- Email: [email protected]
Diathermy training and usage trends among surgical trainees — will we get our fingers burnt?
original article
A. Assiotis1 T. Christo3 D.A. Raptis2 A. Engledow2 C. Imber2 A. Huang3 1
Shefeld Teaching Hospitals NHS Foundation Trust 2 UCL Hospitals NHS Foundation Trust 3 Buckinghamshire Hospitals NHS Trust Correspondence to: Mr T Christo, 4E Portman Mansions, Chiltern Street, London, W1U 6NS Tel: +44(0)7789 036385 Email: theodoroschristo@ hotmail.com
DIATHERMY TRAINING AND USAGE TRENDS AMONG SURGICAL TRAINEES – WILL WE GET OUR FINGERS BURNT? Introduction: We aimed to assess the current trends in diathermy use as well as the presence or absence of formal diathermy training amongst higher surgical trainees (HSTs) in the UK. Materials and methods: A national e-mail survey was implemented, contacting 300 randomly selected HSTs in general surgery. A questionnaire was used to ascertain their current practice and the presence or absence of formal diathermy training. Results: Overall 126 (42%) HSTs across all levels of training and subspecialty interests responded. Only 50.8% stated they had received formal diathermy training whereas 49.2% had no formal training. Diathermy is used by 23.8% of responders for laparotomy skin incisions, while 76.2% use a scalpel. For colonic mobilisation, 49.2% use diathermy and 50.8% scissors. For rectal mobilisation 55.5% use diathermy, 42.9% scissors and 1.6% a harmonic scalpel. Nearly 90% of responders do not place diathermy pads on the patient themselves, 68.3% do not routinely check diathermy equipment before use and 66.7% do not check the diathermy pad site at the end of the operation. Only 80.9% stated that a diathermy complication is the surgeon’s responsibility, while the remaining 19.1% would blame the scrub nurse, circulating nurse, operating department assistant (ODA), manufacturer or a combination of the above. Conclusion: Nearly half of HSTs in this study did not receive any training in the use of diathermy, resulting in failure to adhere to what is considered best practice. This may lead to adverse events for the patient along with medico-legal consequences. This problem could be overcome by ensuring HSTs receive adequate formal diathermy training and we suggest that a dedicated diathermy course is incorporated in basic surgical training curricula. keywords: higher surgical trainees, diathermy, electrosurgery, training, complication Surgeon, 1 June 2009, pp. 132-6
Introduction Diathermy plays an integral part in most operations, either for dissection or coagulation, and as such most surgeons use it on a regular basis. Even though modern diathermy equipment is considered to be ‘safe’, accidents still do happen. Inappropriate use of diathermy can not only lead to adverse events for patients, but also for surgeons. In fact, electrosurgery-induced injuries are the commonest cause for malpractice lawsuits against hospitals in the USA.1 Despite this, little formal training or education in diathermy exists in the UK. We aimed to assess the presence or absence of training for diathermy use amongst HSTs in the UK. We also aimed to ascertain the current trends amongst HSTs regarding the use of diathermy in laparotomy skin incisions and colonic and rectal mobilisation. 132
|
the royal colleges of surgeons of edinburgh and ireland
Materials and methods An e-mail questionnaire (Appendix 1) was sent to 300 randomly selected HST members of the Association of Surgeons in Training in August 2006. A series of questions were asked including age, year of specialist registrar training and subspecialty interest. The trainees were also asked whether they had received any formal training about the use of diathermy such as lectures and practical demonstrations, and whether they routinely place the diathermy pads on patients themselves, and check the diathermy equipment before use and the diathermy pad site at the end of the operation. In the next questions the trainees were asked whether they use diathermy or scalpel in making the skin incision for a laparotomy and what tools they use for colonic mobilisation and dissection of the rectum (scissors, diathermy or other). © 2009 Surgeon 7; 3: 132-6
Fig. 1. Age distribution of responders
Fig. 2. Level of seniority of responders
© 2009 Surgeon 7; 3: 132-6
the royal colleges of surgeons of edinburgh and ireland | 133
Fig. 3. Subspecialty interest of responders
In the last question of the questionnaire the HSTs were asked if a diathermy complication, such as a diathermy burn, were to arise who would be responsible between the surgeon, scrub nurse, circulating nurse, operating department practitioner (ODP) and manufacturer.
Results Out of 300 HSTs, 126 (42.0%) submitted an online response to the e-mail questionnaire. The majority of trainees (92/126, 73.0%) were between 30 and 39 years old, with the remaining covering the entire spectrum from 20 to 60 years of age as illustrated in Figure 1. Figure 2 shows the year of SpR training amongst the responders, ranging from 46 (36.5%) first year HSTs to 10 (7.9%) who had more than six years of SpR experience. Figure 3 illustrates the subspecialty of the responders, with 60 (47.6%) declaring a colorectal subspecialty interest. In the responders there were surgeons of all age ranges (20-59), levels of SpR training and subspecialties of general surgery. Sixty-four (50.8%) of the responders received formal diathermy training, such as lectures and practical demonstrations, while the remaining 62 (49.2%) stated that they did not receive any diathermy training. There was no statistically significant difference between seniority of the trainee and diathermy training. Older surgeons were less likely to use diathermy other than for coagulation (p<0.005). The vast majority of surgical trainees (112 of 126, 88.9%) do not routinely place diathermy pads on patients themselves, 68.3% (86 of 126) do not routinely check diathermy equipment before use, and 66.7% (84 of 126) do not check the diathermy pad site at the end of operation. Ninety-six of the responders (76.2%) use a scalpel for laparotomy skin incisions, while 30 (23.8%) use diathermy. Sixty-two (49.2%) of the trainees use diathermy for mobilisation of the colon during colectomies, while the remaining 64 (50.8%) use scissors. None of the responders use the harmonic scalpel for colon mobilisation. For rectal mobilisation, however, seventy responders (55.5%) use diathermy, 54 (42.9%) use scissors, and 2 (1.6%) use a harmonic scalpel. When asked whose responsibility it was in an event of a diathermy complication, 102 (80.9%) of the responders replied that it is the surgeon’s responsibility, whereas 2 (1.6%) chose the scrub nurse, 6 (4.8%) the circulating nurse, 2 (1.6%) the ODP, 6 (4.8%) the 134 |
manufacturer and the remaining 8 (6.3%) a combination of the above.
Discussion ‘The surgeon, however, need not be expected to know the full details of the electrothermic principles which are involved, though it behooves him to have some familiarity with them if he is to do more than merely run the machine.’ Harvey Cushing, 1928 The history of diathermy goes back to the advances of D’Arsonval in 1893 and Nagelschmidt in 1909 and their experimental use of high frequency electric current on biological tissues.1 Since then the technique and its applications have been adopted universally and widely incorporated in everyday surgical practice. However, even though the use of contemporary diathermy devices is considered to be ‘safe’ accidents still do happen. In the USA, electrosurgery-induced injuries are the commonest cause for malpractice lawsuits against hospitals, resulting from interventions. Studies indicate that the total incidence of diathermy induced injuries is one or two cases per 1000 operations, whereas 50-100 cases of surgical fires occur every year in the USA, with diathermy being the first cause of such fires.1 Farrugia et al clearly state that lack of basic electrophysiology principles and the inappropriate use of electrosurgery can cause serious iatrogenic complications.2 Van Way clearly states that not all doctors receive formal training and that surgeons are usually trained in the use of diathermy by the operating room personnel, which in turn is trained by the manufacturer’s representatives directly.3 Although, in recent years, Surgical Royal Colleges have incorporated diathermy awareness and safety into their core surgical skills courses, it seems that on many occasions practices remain user-dependant and that many surgeons of all grades answer differently when tested on diathermy safety, a fact that is consistent with the findings of our study and indicates that a more vigorous and formal training in the use of electrosurgery is necessary.4 The main hazard to the patient is burning associated with the use of diathermy. Furthermore, such burns are not always detected during the immediate post-surgical period, but sometimes after days or
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 3: 132-6
weeks have elapsed. Cases of diathermy burns have been previously reported in the literature. A widely-known general principle is that in order for a fire to occur, three elements are essential; namely a fuel source, a means of ignition and an oxidizer. Vedovato et al reported a case of burns that occurred during a saphenous vein coronary artery bypass graft caused by the inadequate use of electrosurgical materials.5 Fong et al reported two cases of burns caused by the accidental ignition of alcohol-based antiseptic solution.6 Tooher et al also reported two cases of operating room fires resulting from the ignition of pooled alcohol-based skin preparations, both of them associated with the use of electrocautery for haemostasis.7 Port site diathermy burns during laparoscopy have also been reported with both plastic and metal cannulas.8 Kaddoum et al reported two cases of electrosurgeryinduced fires in the oropharynx, during routine adenotonsillectomies, the possible cause being a small quantity of oxygen leaking around the uncuffed endotracheal tube.9 Unusual accidents do happen as well, such as the case described by Baur and Butler, in which a 72-year-old patient undergoing a tracheostomy operation suffered an electrocautery-induced endotracheal tube fire, which resulted in the patient’s death.10 Another unusual incident was reported by Raval and Weiner, in which a gastric trichobezoar caused excessive gas formation that with the use of diathermy caused a mild explosive event.11 Bipolar diathermy has also been associated with adverse patient events. Isager and Lind reported a case of an accidental third-degree burn caused by bipolar electrocoagulation.12 Demir et al have recently reviewed a series of 19 patients with intra-operative burns requiring plastic surgery input.13 Four patients had deep dermal or full thickness burns requiring debridement, skin grafting or musculocutaneous flaps. They also carried out a technical analysis showing that malfunctioning electrosurgical devices, an incorrectly positioned neutral electrode, moisture under the negative electrode and fluid or blood creating alternate current pathways were some of the causes. They concluded that the surgical team should pay more attention to the probability of burns during surgery and suggested that immediate involvement of plastic and burn surgeons may prevent further complications. Diathermy burns do not only affect patients in the operating room. Hussain et al reported one diathermy burn to a surgeon in their review of accidental injuries to surgeons and their assistants during operations and Massarweh et al state that the belief that surgical gloves offer complete insulation is false, and causes such as breakdown of the glove, hydration of the glove and capacitative coupling lead to injuries to the operating theatre staff.14,15 Spigelman and Swan conducted a risk assessment audit of 10 operating theatres and concluded that operating theatre fires continue to be a major risk for patients’ safety.16 One of their suggested strategies to reduce the risk of fire was education and training of operating theatre personnel in fire hazards. Although burns comprise the vast majority of electrosurgery complications and accidents, they are not the only ones reported. Malfunctioning pacemakers due to alternating current, the danger of arrhythmias, chemical burns due to neglect in removing the diathermy pad and explosions due to the existence of endogenous gases, such as hydrogen or methane, or combustible anaesthetic gases, such as ether and cyclopropane, pose a threat on several occasions.1,17 Furthermore, the direct stimulation of major muscle groups may lead to noticeable contractions and to the false impression of insufficient anaesthesia. All of the aforementioned complications seem to derive from a lack © 2009 Surgeon 7; 3: 132-6
of understanding of basic electrophysiology principles and could be reduced substantially with a basic but organised training scheme. Our study shows that 49.2% of HSTs did not receive formal diathermy training, a fact that may result in a higher incidence of complications and may compromise patient safety. Mayooran et al tested 20 gynaecological laparoscopic surgeons in a practical diathermy station and a written paper on electrosurgical knowledge.18 Their study found ignorance of electrosurgery/diathermy among gynaecological surgeons. Eleven of the original candidates were retested a year later and skills were found to be no better. Aigner et al categorised the possible causes of burns secondary to diathermy application into three types of issues namely training, equipment and disinfecting and covering methods.1 As far as training is concerned, a joint training programme for surgeons, anaesthetists and theatre nurses is suggested, as greater collaboration will further reduce diathermy injuries or improve their treatment. Furthermore, McHenry et al stressed the necessity for the development and implementation of operating theatre hazard education and prevention programmes in order to reduce the rare, yet severe incidents of surgical fires and explosions.19 Finally, Zinder and Parker suggests steps towards a better understanding of the technical characteristics of electrosurgical equipment and to ‘know more than merely how to turn the machine on’.20 Several training methods and models have been suggested, with most authors considering practice on beefsteak or other animal models and supporting the important role that virtual reality diathermy training is increasingly enjoying in recent years.
Conclusion Of the 300 general surgery HSTs, 49.2% reported receiving no formal training in the use of diathermy in the form of lectures or practical demonstrations. This may result in failure to adhere to what is considered best practice and, in turn, lead to adverse events for the patient along with medico-legal consequences for the surgeon. We suggest that this problem could be overcome by ensuring adequate diathermy training is delivered in a purpose-made course that would be a prerequisite in order to progress to higher surgical training.
Copyright © 17 April 2008
the royal colleges of surgeons of edinburgh and ireland | 135
Appendix 1 Questionnaire 1. Please specify the age group that you belong to? 20-29, 30-39, 40-49, 50-59, 60-69 2. What year of SpR training are you in? 1st, 2nd, 3rd, 4th, 5th, 6th, >6th 3. What is your subspecialty interest? Upper GI, colorectal, vascular, breast, endocrine, hepatobiliary, transplant, laparoscopic (If combined please specify --------------------------------------------------------) 4. Have you had formal training in diathermy use (e.g. lectures, practical demonstration)? Yes/no 5. Do you routinely place diathermy pads on patients yourself? Yes/no 6. Do you routinely check diathermy equipment before use? Yes/no 7. Do you routinely check the diathermy pad site at the end of the operation? Yes/no 8. Which of the following tools do you use to make the skin incision for a laparotomy? Knife/diathermy 9. Which tool do you preferably use during colon mobilisation? Scissors/knife/other (If other please specify ----------------------------) 10. Which tool do you preferably use for rectal mobilisation? Scissors/knife/other (If other please specify ----------------------------) 11. If a diathermy complication were to arise (e.g. diathermy burn) who would be responsible? Surgeon, scrub nurse, circulating nurse, ODA, anaesthetist, manufacturer
136
|
REFERENCES 1. Aigner N, Fialka C, Fritz A et al. Complications in the use of diathermy. Burns 1997; 23: 256-64 2. Farrugia M, McGurgan P, McMillan L et al. Recent advances in electrosurgery- VERSAPOINT® technology. Reviews in Gynaecological Practice. Spring 2001; 1(1): 12-17 3. Van Way C. Electrosurgery 101. Current Surgery 2000; 57(2): 172-77 4. Sudhindra TV, Joseph A, Hacking CJ et al. Are surgeons aware of the dangers of diathermy? Ann R Coll Surg Engl (Suppl) 2000; 82: 31–32 5. Vedovato JW, Polvora VP, Leonardi DF. Burns as a complication of the use of diathermy. J Burn Care Rehabil 2004; 25: 120-23 6. Fong EP, Tan WT, Chye LT. Diathermy and alcohol skin preparations – a potential disastrous mix. Burns 2000; 26: 673-75 7. Tooher R, Maddern GJ, Simpson J. Surgical res and alcohol-based skin preparations. ANZ J Surg 2004; 74: 382-85 8. Wilson PD, van der Walt JD, Moxon D et al. Port site electrosurgical (diathermy) burns during surgical laparoscopy. Surg Endosc 1997; 11: 653-54 9. Kaddoum R, Chidiac EJ, Zestos MM et al. Electrocautery-induced re during adenotonsillectomy: report of two cases. J Clin Anaesth 2006; 18(2): 129-31 10. Baur DA, Butler CD. Electrocautery-ignited endotracheal tube re: case report. British Journal of Oral and Maxillofacial Surgery 1999; 37: 142-43 11. Raval M, Weiner T. Beware of the aming hairball—a brief review and warning. Journal of Paediatric Surgery 2005; 40(4): E37-E38 12. Isager P, Lind T. Accidental third-degree burn caused by bipolar electrocoagulation. Injury 1995; 26: 357 13. Demir E, O’Dey DM, Pallua M. Accidental burns during surgery. J Burn Care Res 2006; 27: 895-900 14. Hussain SA, Latif AB, Choudhary AA. Risks to surgeons: a survey of accidental injuries during operations. Br J Surg 1988; 75: 314-16 15. Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: History, principles, and current and future uses. J Am Coll Surgeons 2006; 202(3): 520-30 16. Spigelman AD, Swan JR. Skin antiseptics and the risk of operating theatre res. ANZ J Surg 2005; 75: 556-58 17. Trimble K. Non-electrical ‘burn’ from a diathermy pad. Injury 2002; 33(1): 78-80 18. Mayooran Z, Pearce S, Tsaltas J, Rombauts L, Brown TI, Lawrence AS et al. Ignorance of electrosurgery among obstetricians and gynaecologists. BJOG 2004; 111: 1413-18 19. McHenry C, Berguer R, Ortega R et al. Recognition, management, and prevention of specic operating room catastrophes. J Am Coll Surgeons 2004; 198(5); 810-21 20. Zinder D, Parker G. Electrocautery burns and operator ignorance. Otolaryngology Head and Neck Surgery 1996; 115(1): 145-49
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 3: 132-6
A. Assiotis1 T. Christo3 D.A. Raptis2 A. Engledow2 C. Imber2 A. Huang3 1
Shefeld Teaching Hospitals NHS Foundation Trust 2 UCL Hospitals NHS Foundation Trust 3 Buckinghamshire Hospitals NHS Trust Correspondence to: Mr T Christo, 4E Portman Mansions, Chiltern Street, London, W1U 6NS Tel: +44(0)7789 036385 Email: theodoroschristo@ hotmail.com
DIATHERMY TRAINING AND USAGE TRENDS AMONG SURGICAL TRAINEES – WILL WE GET OUR FINGERS BURNT? Introduction: We aimed to assess the current trends in diathermy use as well as the presence or absence of formal diathermy training amongst higher surgical trainees (HSTs) in the UK. Materials and methods: A national e-mail survey was implemented, contacting 300 randomly selected HSTs in general surgery. A questionnaire was used to ascertain their current practice and the presence or absence of formal diathermy training. Results: Overall 126 (42%) HSTs across all levels of training and subspecialty interests responded. Only 50.8% stated they had received formal diathermy training whereas 49.2% had no formal training. Diathermy is used by 23.8% of responders for laparotomy skin incisions, while 76.2% use a scalpel. For colonic mobilisation, 49.2% use diathermy and 50.8% scissors. For rectal mobilisation 55.5% use diathermy, 42.9% scissors and 1.6% a harmonic scalpel. Nearly 90% of responders do not place diathermy pads on the patient themselves, 68.3% do not routinely check diathermy equipment before use and 66.7% do not check the diathermy pad site at the end of the operation. Only 80.9% stated that a diathermy complication is the surgeon’s responsibility, while the remaining 19.1% would blame the scrub nurse, circulating nurse, operating department assistant (ODA), manufacturer or a combination of the above. Conclusion: Nearly half of HSTs in this study did not receive any training in the use of diathermy, resulting in failure to adhere to what is considered best practice. This may lead to adverse events for the patient along with medico-legal consequences. This problem could be overcome by ensuring HSTs receive adequate formal diathermy training and we suggest that a dedicated diathermy course is incorporated in basic surgical training curricula. keywords: higher surgical trainees, diathermy, electrosurgery, training, complication Surgeon, 1 June 2009, pp. 132-6
Introduction Diathermy plays an integral part in most operations, either for dissection or coagulation, and as such most surgeons use it on a regular basis. Even though modern diathermy equipment is considered to be ‘safe’, accidents still do happen. Inappropriate use of diathermy can not only lead to adverse events for patients, but also for surgeons. In fact, electrosurgery-induced injuries are the commonest cause for malpractice lawsuits against hospitals in the USA.1 Despite this, little formal training or education in diathermy exists in the UK. We aimed to assess the presence or absence of training for diathermy use amongst HSTs in the UK. We also aimed to ascertain the current trends amongst HSTs regarding the use of diathermy in laparotomy skin incisions and colonic and rectal mobilisation. 132
|
the royal colleges of surgeons of edinburgh and ireland
Materials and methods An e-mail questionnaire (Appendix 1) was sent to 300 randomly selected HST members of the Association of Surgeons in Training in August 2006. A series of questions were asked including age, year of specialist registrar training and subspecialty interest. The trainees were also asked whether they had received any formal training about the use of diathermy such as lectures and practical demonstrations, and whether they routinely place the diathermy pads on patients themselves, and check the diathermy equipment before use and the diathermy pad site at the end of the operation. In the next questions the trainees were asked whether they use diathermy or scalpel in making the skin incision for a laparotomy and what tools they use for colonic mobilisation and dissection of the rectum (scissors, diathermy or other). © 2009 Surgeon 7; 3: 132-6
Fig. 1. Age distribution of responders
Fig. 2. Level of seniority of responders
© 2009 Surgeon 7; 3: 132-6
the royal colleges of surgeons of edinburgh and ireland | 133
Fig. 3. Subspecialty interest of responders
In the last question of the questionnaire the HSTs were asked if a diathermy complication, such as a diathermy burn, were to arise who would be responsible between the surgeon, scrub nurse, circulating nurse, operating department practitioner (ODP) and manufacturer.
Results Out of 300 HSTs, 126 (42.0%) submitted an online response to the e-mail questionnaire. The majority of trainees (92/126, 73.0%) were between 30 and 39 years old, with the remaining covering the entire spectrum from 20 to 60 years of age as illustrated in Figure 1. Figure 2 shows the year of SpR training amongst the responders, ranging from 46 (36.5%) first year HSTs to 10 (7.9%) who had more than six years of SpR experience. Figure 3 illustrates the subspecialty of the responders, with 60 (47.6%) declaring a colorectal subspecialty interest. In the responders there were surgeons of all age ranges (20-59), levels of SpR training and subspecialties of general surgery. Sixty-four (50.8%) of the responders received formal diathermy training, such as lectures and practical demonstrations, while the remaining 62 (49.2%) stated that they did not receive any diathermy training. There was no statistically significant difference between seniority of the trainee and diathermy training. Older surgeons were less likely to use diathermy other than for coagulation (p<0.005). The vast majority of surgical trainees (112 of 126, 88.9%) do not routinely place diathermy pads on patients themselves, 68.3% (86 of 126) do not routinely check diathermy equipment before use, and 66.7% (84 of 126) do not check the diathermy pad site at the end of operation. Ninety-six of the responders (76.2%) use a scalpel for laparotomy skin incisions, while 30 (23.8%) use diathermy. Sixty-two (49.2%) of the trainees use diathermy for mobilisation of the colon during colectomies, while the remaining 64 (50.8%) use scissors. None of the responders use the harmonic scalpel for colon mobilisation. For rectal mobilisation, however, seventy responders (55.5%) use diathermy, 54 (42.9%) use scissors, and 2 (1.6%) use a harmonic scalpel. When asked whose responsibility it was in an event of a diathermy complication, 102 (80.9%) of the responders replied that it is the surgeon’s responsibility, whereas 2 (1.6%) chose the scrub nurse, 6 (4.8%) the circulating nurse, 2 (1.6%) the ODP, 6 (4.8%) the 134 |
manufacturer and the remaining 8 (6.3%) a combination of the above.
Discussion ‘The surgeon, however, need not be expected to know the full details of the electrothermic principles which are involved, though it behooves him to have some familiarity with them if he is to do more than merely run the machine.’ Harvey Cushing, 1928 The history of diathermy goes back to the advances of D’Arsonval in 1893 and Nagelschmidt in 1909 and their experimental use of high frequency electric current on biological tissues.1 Since then the technique and its applications have been adopted universally and widely incorporated in everyday surgical practice. However, even though the use of contemporary diathermy devices is considered to be ‘safe’ accidents still do happen. In the USA, electrosurgery-induced injuries are the commonest cause for malpractice lawsuits against hospitals, resulting from interventions. Studies indicate that the total incidence of diathermy induced injuries is one or two cases per 1000 operations, whereas 50-100 cases of surgical fires occur every year in the USA, with diathermy being the first cause of such fires.1 Farrugia et al clearly state that lack of basic electrophysiology principles and the inappropriate use of electrosurgery can cause serious iatrogenic complications.2 Van Way clearly states that not all doctors receive formal training and that surgeons are usually trained in the use of diathermy by the operating room personnel, which in turn is trained by the manufacturer’s representatives directly.3 Although, in recent years, Surgical Royal Colleges have incorporated diathermy awareness and safety into their core surgical skills courses, it seems that on many occasions practices remain user-dependant and that many surgeons of all grades answer differently when tested on diathermy safety, a fact that is consistent with the findings of our study and indicates that a more vigorous and formal training in the use of electrosurgery is necessary.4 The main hazard to the patient is burning associated with the use of diathermy. Furthermore, such burns are not always detected during the immediate post-surgical period, but sometimes after days or
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 3: 132-6
weeks have elapsed. Cases of diathermy burns have been previously reported in the literature. A widely-known general principle is that in order for a fire to occur, three elements are essential; namely a fuel source, a means of ignition and an oxidizer. Vedovato et al reported a case of burns that occurred during a saphenous vein coronary artery bypass graft caused by the inadequate use of electrosurgical materials.5 Fong et al reported two cases of burns caused by the accidental ignition of alcohol-based antiseptic solution.6 Tooher et al also reported two cases of operating room fires resulting from the ignition of pooled alcohol-based skin preparations, both of them associated with the use of electrocautery for haemostasis.7 Port site diathermy burns during laparoscopy have also been reported with both plastic and metal cannulas.8 Kaddoum et al reported two cases of electrosurgeryinduced fires in the oropharynx, during routine adenotonsillectomies, the possible cause being a small quantity of oxygen leaking around the uncuffed endotracheal tube.9 Unusual accidents do happen as well, such as the case described by Baur and Butler, in which a 72-year-old patient undergoing a tracheostomy operation suffered an electrocautery-induced endotracheal tube fire, which resulted in the patient’s death.10 Another unusual incident was reported by Raval and Weiner, in which a gastric trichobezoar caused excessive gas formation that with the use of diathermy caused a mild explosive event.11 Bipolar diathermy has also been associated with adverse patient events. Isager and Lind reported a case of an accidental third-degree burn caused by bipolar electrocoagulation.12 Demir et al have recently reviewed a series of 19 patients with intra-operative burns requiring plastic surgery input.13 Four patients had deep dermal or full thickness burns requiring debridement, skin grafting or musculocutaneous flaps. They also carried out a technical analysis showing that malfunctioning electrosurgical devices, an incorrectly positioned neutral electrode, moisture under the negative electrode and fluid or blood creating alternate current pathways were some of the causes. They concluded that the surgical team should pay more attention to the probability of burns during surgery and suggested that immediate involvement of plastic and burn surgeons may prevent further complications. Diathermy burns do not only affect patients in the operating room. Hussain et al reported one diathermy burn to a surgeon in their review of accidental injuries to surgeons and their assistants during operations and Massarweh et al state that the belief that surgical gloves offer complete insulation is false, and causes such as breakdown of the glove, hydration of the glove and capacitative coupling lead to injuries to the operating theatre staff.14,15 Spigelman and Swan conducted a risk assessment audit of 10 operating theatres and concluded that operating theatre fires continue to be a major risk for patients’ safety.16 One of their suggested strategies to reduce the risk of fire was education and training of operating theatre personnel in fire hazards. Although burns comprise the vast majority of electrosurgery complications and accidents, they are not the only ones reported. Malfunctioning pacemakers due to alternating current, the danger of arrhythmias, chemical burns due to neglect in removing the diathermy pad and explosions due to the existence of endogenous gases, such as hydrogen or methane, or combustible anaesthetic gases, such as ether and cyclopropane, pose a threat on several occasions.1,17 Furthermore, the direct stimulation of major muscle groups may lead to noticeable contractions and to the false impression of insufficient anaesthesia. All of the aforementioned complications seem to derive from a lack © 2009 Surgeon 7; 3: 132-6
of understanding of basic electrophysiology principles and could be reduced substantially with a basic but organised training scheme. Our study shows that 49.2% of HSTs did not receive formal diathermy training, a fact that may result in a higher incidence of complications and may compromise patient safety. Mayooran et al tested 20 gynaecological laparoscopic surgeons in a practical diathermy station and a written paper on electrosurgical knowledge.18 Their study found ignorance of electrosurgery/diathermy among gynaecological surgeons. Eleven of the original candidates were retested a year later and skills were found to be no better. Aigner et al categorised the possible causes of burns secondary to diathermy application into three types of issues namely training, equipment and disinfecting and covering methods.1 As far as training is concerned, a joint training programme for surgeons, anaesthetists and theatre nurses is suggested, as greater collaboration will further reduce diathermy injuries or improve their treatment. Furthermore, McHenry et al stressed the necessity for the development and implementation of operating theatre hazard education and prevention programmes in order to reduce the rare, yet severe incidents of surgical fires and explosions.19 Finally, Zinder and Parker suggests steps towards a better understanding of the technical characteristics of electrosurgical equipment and to ‘know more than merely how to turn the machine on’.20 Several training methods and models have been suggested, with most authors considering practice on beefsteak or other animal models and supporting the important role that virtual reality diathermy training is increasingly enjoying in recent years.
Conclusion Of the 300 general surgery HSTs, 49.2% reported receiving no formal training in the use of diathermy in the form of lectures or practical demonstrations. This may result in failure to adhere to what is considered best practice and, in turn, lead to adverse events for the patient along with medico-legal consequences for the surgeon. We suggest that this problem could be overcome by ensuring adequate diathermy training is delivered in a purpose-made course that would be a prerequisite in order to progress to higher surgical training.
Copyright © 17 April 2008
the royal colleges of surgeons of edinburgh and ireland | 135
Appendix 1 Questionnaire 1. Please specify the age group that you belong to? 20-29, 30-39, 40-49, 50-59, 60-69 2. What year of SpR training are you in? 1st, 2nd, 3rd, 4th, 5th, 6th, >6th 3. What is your subspecialty interest? Upper GI, colorectal, vascular, breast, endocrine, hepatobiliary, transplant, laparoscopic (If combined please specify --------------------------------------------------------) 4. Have you had formal training in diathermy use (e.g. lectures, practical demonstration)? Yes/no 5. Do you routinely place diathermy pads on patients yourself? Yes/no 6. Do you routinely check diathermy equipment before use? Yes/no 7. Do you routinely check the diathermy pad site at the end of the operation? Yes/no 8. Which of the following tools do you use to make the skin incision for a laparotomy? Knife/diathermy 9. Which tool do you preferably use during colon mobilisation? Scissors/knife/other (If other please specify ----------------------------) 10. Which tool do you preferably use for rectal mobilisation? Scissors/knife/other (If other please specify ----------------------------) 11. If a diathermy complication were to arise (e.g. diathermy burn) who would be responsible? Surgeon, scrub nurse, circulating nurse, ODA, anaesthetist, manufacturer
136
|
REFERENCES 1. Aigner N, Fialka C, Fritz A et al. Complications in the use of diathermy. Burns 1997; 23: 256-64 2. Farrugia M, McGurgan P, McMillan L et al. Recent advances in electrosurgery- VERSAPOINT® technology. Reviews in Gynaecological Practice. Spring 2001; 1(1): 12-17 3. Van Way C. Electrosurgery 101. Current Surgery 2000; 57(2): 172-77 4. Sudhindra TV, Joseph A, Hacking CJ et al. Are surgeons aware of the dangers of diathermy? Ann R Coll Surg Engl (Suppl) 2000; 82: 31–32 5. Vedovato JW, Polvora VP, Leonardi DF. Burns as a complication of the use of diathermy. J Burn Care Rehabil 2004; 25: 120-23 6. Fong EP, Tan WT, Chye LT. Diathermy and alcohol skin preparations – a potential disastrous mix. Burns 2000; 26: 673-75 7. Tooher R, Maddern GJ, Simpson J. Surgical res and alcohol-based skin preparations. ANZ J Surg 2004; 74: 382-85 8. Wilson PD, van der Walt JD, Moxon D et al. Port site electrosurgical (diathermy) burns during surgical laparoscopy. Surg Endosc 1997; 11: 653-54 9. Kaddoum R, Chidiac EJ, Zestos MM et al. Electrocautery-induced re during adenotonsillectomy: report of two cases. J Clin Anaesth 2006; 18(2): 129-31 10. Baur DA, Butler CD. Electrocautery-ignited endotracheal tube re: case report. British Journal of Oral and Maxillofacial Surgery 1999; 37: 142-43 11. Raval M, Weiner T. Beware of the aming hairball—a brief review and warning. Journal of Paediatric Surgery 2005; 40(4): E37-E38 12. Isager P, Lind T. Accidental third-degree burn caused by bipolar electrocoagulation. Injury 1995; 26: 357 13. Demir E, O’Dey DM, Pallua M. Accidental burns during surgery. J Burn Care Res 2006; 27: 895-900 14. Hussain SA, Latif AB, Choudhary AA. Risks to surgeons: a survey of accidental injuries during operations. Br J Surg 1988; 75: 314-16 15. Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: History, principles, and current and future uses. J Am Coll Surgeons 2006; 202(3): 520-30 16. Spigelman AD, Swan JR. Skin antiseptics and the risk of operating theatre res. ANZ J Surg 2005; 75: 556-58 17. Trimble K. Non-electrical ‘burn’ from a diathermy pad. Injury 2002; 33(1): 78-80 18. Mayooran Z, Pearce S, Tsaltas J, Rombauts L, Brown TI, Lawrence AS et al. Ignorance of electrosurgery among obstetricians and gynaecologists. BJOG 2004; 111: 1413-18 19. McHenry C, Berguer R, Ortega R et al. Recognition, management, and prevention of specic operating room catastrophes. J Am Coll Surgeons 2004; 198(5); 810-21 20. Zinder D, Parker G. Electrocautery burns and operator ignorance. Otolaryngology Head and Neck Surgery 1996; 115(1): 145-49
the royal colleges of surgeons of edinburgh and ireland
© 2009 Surgeon 7; 3: 132-6