinkling or tunnelling. Spaces between the pad and skin can contribute to a break in the electrical current’s ability to exit the body and can cause patient burns.
Check for an expiration date or, if the gel is dry, discard the pad and open a new package. Do not apply gel to the pad to replace dried gel.
Place the dispersive pad as close to the operative site as possible without obstructing access so that the electrical current traveling through the body is kept to a minimum.
If a pad is placed but the placement is not satisfactory, remove the pad and apply a new pad; do not use the pad that was removed.
Do not let skin prep solutions pool around or under the grounding pad. The solutions can cause the pad to fail to adhere to the skin, cause chemical burns to the patient’s skin, or fumes from the solutions may ignite when exposed to a spark from the ESU pencil.
Flammable anesthetics should not be used during electrosurgery. Precautions should be taken to prevent oxygen or nitrous oxide from igniting during procedures around the head.
Electrocardiogram (ECG) electrodes have metal tips that can serve as an alternate pathway for the current traveling to a ground, thus burning the patient.
A pacemaker or internal defibrillator can malfunction during electrosurgery. Surgical personnel should monitor the patient for potential interruptions and should be prepared with a defibrillator. Bipolar current is preferred for electrically sensitive patients.
Jewelry or other metallic objects that belong to the patient should be removed before surgery to prevent possible patient burns from a current that is seeking an alternate exit pathway to the ground from the active electrode.
The CST sets up the forceps and cord in the same method as the ESU pencil by preparing it for use at the back table and, following draping, securing it to the sterile drape at the sterile field.
The end of the cord is passed off to the circulator for attachment to the generator and the circulator adjusts the power settings according to the surgeon’s preference.
The surgeon will activate the bipolar forceps with the use of a foot pedal.
The bipolar current is as follows:
The current flows from the generator to the active electrode that is one of the prongs of the forceps.
The active electrode delivers the coagulating current to the surgical site tissues or vessels.
The electrical current passes through the tissue between the tips of the forceps prongs.
The current returns to the generator via the return electrode prong and to the cord.
Other types of bipolar and vessel-sealing devices have been developed for various specialties, including general surgery, gynecology, ENT, and neurosurgery.
Examples of these devices include the following:
ENSEAL X1 Large Jaw Tissue Sealer: A bipolar vessel sealing and cutting device designed to accommodate vessels up to 7 mm in diameter for use in multiple specialties.
Liga Sure: A bipolar vessel sealing and cutting device available for open and laparoscopic procedures with minimal thermal spread
Coblator II Surgery System: A bipolar device used in ENT procedures.
Thunderbeat: A combination bipolar and ultrasonic scalpel vessel sealing and cutting device designed to accommodate vessels up to 7 mm in diameter used in multiple specialties.
Spetzler-Malis irrigating bipolar: A nonstick, dual irrigation channel, disposable forceps for neurosurgical and spinal procedure
The advantages of electrosurgery include the following:
Electrosurgery reduces the total blood loss and bleeding is quickly controlled.
It saves time because it is faster to use than applying suture ligatures, also called ties.
Blended current coagulates tissue as it is divided, reducing the need to stop and control bleeding.
The coagulation current seals small spaces in the tissue and lymphatic vessels that would normally ooze fluid postoperatively, reducing resorption of toxic fluids, edema, and postoperative pain.
Hazards of using the ESU
One of the dangers of electrosurgery is electrical burn.
During surgical procedures performed endoscopically, patients may be at risk for unintended and potentially unrecognized burns because of instrument insulation failure or direct coupling.
Some patient burns experience delayed appearance and may not be noticed until several hours after the procedure.
Most endoscopic instruments capable of being electrified by attachment of a monopolar ESU cord have an insulation coating along the length of the shaft of the instrument.
Over time and with routine use, tiny breaks or cracks in the insulation may occur. If the instrument touches tissue distal to the operative site at the point where the insulation is not intact, the electrical current may leak out and burn that area.
Additionally, if two uninsulated portions of instruments touch each other, a direct coupling pathway may be created.
In this case, it may include an uninsulated metal trocar sheath or grasper that inadvertently is touched by an electrified instrument tip, creating an alternate pathway for the electric current and burning any tissues in contact with the instruments.
These types of burns may not be noticed by the surgeon or members of the surgical team because of the narrow field of view created by the endoscope when focused on the operative site and intended target tissue.
Close inspection of instrument insulation must be performed by both sterile processing department personnel and CSTs preparing for these cases and prior to their use to prevent potentially devastating, undetected intraoperative injuries to nonoperative tissues or organs.
The surgical team members are also at risk.
Possible causes for surgical team members sustaining burns include radio frequency (RF) capacitive coupling and dielectric breakdown.
RF capacitive coupling occurs when an alternating current travels from the active electrode, through intact insulation, and into the skin.
For example, this may happen when a surgeon applies a hemostat to a bleeding vessel. While holding the hemostat, the surgeon’s skin and the metal hemostat serve as two conductors.
The surgeon or CST touches the tip of the ESU pencil to the hemostat and activates it to coagulate and seal the vessel.
The current travels down the conductive metal hemostat to the vessel.
Normally, the surgeon’s glove would function as an insulator, protecting the surgeon from the current.
However, if the glove is thin, providing little resistance, the current may travel through the glove following the path of least resistance to the surgeon’s skin, causing a painful shock or burn.
In addition to the thickness of insulation, the risk of capacitive coupling is influenced by the size of the active electrode, the duration of activation of the electrode, and the strength of the current.
To aid in preventing RF capacitive coupling, the tip of the ESU pencil should be placed below the fingers of the individual holding the clamp or forceps.
Dielectric breakdown occurs when high voltage breaks down an insulating material, such as sterile gloves.
During electrosurgery, it may result when the material in the gloves is unable to withstand the current generated by the ESU.
A high voltage can produce a hole in the glove and cause a burn.
Thickness of the insulation, duration of activation of the electrode, and strength of the current influence the outcome.
Risk of dielectric breakdown burns is reduced by the practice of double gloving.
Vaporized tissue plume, smoke and aerosolized tissue, is formed when tissue is thermally destroyed and vaporized using the ESU, laser, or other surgical devices such as power equipment used to cut bone.
Vaporized tissue plume is known to contain harmful chemical and biological by-products, including carcinogens, blood-borne pathogens, and mutagens.
It is recommended that a smoke evacuator system with an ultra-low particulate air (ULPA) filter is used to prevent the plume from spreading.
Handheld evacuator wands can be used on the surgical field, and the tip of the evacuator wand should be positioned as close as possible, 2 in. or less, to the surgical site to allow maximum removal of the plume and additionally aids in visualization of the surgical site.
Newly developed products to aid in removing plume include ESU pencils and lighted retractors with integrated evacuation tubing, as well as insufflation systems for laparoscopic surgery that provide smoke evacuation.
Other sources of energy that assist the surgeon in performing surgery include ultrasonic energy used for the harmonic scalpel, plasma vaporization, and lasers.
The harmonic scalpel uses ultrasonic energy rather than electricity to cut and coagulate tissue at the point of impact.
The ultrasonic scalpel utilizes mechanical vibrations at the rate of 55,500 times per second that separates tissues and coagulates bleeding vessels by denaturing the cellular proteins and creating a sticky coagulum that “welds” severed ends shut.
Ultrasonic energy is precise and tissue coagulates at a lower temperature compared to traditional electrosurgery.
The mechanical energy created by the vibrating instrument tip creates heat; however it remains below the boiling point (100C°) so the surrounding tissues suffer less thermal damage called charring.
Cellular water is liberated during the process and may appear like smoke, but no vaporized tissue plume is produced.
A dispersive pad is not necessary because no electrical current passes through the patient.
Another form of ultrasonic instrument used frequently during procedures involving tumors or pathologies located in highly vascular delicate structures such as the brain or liver is the cavitron ultrasonic surgical aspirator or CUSA.
The CUSA is a device that uses high-frequency sound waves that create imploding bubbles to fragment and emulsify tumor tissue and leave vascular structures intact.
An alternative to traditional transurethral resection or ablation techniques to treat benign prostatic hypertrophy, plasma vaporization utilizes a combination of bipolar current and plasma technology to create a thin layer of highly ionized particles that vaporize the tissue without having to make direct contact.
One type of device uses a mushroom-shaped, button-ended electrode that fits through a resectoscope and provides excellent coagulation with minimal thermal damage to deeper and surrounding tissues.
Lasers have been used in the OR with greater frequency since the first practical model was built in 1960.
The majority of surgical specialties have incorporated the use of lasers as the technology has advanced.
The acronym “laser” means light amplification by the stimulated emission of radiation and refers to the process of converting some form of energy into light energy.
The range of the visible light portion of the electromagnetic spectrum is between 400 nm, near ultraviolet, and 700 nm, near infrared.
The shorter the wavelength, the higher the energy and more dangerous to humans
Biophysics of Laser Light:
Laser light is different from ordinary light that contains all the visible spectral colors.
Laser light is monochromatic, which means the photons that compose the light are all the same color or wavelength.
Its wavelength color determines how it will react with various tissues.
Red laser light, for example, is more highly absorbed by red-pigmented tissue.
As the laser energy is absorbed by tissues, heat energy is produced and the tissue is impacted.
Laser light is collimated, which means that its waves are parallel to each other and do not spread out (diverge) as they travel away from their source.
This property of laser light allows pinpoint precision for surgical applications.
Laser light is also coherent, meaning that the collimated light waves travel in the same direction and in phase with each other, increasing its amplitude and power.
Another important concept to understand is fluence.
Fluence refers to the precision of the laser beam and consists of the four properties spot size, watts, joules, and time.
Fluence is a measurement of joules divided by square centimeters (cm2) .
A joule is a measurement of laser pulse energy based on a 1-second amount of time the beam is activated.
Laser power measures the rate at which energy is produced or put another way, 1 watt means that 1 joule of energy is produced in 1 second.
The effect of the laser beam on the tissue will vary if any of the four properties are changed.
For example, a laser beam contacts the tissue at 75 watts for 5 seconds. A second laser beam contacts the tissue at 5 watts for 75 seconds, delivering the same amount of energy as the first laser beam, but more adjacent thermal tissue damage because of the longer length of time that the laser beam contacts and heats the tissue.
The concept of fluence emphasizes the importance of using the highest safe wattage for the shortest time possible to keep damage to the adjacent tissue to a minimum.
Four Interactions with Tissue
When a laser beam contacts tissue, the four interactions that can occur are absorption, transmission, reflection, or scattering.
Absorption
Thermal damage to tissue because of the absorption of the laser energy depends on the fluence and wavelength of the laser beam, tissue color and consistency, and cellular water content.
As the laser energy is absorbed by the tissue, heat is produced and damage to the tissue can occur.
The spread of heat energy depends on the tissue consistency and quality of blood flow that aids in cooling the laser impact site.
When the laser energy impacts the tissue and is absorbed, the cellular water content is heated beyond the boiling point, causing the water to be converted to steam.
The pressure within the cell increases and eventually bursts, releasing debris and smoke from the tissue that is referred to as laser plume.
The factors that determine the penetration depth of the beam include power of the laser beam, color and consistency of the tissue, laser wavelength, and duration of the beam exposure.
As the laser beam penetrates the tissue, it continues to heat the deeper tissues.
To prevent damage to the adjacent tissues and limit the absorption of the laser energy, a backstop (protective barrier) may be used.
Wet sponges, titanium, or quartz rods are examples of backstops.
The absorption of the laser energy of the argon and Nd:YAG lasers depends on the chromophores hemoglobin and melanin.
The wavelength of the laser beam is absorbed by the chromophores, causing heating of the surrounding tissue.
laser energy is absorbed by cellular water and is not dependent on tissue color.
Most of the energy is absorbed by and heats the cellular water.
Transmission
Transmission is described by the following two examples.
The Nd:YAG energy can be transmitted through the distending media, such as glycine that has been introduced into the bladder to vaporize bladder wall tumors.
The argon laser energy travels through the clear aqueous and vitreous humors contained in the anterior and posterior chambers of the eye to coagulate blood vessels of the retina.
Reflection or Scattering
The laser beam can be reflected from the impact site.
This reflection can either cause harm by hitting nontarget tissue or be purposefully diverted, as in the case of specular reflection.
Specular reflection is when the angle of the reflection is equal to the angle of the oncoming light, thereby maintaining the beam.
This type of reflection is used when the beam is reflected off a laser mirror to direct it toward hard-to-reach tissues or areas.
Specular reflection can be a hazard if the laser beam reflects off a surgical instrument, causing it to scatter unpredictably.
When a surgical laser is being used, the CST must make sure that nonreflective instruments are available for the surgeon to use, especially in narrow spaces such as the vagina and oropharynx.
A laser is named for the active medium it uses..
Media
Characteristic:
Gas
This active medium is energized by electricity to produce the laser light. Examples include carbon dioxide, helium-neon, krypton, argon, and excimer.
Solid
An energy-producing element on a rod is energized by flash lamps to produce the laser light. Examples include ruby and Nd:YAG.
Liquid
An organic dye is energized by a laser beam to produce the laser light in various wavelengths.
Semiconductor crystals
Laser energy is delivered directly to tissue through a filter or slit-lamp microscope.
Most laser unit components are similar and include a console, cooling system, and vacuum pump.
The console houses and protects the inner components.
The air- or water-cooling system prevents the laser from overheating.
The vacuum is used to remove gas vapors and surgical plume.
The control panel contains the controls for operating the laser system, including wattage, duration of activation, and mode (continuous or pulsed).
An access key may be required to make the laser operational.
HCFs typically require additional education and training for laser operators and have an assigned laser safety officer to ensure all precautions are met prior to and during use.
The lasers commonly used in surgery include the , diode, Nd:YAG and Holmium:YAG, krypton, and argon
The CO2 laser has been one of the most frequently used lasers in surgery.
. The beam is invisible and is located in the middle of the infrared region of the electromagnetic spectrum, making its wavelength longer than other surgical lasers (10,600 nm)
Because the beam is invisible, a helium–neon (He-Ne) laser beam is combined with the laser beam to aid the surgeon in aiming at target tissue. The He-Ne laser beam is red and has no effect on the tissue.
The advantage of the CO2 laser beam is that it permits precise cutting and coagulating because of the absorption of the energy by the fluids in cells and is not dependent on the tissue color or consistency.
Because the laser beam is absorbed by water, the CO2 laser is not effective for transmission through clear fluids.
The beam also cannot transmit through clear glass such as windows or protective eye goggles.
For precision cutting, higher power with a focused beam is used with short exposure that decreases the thermal damage to the adjacent tissues.
For coagulation, the beam is enlarged, increasing the spot size and spreading the energy.
During cutting or coagulation, the beam will penetrate the deeper tissue and a backstop may be used.
In general, the laser provides the shallowest depth of penetration of surgical laser systems.
For this reason, the laser is commonly used for dermatological indications.
Also referred to as an ablation laser, it can reduce wrinkles, scar tissue, and remove benign skin growths.
The beam, combined with the He-Ne aiming beam, is usually delivered through an articulated arm that is a hollow tube.
Mirrors are positioned inside the tube at the articulations (joints), and the long wavelength beams are reflected off the mirrors down the tube.
When transporting the laser to the OR and setting it up, the CST must be very careful to prevent the arm from hitting anything to prevent misalignment of the mirrors and laser beam.
If the alignment is not correct, the aiming beam could appear at one point and the invisible beam might impact tissue at a different location.
CO2 lasers can use flexible fibers to deliver the beam to hard-to-reach anatomical areas.
A handpiece is attached to the end of the articulated arm or flexible fiber that allows the surgeon to use the laser in a freehand style.
Additionally, both the articulated arm and flexible fibers can be attached to special filters mounted on operating microscopes for use in neurosurgical or reconstructive procedures. The options for delivering the beam include pulsed, repeat pulse, super-pulse, and continuous wave (CW).
Diode Laser
Another common laser frequently utilized for soft tissue ablation in various treatments including dental applications or treatment of vascular lesions is the diode laser.
The diode wavelengths can range 810 to 980 nm in a continuous or pulsed mode.
The photons are produced by an electric current and can generate laser radiation through a semi-conductor, making them applicable for vaporization of the prostate.
The laser may penetrate tissue from 2 to 3 mm or more depending on the wavelength.
These lasers are also absorbed by pigmented structures and optimal for vascular areas as it works to provide hemostasis and coagulation
Nd:YAG and Holmium:YAG Lasers
The Nd:YAG and Ho:YAG wavelengths are invisible, located outside of the visible light section in the near-infrared region of the electromagnetic spectrum.
The two lasers utilize yttrium–aluminum–garnet solid crystals that are combined with the elements neodymium or holmium.
The Nd:YAG wavelength is 1064 nm and the Ho:YAG is 2100 nm.
The neodymium and holmium are what produce the light energy when exposed to flash lamps and because they are invisible, require an He-Ne laser aiming beam.
The Nd:YAG laser beam is absorbed by darker pigmented tissue, causing a greater coagulation reaction.
A significant advantage of both YAG lasers is that the beams can be transmitted through clear fluids, making them useful in urological and ophthalmological procedures.
The Ho:YAG laser, in particular, is frequently used in cases such as lithotripsy and treatment of benign prostatic hyperplasia.
The laser beam can be delivered to the tissue either by a contact or noncontact fiber delivery system.
The noncontact system used with the holmium lasers has a quartz insert in the fiber.
The laser beam travels through the fiber end aided by a lens system that may be damaged if it comes into direct contact with tissue.
The farther the fiber is held from tissue, the larger the spot-size and area impacted; however, there is a decrease in power density.
Contact fiber systems are facilitated by the use of special tips that deliver the laser energy and are held directly against the target tissue.
Laser tips of varying shapes are available that produce the desired shape of laser energy distribution to cut, vaporize, or coagulate tissue.
The tip must remain in contact with tissue while the laser is in use or it will overheat and break.
Fluid or air will flow through the length of the fiber and exit at the tip. This aids in cooling the tip while the laser is being used. The side holes on the tip must be kept from being clogged to maintain the continuous flow of fluid or air.
The CST should clean, handle, and store contact tips according to the manufacturer’s recommendations.
The tips can be soaked in hydrogen peroxide to loosen any tissue and debris prior to cleaning.
The majority of tips can be steam sterilized.
Some Nd:YAG laser units have the capability of providing an alternative wavelength by passing the beam through a crystal of potassium-titanyl-phosphate (KTP), also called a green light laser.
The 532 nm wavelength is within the visible part of the light spectrum and emits a green light that is highly absorbed by darker pigmented tissues, blood vessels, and tattoo inks.
No aiming beam is required because of the visibility of the green laser beam.
Nd:YAG lasers are commonly used in ophthalmology surgery, such as treatment for posterior capsular opacification after cataract surgery.
Erbium: YAG: lasers are used for skin resurfacing as an alternative to chemical peels and dermabrasion.
Often used with local anesthesia, multiple treatments are often performed to promote re-epithelialization of dermal layers, giving a more youthful appearance.
The 2940 nm wavelength used with 250-microsecond duration pulses creates a depth of penetration comparable to and even slightly shallower than the laser.
These procedures may be more commonly performed in small surgical centers or aesthetic (plastic) surgery facilities.
Krypton Laser
The krypton laser is a gas laser.
An electrical current activates the krypton medium to create the laser energy.
The visible wavelengths vary from 476 to 647 nm, including green, yellow, and red laser beam colors, though the red light is the most frequently used.
The krypton laser beam is absorbed less by hemoglobin than the argon laser beam; therefore ophthalmologists are increasingly using the krypton laser to destroy tissue on the retina of the eye.
Argon Laser
The argon laser produces a visible blue or green light with wavelengths of 450 and 530 nm in the electromagnetic spectrum. Both blue and green light contribute to excellent tissue absorption and require no additional aiming beam. The primary component of the laser system is a plasma tube that contains the argon gas. An electrical current travels down the tube through the gas to excite the argon atoms to produce the laser energy. This energy is converted to heat and, when absorbed, produces the effects of coagulation or vaporization. The chromophores hemoglobin and melanin selectively absorb the argon laser energy.
The argon laser beam can travel through clear fluids and tissues, making it useful for treating diabetic retinopathy, a condition in which bleeding vessels on the retina impair vision. With its shallow beam, argon can also be used through an endoscope to treat angiodysplasias within the thin wall of the intestine
Surgical Laser Applications – Simplified Overview
1. General Use
Lasers are used in many surgical specialties, but are most common in minimally invasive (endoscopic) procedures.
Their main benefits:
Precision (focused tissue cutting)
Reduced bleeding (coagulation)
Minimal tissue trauma
System-Specific Applications
Gastrointestinal Endoscopy
Nd:YAG used to coagulate or destroy deep tumor tissue.
Urology (Lithotripsy)
Ho:YAG laser fragments urinary calculi (stones).
Safety tip: Avoid contact with metal snares to prevent melting.
Airway Surgery
Nd:YAG and CO₂ lasers used for bronchoscopy and microlaryngoscopy (treating throat tumors).
Important: Keep airway gases controlled to prevent fire near endotracheal tube.
Orthopedic / Arthroscopy
Nd:YAG or Ho:YAG used to vaporize protein, bond collagen, or smooth cartilage.
Also used in percutaneous diskectomy (minimally invasive spine procedure).
Gynecology
Hysteroscopy: Nd:YAG removes polyps, fibroids, and uterine septa.
Laparoscopy: vaporizes endometriosis, treats ovarian cysts, ectopic pregnancies, and blocked tubes.
General Surgery
Used in laparoscopic cholecystectomy (gallbladder removal) for precision dissection.
Colorectal Surgery
Colonoscopes with argon or Nd:YAG treat polyps, bleeding, and tumors by ablation or coagulation.
Key Takeaways:
Nd:YAG = Deep coagulation and tumor destruction.
Ho:YAG = Stone fragmentation and tissue cutting.
Argon/KTP = Superficial coagulation and precise cutting.
Lasers reduce bleeding and promote faster healing, but safety protocols are critical.
Endoscopic surgeries are the most common settings for laser use.
Room and Environmental Controls
Post warning signs on all entrances to laser rooms.
➤ Alerts anyone nearby that laser activity is occurring and limits room traffic.
Cover windows with optical density filters or shades to prevent laser beams from escaping.
2. Protecting the Patient
Shield the eyes using appropriate protection (corneal shields or eye pads) depending on laser wavelength.
Avoid flammable skin preps. Solutions like alcohol must dry completely before draping. Never let them pool under the patient.
Minimize oxygen buildup. Arrange drapes to allow airflow and prevent trapped oxygen from fueling fires.
3. Staff Protection
Wear proper PPE specified by the LSO:
Laser-rated goggles (NOT regular plastic eyewear) with side protection.
High-filtration masks to reduce plume inhalation.
Non-reflective gowns and gloves to prevent light scattering or burns.
Check all instruments: Use anodized (dark, non-reflective) tools only. Avoid scratched or etched surfaces that can reflect beams.
Keep a basin of sterile water ready for quick fire suppression (for ignited drapes or sponges).
Use moistened towels and drapes—dry materials catch fire easily.
Avoid foam positioning pads unless pre-moistened with saline or water.
Key Takeaways:
LSO (Safety Officer) oversight is mandatory in any laser-equipped OR.
Laser warning signs and window filters protect others outside the OR.
Eye protection must match the specific wavelength of the laser in use.
Moist, non-flammable draping and proper oxygen control are essential to prevent fires.
Always use anodized, scratch-free instruments and keep sterile water nearby.
Laser plume is a biological hazard—use smoke evacuation and proper masks.
Understanding Fire Risk
Lasers are powerful ignition sources in surgery.
A laser fire can start instantly when heat meets fuel and oxygen.
To prevent this, all surgical personnel must understand the Health Care Facility (HCF) fire-prevention plan.
Potential Fuel Sources:
Fabrics: gowns, drapes, masks, head covers, shoe covers, towels, warming blankets.
Equipment: laser circuitry, rubber/plastic devices (endotracheal tubes, suction catheters, gloves).
Agents and materials: alcohol-based preps, ointments, gels, gastrointestinal gases, and even patient hair.
Key Prevention Points:
Allow preps to dry completely before draping.
Keep moistened towels near the site to prevent ignition.
Maintain communication with anesthesia to manage oxygen concentration near the field.
Never ignore smoke or unusual odor — they may signal smoldering drapes or tubing.
Laser Plume Hazards
What Is Laser Plume?
Laser plume is the smoke and vaporized tissue released during laser surgery.
It contains:
Blood and carbonized tissue
Viral and bacterial DNA
Potentially carcinogenic and mutagenic particles
Health Risk: Inhalation can irritate lungs or spread viral particles (like HPV).
Control Measures
Always use a high-efficiency local exhaust ventilation (LEV) system.
Combine LEV with room ventilation—general airflow alone isn’t enough.
During smaller cases, the CST may hold a plume evacuator within 2 inches of the surgical site.
Everyone in the OR should wear high-filtration masks (N95 or laser-rated).
Laser Safety Checklist and Time-Out
Laser Time-Out
In addition to the surgical time-out, perform a laser-specific safety check before activation.
Items to Confirm:
Procedure and laser type identified.
Laser mode and wattage verified.
Key removed when not in use.
Windows covered and warning signs posted.
Laser test-fired and integrity confirmed.
Sponges/towels wet; non-flammable ET tube used.
Eye protection in place for both patient and team.
Plume evacuator ready and functioning.
Fire extinguisher present and full.
If a Fire Occurs
Announce “FIRE!” — stop all activity immediately.
Stop anesthetic gas flow.
Remove burning materials from the patient.
CST douses flames with sterile water.
If uncontrolled, use a fire extinguisher.
Provide post-incident care and documentation.
Continuing Education
Laser use and safety standards are constantly evolving.
Annual training and competency checks are required for all surgical staff who assist in laser procedures.
CSTs should stay current through continuing education programs on:
New laser systems and wavelengths
Updated ANSI/AST standards
Emergency and fire-response simulations
Key Takeaways
Always assume the laser is “live.”
Maintain a wet field, clear communication, and ready water basin.
Protect from plume inhalation—use evacuators and masks.
Review the laser checklist before every procedure.
Safety is a team responsibility, led by the Laser Safety Officer (LSO).