- Email: [email protected]
Histologic Changes Associated With Electrosurgical Injury
Special Article
Histologic Changes Associated With Electrosurgical Injury Richard M. Soderstrom, MD, FACOG* From the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington.
Keywords:
DISCUSS
Bipolar; Burns; Electrosurgery; Injury; Monopolar
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-20-3-12-00248
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Table 1
Fig. 1
Histologic features of traumatic and electrosurgical injuries
The sharp demarcation between normal intestinal mucosa and the transmural coagulation zone is the hallmark of electrosurgical injuries.
Histologic features of traumatic injuries A limited, non–coagulative-type cell necrosis, more severe in the muscle coat than the mucosa A rapid and abundant capillary ingrowth with rapid white cell infiltration A rapid fibrin deposition at the injury site followed by fibroblastic proliferation Significant reconstruction of the injured muscle coat by 96 hours Histologic features of electrosurgical injuries An absence of capillary ingrowth of fibroblastic muscle coat reconstruction An absence of white cell infiltration except in focal areas at the viable border of the injury An area of coagulation necrosis
The importance of the histologic appearance noted with suspected electrosurgical injuries during laparoscopic surgery was first evaluated by Levy et al [1] after their study of bowel injuries inflicted on white New Zealand white rabbits using a randomized, blinded evaluation. This study compared the gross and histologic findings after both traumatic and electrosurgical bowel injury (monopolar and bipolar) in these study animals. The animals were blindly selected The author declares that he has no conflict of interest. Corresponding author: Richard M. Soderstrom, MD, FACOG, 379 Desert Lakes Drive, Palm Springs, CA 92264. E-mail: [email protected] Submitted May 14, 2012. Accepted for publication January 23, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.01.008
for reoperation in a random fashion after 24, 48, 72, and 96 hours. The surgeons were ‘‘blinded’’ as to the cause of each injury found and removed for histologic examination. The findings, after the ‘‘blind code’’ assigned to each animal was opened, showed a distinct histologic difference between sharp and electrosurgical trauma. Table 1 lists these differences. These distinguishable differences found with electrosurgical injury are consistent with the thermal effect of highfrequency radio waves passing through living tissue as they seal the blood vessel supply to the injured site (Fig. 1). As such, unlike traumatic tissue injury, after an electrosurgical injury, capillary ingrowth and white cell infiltration do not occur. With sharp trauma, the opposite occurs (Fig. 2). Since this study was published, numerous cases of suspected electrosurgical injuries during laparoscopy have
300
Fig. 2 A sharp traumatic injury revealing an intense, capillary ingrowth with white cell infiltration.
Journal of Minimally Invasive Gynecology, Vol 20, No 3, May/June 2013
usually preventable. Methods of reducing electrosurgical injury risk are discussed later in this series. Unfortunately, many expert witnesses initially assume that the probable cause of a delayed bowel injury was created by improper, electrosurgical injury, prompting numerous litigation claims [2–4]. Therefore, the importance of having a keen appreciation of finding a correct diagnosis via the injury’s histology is significant.
References
been evaluated that support this research. Traumatic injury to the bowel is a well-recognized risk of abdominal laparoscopy; electrosurgical desiccation of the bowel is
1. Levy BS, Soderstrom RM, Dail DH. Bowel Injuries during laparoscopy: gross anatomy and histology. J Reprod Med. 1985;309: 168–172. 2. Soderstrom RM. Bowel injury litigation after laparoscopy. J Am Assoc Gynecol Laparosc. 1993;1:74–77. 3. Pooley A, Soderstrom RM. Bowel complications of laparoscopic surgery. In: Sutton C, Diamond M, editors. Endoscopic Surgery for Gynecologists. London: WB Saunders Co. Ltd; 1998. 4. Soderstrom RM, Brill AI. Principles of electrosurgery as applied to gynecology. In: Rock JA, Thompson JD, editors. Te Linde’s Operative Gynecology. Philadelphia: Lippincott; 2008. p. 280–297.
Histologic Changes Associated With Electrosurgical Injury Richard M. Soderstrom, MD, FACOG* From the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington.
Keywords:
DISCUSS
Bipolar; Burns; Electrosurgery; Injury; Monopolar
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-20-3-12-00248
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Table 1
Fig. 1
Histologic features of traumatic and electrosurgical injuries
The sharp demarcation between normal intestinal mucosa and the transmural coagulation zone is the hallmark of electrosurgical injuries.
Histologic features of traumatic injuries A limited, non–coagulative-type cell necrosis, more severe in the muscle coat than the mucosa A rapid and abundant capillary ingrowth with rapid white cell infiltration A rapid fibrin deposition at the injury site followed by fibroblastic proliferation Significant reconstruction of the injured muscle coat by 96 hours Histologic features of electrosurgical injuries An absence of capillary ingrowth of fibroblastic muscle coat reconstruction An absence of white cell infiltration except in focal areas at the viable border of the injury An area of coagulation necrosis
The importance of the histologic appearance noted with suspected electrosurgical injuries during laparoscopic surgery was first evaluated by Levy et al [1] after their study of bowel injuries inflicted on white New Zealand white rabbits using a randomized, blinded evaluation. This study compared the gross and histologic findings after both traumatic and electrosurgical bowel injury (monopolar and bipolar) in these study animals. The animals were blindly selected The author declares that he has no conflict of interest. Corresponding author: Richard M. Soderstrom, MD, FACOG, 379 Desert Lakes Drive, Palm Springs, CA 92264. E-mail: [email protected] Submitted May 14, 2012. Accepted for publication January 23, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.01.008
for reoperation in a random fashion after 24, 48, 72, and 96 hours. The surgeons were ‘‘blinded’’ as to the cause of each injury found and removed for histologic examination. The findings, after the ‘‘blind code’’ assigned to each animal was opened, showed a distinct histologic difference between sharp and electrosurgical trauma. Table 1 lists these differences. These distinguishable differences found with electrosurgical injury are consistent with the thermal effect of highfrequency radio waves passing through living tissue as they seal the blood vessel supply to the injured site (Fig. 1). As such, unlike traumatic tissue injury, after an electrosurgical injury, capillary ingrowth and white cell infiltration do not occur. With sharp trauma, the opposite occurs (Fig. 2). Since this study was published, numerous cases of suspected electrosurgical injuries during laparoscopy have
300
Fig. 2 A sharp traumatic injury revealing an intense, capillary ingrowth with white cell infiltration.
Journal of Minimally Invasive Gynecology, Vol 20, No 3, May/June 2013
usually preventable. Methods of reducing electrosurgical injury risk are discussed later in this series. Unfortunately, many expert witnesses initially assume that the probable cause of a delayed bowel injury was created by improper, electrosurgical injury, prompting numerous litigation claims [2–4]. Therefore, the importance of having a keen appreciation of finding a correct diagnosis via the injury’s histology is significant.
References
been evaluated that support this research. Traumatic injury to the bowel is a well-recognized risk of abdominal laparoscopy; electrosurgical desiccation of the bowel is
1. Levy BS, Soderstrom RM, Dail DH. Bowel Injuries during laparoscopy: gross anatomy and histology. J Reprod Med. 1985;309: 168–172. 2. Soderstrom RM. Bowel injury litigation after laparoscopy. J Am Assoc Gynecol Laparosc. 1993;1:74–77. 3. Pooley A, Soderstrom RM. Bowel complications of laparoscopic surgery. In: Sutton C, Diamond M, editors. Endoscopic Surgery for Gynecologists. London: WB Saunders Co. Ltd; 1998. 4. Soderstrom RM, Brill AI. Principles of electrosurgery as applied to gynecology. In: Rock JA, Thompson JD, editors. Te Linde’s Operative Gynecology. Philadelphia: Lippincott; 2008. p. 280–297.