A Continuing Nursing Education Activity

Sponsored by

Grant funds provided by

Welcome to

(An Online Continuing Education Activity)

This educational activity is being offered online and may be completed at any time.
STEPS FOR SUCCESSFUL COURSE COMPLETION
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the
end of the activity, you will be assessed on the attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer
choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.
Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary,
for 7 years. Requests for certificates must be submitted in writing by the learner.
If you have any questions, please call: 720-748-6144.

2101 S Blackhawk Street, Suite 220

Aurora, CO 80014-1475
Phone: 720-748-6144
Fax: 720-748-6196
Website: www.pfiedlerenterprises.com
2014
All rights reserved
Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
2014 Covidien
All rights reserved. Contents of materials presented or distributed by Covidien may not be reproduced in
any form without the written permission of Covidien.

An Online Continuing Education Activity

OVERVIEW
The historical development of the field of minimally invasive procedures demonstrates an interest in techniques that
reduce the physical trauma of open surgical procedures. The number of minimally invasive procedures performed
around the world has continued to increase since the laparoscopic revolution began in the early 1980s. As minimally
invasive technology continues to improve, more complex procedures are added to the list of those that can be safely
done laparoscopically. Robot assistance, surgery through single incisions, as well as surgery through natural orifices
will continue to increase patient safety and satisfaction with minimally invasive approaches. Both mechanical and
electrical safety concerns, however, still exist. This online continuing education activity will discuss the historical
development of minimally invasive procedures, explore safety concerns and discuss best practices to reduce the
likelihood of patient injury during minimally invasive procedures. The purpose of this continuing education activity is
to assist perioperative professionals deliver safe patient care during minimally invasive procedures.
OBJECTIVES
Upon completion of this continuing education activity, the participant should be able to:
1. Discuss the evolution and advancement of minimally invasive procedures.
2. Describe hazards that can be present during minimally invasive procedures.
3. Relate how endoscopic instrumentation has contributed to increased patient safety.
4. Identify best practices that increase patient safety during minimally invasive procedures.
INTENDED AUDIENCE
The intended audience for this online continuing education activity includes surgeons, perioperative registered nurses
and other healthcare team members who provide care during operative and minimally invasive procedures..
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number
CEP14944, for 2.0 contact hour(s).
Obtaining full credit for this offering depends upon completion, regardless of circumstances, from beginning to end.
Licensees must provide their license numbers for record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be retained in the participants
records for at least four (4) years as proof of attendance.

IACET Credit for Allied Health Professionals

Pfiedler Enterprises has been accredited as an Authorized Provider by the
International Association for Continuing Education and Training (IACET). In obtaining
this accreditation, Pfiedler Enterprises has demonstrated that it complies with the
ANSI/IACET Standard which is recognized internationally as a standard of good
practice. As a result of their Authorized Provider status, Pfiedler Enterprises is
authorized to offer IACET CEUs for its programs that qualify under the ANSI/IACET Standard.
CEU Statements
As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs that qualify under the
ANSI/IACET Standard.
Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program.
RELEASE AND EXPIRATION DATE
This continuing education activity was planned and provided in accordance with accreditation criteria. This material
was originally produced in March, 2015 and can no longer be used after March, 2017 without being updated;
therefore, this continuing education activity expires in March, 2017.
DISCLAIMER
Accredited status as a provider refers only to continuing nursing education activities and does not imply endorsement
of any products.
SUPPORT
Grant funds for the development of this activity were provided by Covidien.
AUTHORS/PLANNING COMMITTEE/REVIEWER
Julia A. Kneedler, RN, MS, EdD
Chief Executive Officer/Reviewer
Pfiedler Enterprises

Aurora, Colorado

Judith I. Pfister, RN, BSN, MBA

President/Planner
Pfiedler Enterprises

Aurora, Colorado

Donna S. Watson, RN, MSN, CNOR, FNP

Manager, Professional Nursing Education
Manager, Course Curriculum Development
Covidien

Boulder, Colorado

Carol J. Wilcox, MT (ASCP), MA, BS

Consultant/Reviewer
Pfiedler Enterprises

Aurora, Colorado

DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO CONTROL

CONTENT FOR THIS ACTIVITY
Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control
content for an educational activity. Information listed below is provided to the learner, so that a determination can be
made if identified external interests or influences pose a potential bias of content, recommendations or conclusions.
The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific
rigor in the activity.
Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may
be presented in this educational activity. Relevant financial relationships are those in any amount, occurring within
the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing,
reselling, or distributing health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Julia A. Kneedler, RN, MS, EdD
Co-owner of company that receives grant funds from commercial entities
Judith I. Pfister, RN, BSN, MBA
Co-owner of company that receives grant funds from commercial entities
Donna S. Watson, RN, MSN, CNOR, FNP
Employee of grant provider
Carol J. Wilcox, MT (ASCP), MA, BS
No conflicts of interest

PRIVACY AND CONFIDENTIALITY POLICY

Pfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations
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HISTORICAL DEVELOPMENT IN MINIMALLY INVASIVE PROCEDURES

Throughout the history of medicine and surgery, discoveries of yesterday serve as a platform for the innovations of
today and tomorrow. That is especially true for minimally invasive procedures. Less-invasive approaches and
techniques are not new. Historical references to endoscopy date to the time of Hippocrates (460-375 BC) with a
description of a rectal examination using a speculum.1 A vaginal speculum was reportedly found in the Pompeii ruins
(70 AD), which indicates a long history of interest in looking at the internal organs of humans.2
Over the centuries, researchers developed instruments and equipment to examine internal organs, culminating in the
field that encompasses minimally invasive procedures today. An overview of the development demonstrates an
interesting view of how the science and technology progressed over time.
Figure 1. The Bozzini light conductor (a) side view; (b) view from above.
Phillip Bozzini (1773-1809) of Germany developed the first endoscope
in the early 1800s. His medical career began in 1797, and from the
start Bozzini was intrigued with viewing inside the body. As early as
1804 he constructed a device made of optics, a light source and
mechanical pieces that could adapt to the human body. He published
(a)
(b)
his work in 1806 in a paper entitled Der Lichtleiter (the light
conductor). Bozzini described it as an instrument to observe internal
organs and diseases. A variety of attachments allowed for visualization inside body cavities. The light conductor used
a candle and a mirror to reflect the light into a cavity and a lens to view the reflected image (Figure 1). One of the
adverse outcomes of using the light conductor was burns from the heat of the candle. Bozzini was far ahead his time,
not only with his endoscope, but also in his belief that surgery could be done through the bodys natural orifices.3
Figure 2. Desormeaux endoscope of 1853
In 1853, French surgeon Antoine Jean Desormeaux (1815-1882)
refined the Bozzini light conductor and used it on a patient. His
instrument had a system of mirrors and lens and replaced the candle
with a lamp flame to provide light. It burned a mixture of alcohol and
turpentine and, as with the light conductor, patient burns were a major
hazard. The instrument incorporated a mirror with a central hole tilted
at a 45-degree angle over the flame, which allowed direct vision to
where the light was reflected. Desormeaux called his instrument an
endoscope, the first use of the term (Figure 2). He is considered to
be one of the fathers of endoscopy.4

In 1877, Maximilian Nitze (1848-1906) of Dresden created the first modern optical system. His system used a heated
wire for illumination at the tip of the scope and a water cooling system. He later modified Thomas Edisons light bulb
by making a miniaturized version of the filament globe, thereby creating the first electrical source of illumination of the
cystoscope.5
In 1901, Georg Kelling (1866-1945), a gastroenterologist and surgeon from Dresden, performed the first laparoscopic
operation on a dog at the 73rd meeting of the German Natural Scientist Society in Hamburg. He called his procedure
a celioscopy. Following the demonstration, Kelling said: I will now close, gentlemen, by expressing the wish that
the endoscopic method finds more usage than has been the case until now, considering the fact that it is truly more
useful than the method of laparotomy used at present.6
This event heralded in the laparoscopic age as other surgeons began to use minimally invasive methods and added
to the body of endoscopic knowledge. In 1910, H. C. Jacobaeus of Stockholm used the term laparothorakoskopi in
a report he published on laparoscopy and thoracoscopy. The first laparoscopy performed in the U.S. was in 1911 by
Bertram M. Bernheim of Johns Hopkins. Berheim used a proctoscope and called his procedure organoscopy.7
YEAR

NAME / COUNTRY

INNOVATION

1801

Philip Bozzini (Germany)

First lighted endoscope, called Der Lichtleiter, the light

conductor.3

1853

Antonin Jean Desormeaux (France)

Modified Bozzinis light conductor and used it on a patient.4

1877

Maximilian Nitze (Germany)

Developed the first electrically lighted endoscope.5

1901

Georg Kelling (Germany)

First laparoscopy on a dog using Nitzes cystoscope.6

1911

Bertram M. Bernheim (United

States)

First United States laparoscopycalled his procedure an

organoscopy.7

1920

Benjamin Orndoff (United States)

Developed a sharp pyramid shaped trocar.7

1929

Heinz Kalk (Germany)

Developed the 135 degree lens system. Founder of the German

School of Laparoscopy8

1934

John C. Ruddock (United States)

Developed bipolar electrosurgery device.9

1938

Janos Veress (Hungary)

Developed the first spring-loaded needle for insertion into the

peritoneum.7

1970s

Kurt Semm (Germany)

Developed thermocoagulation, laparoscopic suturing, and the

automatic electronic insufflator.10, 11

1987

Phillipe Mouret (France)

First European laparoscopic cholecystectomy.12

1988

J. Barry McKernan & William B.

Saye (United States)

Performed first laparoscopic cholecystectomy in the United

States.8

Table 1. Innovations in endoscopy and laparoscopy

Another early pioneer of endoscopy in the U.S. was John C. Ruddock, (1891-1964). Ruddock was an internist in the
Los Angeles area who used a modified cystoscope to view inside the abdomen in a procedure he termed
peritoneoscopy. He was a staunch proponent of laparoscopy over laparotomy. By 1937 he had published a review
of 500 of his cases to support his claims. Over the next 20 years, Ruddock performed 5,000 cases, publishing his
results in a 1957 article.9 Ruddock was an early user of electrosurgery during laparoscopy, modifying an instrument
so that he could apply bipolar radiofrequency current to bleeders during the procedure:
8

By means of special nippers he can snip out a piece of suspect tissue from an internal organ and immediately seal
the wound with an electric current.13
Many men of medicine have contributed to the field of endoscopy and laparoscopy. Table 1 gives a brief overview of
some of the contributions. From the time of Ruddock, the specialty of gynecology embraced laparoscopy as a
diagnostic and therapeutic tool. Physicians Power and Barnes reported on their technique of laparoscopic
sterilization in 1941.14 During the next several decades, these procedures became commonplace among
gynecologists.
In 1987, laparoscopy swept into general surgery when Phillipe Mouret of Lyon, France removed a patients
gallbladder laparoscopically.12 The first laparoscopic cholecystectomy in the U.S. was performed by J. Barry
McKernan and William B. Saye in Marietta, Ga. on June 22, 1988.8 Others followed, and the laparoscopic revolution
spread quickly across the country. The tools and the technology have continued to evolve and expand to other
surgical specialties as patients and practitioners enjoy the benefits of minimally invasive procedures.
HEALTHCARE SHIFT TO MINIMALLY INVASIVE TECHNIQUE
Gynecologists popularized laparoscopy in the U.S. in the 1970s, primarily in response to an increased demand by
female patients who greatly benefited from the minimally invasive procedure.15
The American Association of Gynecologic Laparoscopists (AAGL) was founded in 1971 by Jordan Matthew Phillips.
The professional organization provided a framework for teaching and studying new minimally invasive techniques
and a forum where ideas and innovation could flourish.16
Since then, perioperative practitioners have been challenged to stay abreast of a field with changing techniques,
instruments and equipment. The laparoscopic revolution of the 1980s propelled the changes onto the fast track as
more specialties devised ways to treat patients with smaller incisions. In 1983, the implementation of the diagnosis
related groups (DRGs) prospective payment system through Medicare strongly influenced healthcare facilities to
provide ambulatory care.17
Figure 3. Increase in number of procedures 1980 to 2006

Number of Surgeries (in millions)

40

35
30
25
20
15
10
5
0
1980

1996

Year

2006

The shift from inpatient to outpatient from laparotomy to laparoscopy is shown in the increase in the number of
minimally invasive procedures. About 3 million outpatient surgery procedures were performed in 1980.17 By 1996 the
number of ambulatory surgery visits had increased to 20.8 million, and by 2006 increased to 34.7 million (Figure
3).18,63 This shift is expected to continue as the tools and surgical techniques improve.
Reason

2004

2007

Decreased length of stay

74%

85%

Improved quality of life

57%

74%

Patient preference

46%

60%

Improved cosmesis

46%

59%

Improved visualization

18%

41%

Table 2. Reasons for laparoscopy by SGO members19

Patient satisfaction with less-invasive procedures is another reason the shift has continued. Smaller scars are just
one benefit to less-invasive procedures. Patients report less pain and quicker recovery periods, which facilitate a
faster return to normal activities. Smaller external scars also mean less scarring internally, which decreases
adhesions. Patients often lose less blood, which also means faster recovery. Surveys of members of the Society of
Gynecologic Oncology (SGO) in 2004 and 2007 revealed (Table 2) that surgeons perform laparoscopic surgery for
some of the same reasons that patients prefer this approach, including decreased length of hospital stay and
improved quality of life.19
Figure 4. Nonsurgical advances shifting treatment out of the operating room

Endovascular Treatments
Carotid stenting
Percutaneous aortic valve
replacement

Ablative Interventions
Radiofrequency ablation

Catheter embolization

Thermal ablation

Noninvasive Surgery
Stereotatic radiosurgery
Ultrasound-guided focused
ultrasound
MR-guided focused
ultrasound

Cryoablationt

10

Breakthrough Therapeutics
Biopharmaceuticals
Novel vaccines
Gene therapy

Figure 5. Biomedical innovations that may fuel future minimally invasive surgery

Science and technology are advancing at an incredible pace, in some cases reducing the need for surgery by moving
patients out of the operating room and into procedure suites. Procedures that were once only performed in the
operating room are now being safely done in endoscopy units and radiology suites. Biotechnology and gene therapy
help to further reduce the need for minimally invasive surgery and replace it with minimally invasive procedures
(Figure 4). There are, however, innovations in various stages of development that will keep patients seeking surgical
care as well (Figure 5):
Bioengineering scientists at the University of Pittsburgh in Pennsylvania are developing valves to replace human
heart valves. Japanese researchers have successfully created an autologous heart valve by growing it in the body
of a rabbit. The valve has the potential to be a prosthetic human heart valve replacement.20
Researchers at Wake Forest University in Winston-Salem, N.C. have engineered bladders grown in the lab from
the patients cells and implanted the bladders into patients.21
Tengion, a U.S.-based biotech firm, is conducting research to use healthy cells from patients to engineer organs to
be implanted, such as the bladder, kidney and vessels.22
Researchers from several universities in the U.S. and Europe are investigating use of a combination of
biodegradable polymers and mesenchymal stem cells to generate vascularized bone for reconstructive surgery.23
An aging population and biomedical engineering of body tissue and organs will fuel the continued need for and
advancement of surgery, including minimally invasive procedures.
INNOVATIONS ADVANCING MINIMALLY INVASIVE PROCEDURES
ROBOTICS
Since the 1990s, healthcare has experienced a virtual explosion in medical technology. One of the major
advancements is in robotics. Computer capabilities make it possible for surgeons to perform procedures without
touching the patient. With robotic-assisted technology a surgeon can perform a procedure on a patient in Asia from
11

a facility in New York. The evidence to support robotics is increasing as more and more facilities implement the use
of robot assistance in surgery. From the surgeon perspective the advantages of robotic assistance include:
Three-dimensional vision
Hand tremor reduction
Increased intra-abdominal articulation
Motion scaling19
The benefits for the patient when surgeons use robotic assistance include:
Smaller incisions
Decreased postoperative pain
Shorter hospital stays
Better cosmesis
Reduced blood loss
Reduced tissue loss
Faster return to work24
Current robotic-assisted surgeries include cardiac, genitourinary, gynecologic and general surgery. As roboticassisted surgery becomes more prevalent in the surgical setting, facilities may see the need for a perioperative
robotics nurse specialist. The role of the robotics specialist will be dynamic and multifaceted, and may include:
Ensuring instrument availability and care
Assisting intraoperatively with all robotic procedures
Providing patient and staff educational tools
Assisting with research efforts
The high startup cost of initially setting up a robotic system (more than $1 million) and time commitment to gain the
knowledge and skills required to run a program efficiently supports implementation of a robotics nurse specialist.25
In May 2009, the Association of periOperative Registered Nurses MIS/Laser Specialty Assembly added robotics to
its focus. The increase in the number of nurses working with robotics prompted the expansion of the specialty
assembly to provide a format for sharing of education and resources.26
SINGLE-INCISION LAPAROSCOPIC SURGERY
Performing surgery through a single umbilical incision is not new. Gynecologists used that approach in the 1970s with
laparoscopic tubal ligations and diagnostic laparoscopy. But, the single-umbilical entry site is new for the more
complex procedures developed by general surgeons and other specialties since the 1970s. As laparoscopic
procedures became more complex, the number of ports or entry sites into the abdominal cavity increased. Singleport access is known by several different acronyms single-incision laparoscopic surgery (SILS), single-port
access (SPA) or one-port umbilical surgery (OPUS).
Single-incision laparoscopic surgery was pioneered at Drexel University College of Medicine in Philadelphia in May
2007 when surgeon Paul G. Curcillo removed the gallbladder of a 28-year-old woman through a single umbilical
incision.27 Single-port access is an advanced minimally invasive surgical procedure where all instrumentation is
passed through a single entry point at the navel.
12

Figure 6. Traditional laparoscopy port sites compared to single-incision laparoscopy surgery

Traditional minimally invasive procedures may have two or more
ports inserted into the abdominal cavity. An MIS cholecystectomy
has several incisions one at the rim of the navel, one beneath the
navel and two beneath the navel on the right side of the abdomen
(Figure 6). In single incision procedures the scope and instruments
are passed through one 1.5 cm to 2 cm incision within the navel.
The advantage of single incision laparoscopic surgery is that
standard laparoscopic instruments can be used.28
Figure 7. Single-port access laparoscopy
Single-incision procedures are currently performed with standard
MIS instrumentation including 2 mm ports, 3 mm ports, endoroticular graspers, endo-roticular dissectors and endo-roticular
shears. New instrumentation and trocars are being developed
(Figure 7). In single-port access procedures a trocar with multiple
instrument ports and bendable, articulating instruments are
necessary to accommodate for the space restriction and limited
range of motion. Newer devices and equipment currently in
development will assist the surgeon with increased dexterity and
maintenance of the pneumoperitoneum (Figure 8).
Figure 8. Single-incision laparoscopy surgery port
As surgical innovation continues to move into the 21st century, the number and types of
procedures that can be done through a single incision will increase. The new surgical
technique reduces scarring and produces a better cosmetic effect,29 which captures the
attention of the public and healthcare providers alike. Procedures currently being
performed through a single incision include:
Appendectomy
Cholecystectomy
Gastrectomy
Hysterectomy
Nephrectomy
Oopherectomy30

13

NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)

Despite Bozzinis belief in the 1700s that surgery could be done through the bodys natural openings,3 it was not until
the 21st century that researchers renewed efforts to use this approach. Some have referred to natural orifice
translumenal endoscopic surgery, or NOTES, as the next frontier in minimally invasive procedures that will
advance the minimally invasive discipline. The rationale for gaining access to the abdominal cavity through natural
body openings is to further reduce postoperative pain, wound and pulmonary complications, and to improve cosmetic
effects, early ambulation and quicker patient discharge.31
Figure 9. Ports of entry into the peritoneum for NOTES
The approaches that can be used for NOTES are the transgastric,
transvaginal, transvesical or the transcolonic (Figure 9). The first
reported NOTES procedure was by Gettman and colleagues in 2002
who removed a kidney transvaginally in a porcine model.32 In 2004
Kalloo reported using the transgastric approach to access the
peritoneum in an animal model.33 Chukwumah and colleagues (2010)
reported 255 human notes reported in the literature between 20072010 that could be performed employing NOTES techniques:34
Appendectomy
Cancer Staging
Cholecystectomy
Colectomy
Nephrectomy
Perioneoscopy
PEG Rescue
Sleeve Gastrectomy
Figure 10. NOTES cholecystectomy procedure
As an example, the procedure for transgastric cholecystectomy
would involve insertion of an endoscope down the esophagus,
placing an incision in the stomach or digestive tract to access the
abdominal cavity and removing the gallbladder through the mouth
(Figure 10).35

14

There are challenges that must be addressed to ensure the procedure has less morbidity and mortality than
traditional minimally invasive or open approaches, and is indeed better for patients. In an effort to address concerns
related to procedures through natural orifices, in 2005 the Society of American Gastrointestinal Endoscopic Surgeons
and the American Society of Gastrointestinal Endoscopy formed a working group called Natural Orifice Surgery
Consortium for Assessment and Research (NOSCAR). The group was to identify barriers to using this approach to
include:
Access
Closure
Infection
Suturing technology
Orientation
Physiology
Complications
Training
Platform development36
Some challenges for NOTES are the development of the tools needed to perform the procedure. Others
require training to ensure practitioners have the skill and the knowledge to do the procedures safely. Continued
collaboration in developing safe and effective practice models will dictate future development of these procedures.
VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS)
Thoracic surgery has seen an increase in the number of procedures done in a minimally invasive manner. The
advantages gained from using techniques that do not require rib spreading are of benefit to patients since there
is less postoperative pain and shorter hospitalization. Procedures that can be done include pulmonary and
esophageal resection, thymectomy and sympathectomy. Technology development and increased skill and
knowledge will result in patient and overall healthcare benefits.37
INCREASED SPECIALIZATION OF TOOLS TO FACILITATE MIS PROCEDURES
Minimally invasive procedures have continued to grow and the tools surgeons use have become more specialized.
The laparoscopes of today are very different than Bozzinis light conductor of the 1800s. The goal of increased
specialization of the tools is to reduce risk and increase patient safety. The development of MIS instrumentation
has been the result of surgeons, nurses, engineers and medical manufacturers working together to produce the
best possible equipment and instrumentation.
LAPAROSCOPES
Laparoscopes are a type of endoscope used to view organs and tissues within the abdominal cavity. Scopes
can be rigid or flexible with optical systems that provide light, a field of view, magnification and high resolution.38
Laparoscopes are available as strictly diagnostic systems with no operating channels, or operating scopes with
channels and connectors for instruments, suction and irrigation. They are available in a variety of sizes and
configurations.

15

TROCAR/CANNULA SYSTEMS
The trocar/cannula system allows access into the patients body once the pneumoperitoneum is established, typically
with a Veress needle. The systems can be reusable, reposable or disposable. Reusable trocar/cannula systems are
generally made of metal, which can be steam sterilized. The metal trocar must be sharpened frequently to facilitate
peritoneal access. The stopcock and valves in the cannula must be cleaned to be sure that no bioburden is passed
on to patients. They should be inspected before and after each use to ensure they are in proper working order.
Trocar/cannula systems are available as multiple-use items, referred to as reposable. They are generally plastic and
must be cleaned and inspected just as the metal systems to ensure proper function. The reusable systems allow
facilities to save some cost through multiple uses, but should not be used beyond the useful life of the instrument.
Disposable trocar/cannula systems are designed to be used
once and discarded (Figure 11). They are made of
plastic and have safety features not available in the metal
systems. They may be bladed or non-bladed and some are
translucent to allow for greater visualization during the use of
X-ray or fluoroscopy. Radially expanding systems can be used
Figure 11. Blunt Trocar/cannula system
on patients with adhesions from previous surgeries or
pediatric patients. The muscles are not cut but spread,
decreasing possible damage to abdominal organs and vessels. Surgeons also have the option of using an optical
trocar system, which consists of an optical obturator encompassing a blunt clear window at the distal end.24
INSTRUMENTS
Instruments used during MIS procedures mimic those used during open procedures. The surgeon must have the
ability to cut, dissect, clamp, retract and grasp tissue. Dissecting instruments available include scissors that may be
curved, blunt, angled, hooked or sharp. Dissecting instruments may also be insulated and energized.
Instruments to grasp tissue can also be used to dissect tissue. Graspers can be used to hold tissue and may be
ratcheted or non-ratcheted, traumatic or atraumatic. Forceps are another type of grasping instrument, which can also
biopsy tissue. Grasping instruments may be insulated and energized to provide hemostasis.
Other instruments include retractors to hold tissue and/or expose the operative target. Retractors may be blunt, mini
or balloon configurations. Probes are available to assist with tissue manipulation. Irrigating and aspirating
instruments help to keep the field clear with irrigating fluid, and suction to clear the field of excess fluid or blood.
Specimen bags have also been designed to contain organs or tissue removed from the patient. These are an
ingenious system deploying a bag that can be closed to contain the specimen.
SUTURES AND STAPLES
Perhaps the greatest specialization and adaptation to minimally invasive procedures has occurred with sutures and
staples. The difficulties early laparoscopists encountered in suturing and stapling within the confined space of the
abdominal cavity must have been enormous. Sutures, needles holders and closing devices have been developed to
facilitate tissue approximation within the body cavity (intracorporeal) and outside the body (extracorporeal). Some
suture carriers are designed to pass the needle endoscopically from one side of the holder to the other.

16

Specially designed endoscopic staples and clip appliers achieve or maintain hemostasis. Staplers and clips appliers
come in a variety of lengths, diameters and sizes. They are disposable or reusable offering the surgeon a wide
choice in handling characteristics and ease of use. Figure 12 shows an example of endoscopic instrumentation used
during a cholelcystectomy.
Figure 12. Example of laparoscopic instrumentation during a cholecystectomy

traction

Grasping

hook

clipped

SAFETY CONSIDERATIONS DURING MIS PROCEDURES

Perioperative professionals are aware that teamwork is very important in the operating room. That is especially
true during minimally invasive procedures when the surgeon must depend on team members and complex
equipment that function efficiently and effectively. There is increased emphasis on safe surgery around the world.
The World Health Organization estimates that of the 234 million surgeries performed worldwide annually, about half
of the reported complications are preventable.39 Identifying safety concerns and building safety into technology and
perioperative teams can reduce adverse outcomes.
CATEGORIES OF PATIENT INJURIES
The two major categories of patient injuries during minimally invasive procedures are classified as mechanical
trauma and thermal injuries.40, 41 The complications that have been identified include bleeding, perforations,
lacerations, infections, dehiscences and occlusions. Adverse outcomes that are among the never events in
surgery include retained foreign objects, wrong-site surgery, fires/burns, neuropathies from improper positioning,
pressure ischemia and well-leg compartment syndrome.41 Never events in surgery are those complications/injuries
that should never happen because they are preventable. Equipment failure can contribute to or cause some of the
complications.
MECHANICAL
In the mechanical trauma category, perforations of vital structures are the most common complications during
laparoscopic surgery because of the initial blind placement of the Veress needle and the first laparoscopic port.
During approximately a five-year period, 1,353 serious injuries and 31 deaths were reported to the U.S. Food and
Drug Administration (FDA).41 Most injuries were perforations of the bowel or the vascular system from the trocar
17

puncture into the abdominal cavity. Manufacturers of trocar systems have worked to improve the safety of the
devices, and it is important to be aware of the fact that of the 41 suspected trocar malfunctions, only one trocar was
found to be defective.41 Studies of perforation injuries indicate that the most likely time that an injury will
occur is during stablishment of the primary port when the internal structures cannot be visualized.
Figure 13. Categories of equipment failures during laparoscopy

Equipment failures are a problem in any surgical procedure, but can be especially hazardous during minimally
invasive procedures. As the equipment becomes more complex and more sophisticated, the possibility of
failure increases. A French study examined equipment failure and determined that most fell into one of four
categories (Figure 13):
1. Failure of electrical equipment
2. Failure of imaging systems
3. Failure of accessory equipment (fluid, light or gas devices)
4. Failure of surgical instruments
When there is equipment failure during a minimally invasive procedure, the quality of the surgical intervention can
be adversely affected. The outcome could be a delay in completion of the procedure, but equipment failure could
also have more dire consequences. The French study supported that many of the failure events were preventable.
A laparoscopy checklist was developed in an effort to reduce the possibility of human error (Table 3).
Implementation of the checklist reduced the number of equipment failures in the study facility.43 The results of
this study could doubtless be replicated elsewhere even though the sample was small. Reducing human error
through use of checklists is supported by the World Health Organizations safe surgery initiative.39
THERMAL
John R. Clarke, M.D., Professor of Surgery at Drexel University, Clinical Director of the Pennsylvania Patient
Safety Reporting System, and ECRI makes three important points about thermal injuries:
1. Most thermal injuries involving minimally invasive surgery result from electrosurgery
2. Many of the complications from electrosurgery may arise from bad habits or lack of awareness of risky
behavior
3. The necessity of electrosurgery makes education about best electrosurgical practices important41
18

BASIC PRINCIPLES OF ELECTRICITY

Electricity is the power behind radiofrequency electrosurgery generators. Electricity is a naturally occurring
phenomenon that always follows the path of least resistance and always seeks to return to ground or its source, and
needs a complete circuit to function.44 The pathway of the electrical current as it flows through a conductor is called
the electrical circuit. The circuit must be complete before an electrical device will function. The two types of electrical
current are direct current (DC) and alternating current (AC). Direct current is a simple circuit where the electricity
flows in one direction. Batteries are an example of a simple DC circuit. Energy flows from one terminal on the battery
and returns to the other terminal to complete the circuit.
Figure 14. Radiofrequency spectrum

Alternating current (AC) changes or alternates direction of the

electrical flow. The frequency of the alterations is measured in
cycles per second or Hertz. Household current alternates between
positive and negative poles at 60 cycles per second, as does much
of the electrical equipment used in operating rooms. Alternating
current at 60 Hz can cause tissue injury. Early researchers
discovered neuromuscular stimulation ceases at about 100,000
Hz.discovered neuromuscular stimulation ceases at about 100,000 Hz. Electrosurgery generators operate in the
radiofrequency range of 200,000 Hz to 3.3 megahertz (MHz) (Figure 14). As electrons flow through a conductor, that
flow is measured in amperes or amps.45
Preoperative Circulating Nurse

Pre-Procedure Surgeon/Scrub Nurse

YES

YES

ELECTROSURGERY

INSUFFLATOR
Connected

Monopolar and bipolar instruments connected

Settings checked

Connections checked pins seated

Gas cylinder full

Monopolar and bipolar foot pedals tested

Gas cylinder open

Bipolar tested on wet sponge

Insufflation switched off

VIDEO/LIGHT SOURCE

ELECTROSURGERY UNIT

Light intensity increased and checked

Generator connected and turned on

Focus adjusted

Patient return electrode applied after patient

positioned

White balance performed

Light intensity decreased

Foot pedal connected and tested

Generator settings checked

SUCTION/IRRIGATION

VIDEO/LIGHT SOURCE

Irrigation working

Suction working

Video system connected and turned on

INSUFFLATION

Camera head connected

Gas delivery checked

Screen lighted and image visualized

Automatic interruption of insulation tested by

blocking gas lead

Light source connected, turned on to standby mode

Intensity of light source set to minimum

INSTRUMENTS

SUCTION/IRRIGATION

Trocar inserted into cannula without resistance

Connected to main suction

Forceps open and close without resistance

Irrigation fluid checked, connected, and opened

Spring mechanism of Veress needle tested

Suction canisters connected and working

Insulation of active electrode instruments intact

19

LAPAROSCOPY/ENDOSCOPY CHECKLIST
Factors that impact current flow and electrosurgery generator performance include resistance, voltage and power:
Impedance/resistance is the opposition to the flow of the electrical current. Impedance is measured in ohms. In
the operating room one source of resistance or impedance is the patient. All patient tissues have different ohms of
resistance. Muscle and blood have the lowest resistance and easily allow for the flow of electrons.
Voltage is the force that will cause one amp to flow through one ohm of impedance. It is measured in volts. The
voltage in an electrosurgical generator provides the force that pushes electrons through the circuit. Electrosurgery
generator voltages can range from about 2,000 to as much as 10,000 volts of electricity, depending on the type of
generator and how the generator is used.
Power is the energy produced. The energy is measured in watts. A watt is the amount of energy produced by one
volt times one ampere of current. Electrosurgical generator power settings can be printed on an LED screen in watts,
or a percentage of the wattage is demonstrated on a numerical dial setting. Most electrosurgical generators have a
maximum coagulation output of 120 watts, and a maximum vaporization or cut output of 300 watts.
Current flow through a completed circuit, impedance/resistance and voltage are all components that must be present
in order for the electrosurgical generator to function. Knowing the role that each one plays during use of the
generator will help to insure safe use of the electrosurgery generator.
Figure 15. Electrosurgery tissue effects are named

ELECTROSURGERY WAVEFORMS
Researchers who experimented with radiofrequency current discovered that the output current could be manipulated
to produce different tissue effects. The variations in output are referred to as waveforms and were named by the
resulting tissue effect each produced (Figure 15). When the electrosurgery generator is connected to an oscilloscope
each waveform also has a distinctive pattern (Figure 16).46
Figure 16. Typical electrosurgery waveforms

20

Vaporization (Cut) The cutting current produced by an electrosurgical generator is a continuous waveform. Since
the delivery of current is continuous, much lower voltages are required to achieve tissue vaporization. To produce
a cutting effect, the active electrode tip is held just over the tissue. The current vaporizes cell walls and divides the
tissue. The Cut mode can also be used for coagulation of tissue through desiccation. In this application, the active
electrode is in direct contact with tissue.
Fulguration (Coag) Tissue fulguration is produced with the coagulation (Coag) mode on the generator. The
coagulation current is an interrupted or dampened waveform with a duty cycle on about 6 percent of the time. The
tissue is heated when the waveform spikes and then cools down during the 94 percent off time of the duty cycle,
thus producing coagulation of the cell. The proper method for achieving hemostasis when using coagulation is to
hold the active electrode tip slightly above the target tissue and let the spark from the tip do the work.
Blend The Blend mode on a generator is a function of the cut waveform, typically indicated by the yellow section on
most generators. When Blend is selected the cut current is modified to a dampened waveform that produces some
hemostasis. The voltage is increased and the off time of the generator is adjusted, depending on the blend setting
selected. There are several blend settings that provide different ratios of coagulation to cutting current. The ratios and
number of blend settings vary depending on the manufacturer of the generator.
Desiccation Electrosurgical desiccation can be produced using either the Cut or the Coagulation mode on the
generator. The difference is that the active electrode tip must contact the tissue in order to achieve desiccation. The
desired mode to achieve tissue desiccation through direct contact is the Cut waveform because of the lower
cut voltage.46
ELECTROSURGICAL TISSUE EFFECT VARIABLES
The electrosurgery waveform produces a specific effect in patient tissue.
Active electrode activation time determines the degree of tissue effect. Long activations produce wider and deeper
tissue damage. Activations that are not long enough will not produce the desired tissue effect.
The power setting alters tissue effect. Always use the lowest possible power setting to achieve the desired tissue
effect. That will vary with the patient.
The size of the active electrode influences the tissue effect. A large electrode requires higher power settings than a
small electrode. A clean electrode will conduct current more effectively than a dirty electrode, requiring lower
power settings.
ELECTROSURGICAL INNOVATIONS
The two primary types of electrosurgery technologies are bipolar and monopolar generators. Most electrosurgery
units will have both in the same generator, although some manufacturers produce bipolar-only generators. Bipolar
is considered safer because it has lower voltages, and the electricity never flows through the patient. A patient
return electrode is not required. A typical bipolar unit will produce up to 2,000 volts, depending on the manufacturer,
with a power output of 70 watts; however, bipolar does not produce enough power to handle the more demanding
types of surgical procedures.
Monopolar electrosurgery is the more powerful of the electrosurgical generators and the most flexible. Monopolar
units contain coagulation, vaporization and blend functions. The use of a patient return electrode is required to
complete the electrosurgical circuit. The coagulation (blue) output of the monopolar generator is high voltage up to
about 10,000 volts, depending on the generator, with power output of 120 watts. The vaporization (yellow) output,
21

depending on the generator will be 2,000 to 3,000 volts, and up to 300 watts. The blend function on any generator
uses the low voltage vaporization (yellow) output. The voltage is increased and the waveform interrupted, or
dampened. It is the interruption of the waveform that allows the tissue to cool down and sets up the coagulum.
Some generators will have only one blend setting; others may have more than one, with different ratios of the on-off
cycle of the waveform.
PATIENT RETURN ELECTRODES
There are two basic types of patient return electrodes: those with contact quality monitoring and those without it.
Contact quality monitoring was introduced in 1981 and represents a significant patient safety feature. Contact
quality monitoring or return electrode monitoring is a split pad system that allows the generator to continuously
monitor the quality of the contact between the pad and the patient. An interrogation circuit from the generator
constantly monitors impedance or resistance at the pad site. If a condition develops at the return electrode site
that could result in a patient injury, the quality contact monitoring system will inactivate the generator.47 For the
greatest assurance of patient safety, only patient return electrodes equipped with contact quality monitoring
should be used. Patient return electrodes that bypass this important safety feature should never be used.
Capacitive pads are an example of the type of patient return electrodes that bypass the monopolar electrosurgery
safety feature of contact quality monitoring. Large, reusable, capacitive-coupled return electrode systems should be
used according to manufacturers written instructions for safe operation in conjunction with a compatible
electrosurgery generator. When using a reusable, capacitive-coupled return electrode, personnel should ensure
adequate contact (i.e., weight-bearing area) with the patient and use minimal materials between the pad and
patients. Thick foam, gel pads and extra linen increase the distance between the patient and electrode and should
not be used. Some complex patient positioning also decrease contact between the skin and the electrode.
Distance and barrier between the patient and electrode increase impedance, which has the potential to result in
an alternate site injury. The reusable, capacitive-coupled return electrode does not activate the contact quality
monitoring system. The safest electrosurgery generators of today will only work when a contact quality monitoring
patient return electrode is used.
Personnel should verify that no metal (e.g., snap-on gowns) is in contact with the patients skin. Current can
concentrate at the site of metal contact. All metal jewelry should be removed when it is between the active and the
patient return electrode to minimize risk of thermal injury from direct current and manufacturer instructions for use
should be followed.48
TISSUE-DENSITY FEEDBACK ELECTROSURGERY
Computer capabilities increased throughout the 1990s and researchers were able to more precisely control the
output of monopolar generators. One control mechanism is referred to as tissue-density feedback. The technology
uses a computer- controlled, instant response system that senses tissue and provides consistent clinical effect
through all tissue types. The generator rapidly senses tissue resistance and automatically adjusts the output voltage
to maintain consistent tissue effect. This is called an adjustment mode or effect mode, which reduces the need to
adjust power settings during the surgical procedure. Generators equipped with this feature perform better at lower
voltages, which contributes to patient safety. This safety system, however, was only available in the Cut or
Vaporization mode when it was introduced in 1995, and Coagulation continued to be the primary mode used by
practitioners.45

22

VESSEL FUSION
Smaller and faster computers speeded up the pace of new developments in electrosurgery. Tissue response
technology was followed by tissue fusion in 1999. Tissue fusion is revolutionary in the world of electrosurgery. A
combination of pressure and bipolar-type energy fuses vessels and tissue bundles. The pressure and energy
changes the nature of the collagen between the forceps creating a permanent tissue weld. Thermal spread during
fusion is minimal. A 2009 study published by Song and colleagues: confirmed the efficacy of theenergy
platform in optimizing the power output and thus avoiding charring, fragmentation, and thermal spread. Thermal
spread during device activation was limited to the device tips, and histological studies confirmed tissue
damage within a limited safe range.49
The seal is strong, capable of withstanding three times normal systolic blood pressure. The vessel fusion system
reduces and/or eliminates the need for sutures, clips and staples. Until the introduction of vessel fusion, the surgeon
did not have the ability to seal vessels and tissue bundles up to (and including) 7 mm in size. Patient safety is greatly
increased since the bipolar-like design of the system does not require a patient return electrode.50
Figure 17. Closed-loop coagulation waveform compared to traditional coagulation
CLOSED-LOOP COAGULATION
A recent engineering innovation occurred in 2006 with the
introduction of tissue sensing capabilities on the
coagulation side of the generator with closed-loop control.
The technology builds on and improves the best tissue
sensing engineering developments of the last 25 years
beginning with quality contact monitoring. Closed-loop
coagulation is a computer-controlled system that senses
tissue resistance and adjusts output voltage, current and
generator power more than 3,000 times per second.
Closed-loop control provides consistent electrosurgical
effect across different tissue. This is the first time tissue
sensing has been available to the surgeon in the
Coagulation mode. The difference in traditional
Coagulation and closed-loop Coagulation is seen by
comparing waveform printouts (Figure 17). The tissue
sensing technology communicates information about the patients tissues back to the generator, which delivers
precisely the required amount of energy, making each surgical procedure custom and specific to each patient.50

ELECTROSURGERY SAFETY DURING MIS PROCEDURES

The number and type of minimally invasive procedures has continued to increase since the 1980s. Laparoscopic
cholecystectomy leads the way with an estimated 700,000 procedures performed yearly in the U.S.51 Minimally
invasive procedures have expanded beyond the operating room and outpatient surgery suites into radiology
departments, endoscopy suites and doctors offices. Electrosurgery is the most commonly used hemostatic device
because it is versatile and economical. MIS procedures require the vigilance of perioperative professionals to avoid
consequences of practices that could result in patient injury.41 Some of the concerns related to the endoscopic use of
electrosurgery are:
Direct coupling
Insulation failure
23

 Capacitive coupling
Residual heat
Endosurgical smoke plume
Figure 18. Four zones of laparoscopic injury

Each of these can cause adverse patient outcomes

that could result in injury. Perioperative practitioners
should be aware of how and when the conditions could
occur and take steps to reduce patient risk. To
determine the root cause of potential hazards, it is
useful to divide the active electrode and cannula
system into four zones (Figure 18):

1. ZONE 1 the small area at the tip of the active electrode; the only area in direct view of the surgeon.
2. ZONE 2 the area just beyond the active electrode tip to the distal end of the cannula; outside the surgeons view.
3. ZONE 3 the area of the active electrode covered by the cannula system; outside the view of the surgeon.
4. ZONE 4 the portion of the active electrode and cannula system; outside the patients body.
The greatest concern and possible patient hazard is the incidence of stray radiofrequency current in Zones 2 and 3,
which are outside the surgeons view. The stray current could be due to insulation failure, direct coupling or
capacitive coupling.52
Direct coupling occurs when the active electrode is activated in close proximity or in direct contact with other
conductive instruments within the abdominal cavity. Direct coupling can occur in Zones 1, 2 or 3. Should direct
coupling occur outside the field of the surgeons vision and the current is sufficiently concentrated, patient injury
could occur. The surgeon should only activate the active electrode when he/ she is confident that only the target
tissue will be affected, and that no other conductive instruments are close enough to be energized.
Insulation failure occurs when the insulating coating on the active electrode is compromised. This can happen
in multiple ways ranging from instrument damage due to rough handling to defects resulting from high voltage
electrosurgical current, such as Coagulation. Insulation damage can occur during instrument cleaning, but it can also
develop during surgery from repeated insertions and removals into the cannula system. High-voltage radiofrequency
current can be powerful enough to compromise intact active electrode insulation if the surgeon activates the active
electrode when it is not in close proximity to target tissue. This is referred to as open-circuit activation, which
increases generator voltage output.

24

Figure 19. Insulation failure

Figure 20. Capacitive coupling

Depending on the electrosurgery generator being used, coagulation

voltages can be as high as 8,000 to 10,000 volts of electricity. There
is also concern that some manufacturers may apply thinner insulation
on laparoscopic active electrodes, which will break down quicker than
more robust insulation. Reusable active electrodes have thicker
insulation than disposable active electrodes. Insulation failure that
occurs in Zones 2 or 3 could escape detection by the surgeon and
cause injury to adjacent body structures as the current is likely to be
delivered in a more concentrated manner (Figure 19).

Capacitive coupling is the most difficult concept to understand as

a potential endoscopic electrosurgery phenomenon. The definition
of a capacitor is two conductors separated by an insulator.
Laparoscopically, a capacitor is created by inserting an active
electrode surrounded by insulation into a conductive metal cannula
system (Figure 20). When the electrode is activated, capacitively
coupled electrical current can be induced to flow from the active
electrode, through intact insulation into the conductive metal
cannula. Should the cannula then come in contact with body
structures, the current could be discharged causing injury to the
tissue.53

When using an all-metal cannula any electrical energy stored in the cannula will tend to disperse into the patient
through the relatively large contact area between the cannula and the muscular abdominal wall. The large area of
contact serves to disperse the electrical energy, which is far less dangerous than areas of higher concentration. For
this reason, it is unwise to use plastic anchors to secure the cannula because the plastic anchor isolates the electrical
current from the abdominal wall and increases the likelihood that it could accumulate on the cannula and discharge
into body tissues. This is referred to as a hybrid system; the cannula is conductive, but the anchor is not. Injury from
capacitive coupling can be minimized by using conductive systems that allow energy to dissipate over a larger
surface area.52
Residual Heat Radiofrequency electrosurgery devices produce heat instantaneously to achieve quick hemostasis.
Once used, the active electrode tips do not cool down instantaneously. There is enough heat remaining in an active
electrode tip to produce a tissue effect just after the tip has been deactivated. Because of the residual heat,
surgeons must be aware of the position of a deactivated tip in relationship to the tissue or other metal devices
within the abdomen to avoid unintended tissue effect.
Best practices to reduce the risk of patient injuring during laparoscopic use of electrosurgery include:
1. Inspect insulation carefully
2. Be sure the active electrode tip is clean
3. Use the lowest possible power setting
4. Use the lower voltage Cut or Blend modes
5. Use brief intermittent activations versus prolonged activations of the active electrode
25

6. Do not activate the active electrode in an open-circuit method

7. Do not activate the active electrode in close proximity or in direct contact with metal or conductive objects in the
abdomen
8. Use bipolar whenever possible
9. In the active electrode operative channel select a conductive trocar cannula system to reduce electrical buildup on
the cannula
10. Avoid hybrid systems (metal cannula/plastic anchor)
ELECTROSURGERY TECHNOLOGIES
During laparoscopic minimally invasive electrosurgery it is critical to take advantage of improvements in technology.
Advancements in surgical devices and instrumentation often solve technical problems present in older models.
Technology improvements make surgery safer for patients and practitioners alike. There are many electrosurgery
technology improvements available today. Some of those include:
1. Tissue response generators because they reduce capacitive coupling in the low voltage Cut waveform.
2. Newer tissue sensing generators reduce capacitive coupling across all electrosurgery modes Cut,
Blend and Coagulation.
3. Vessel fusion electrosurgery generators offer the safety of bipolar with the ability to fuse vessels and tissue
bundles up to 7 mm in size. A study by Lamberton and associates concluded that vessel sealing:
..had the best overall performance with the highest burst pressure, fast sealing time, low thermal spread, and
low smoke production.54
Figure 21. Traditional bipolar
Practitioners must be able to distinguish between traditional bipolar
and vessel fusion. Traditional bipolar merely collapses the vessel
walls together (Figure 21). When using traditional bipolar a proximal
thrombus must still be present to impede blood flow. When using
vessel fusion and the specially designed forceps the energy delivery
changes the nature of the collagen creating a permanent seal
Figure 22).
Figure 22. Vessel fusion seal

It is not uncommon for perioperative professionals to

compare the vessel fusion device and ultrasonic devices.
They are two very different technologies. Ultrasonic devices
have gained popularity as dissection and hemostasis
tools. Ultrasonic dissection interacts with tissue by rapid
mechanical action. It does not produce soundwaves. It is
called ultrasonic because vibrations that occur are from
23-55 kHz and are above the range of human hearing.

Ultrasonic aspirators have hollow tips. With a hollow tip, only the tissue in direct contact with the outside edge of the
tip is impacted. Minimal thermal damage occurs because the heat generated by the tip is conducted away via the
26

irrigation fluid. The tip irrigation does produce a fine mist, but the surgical field is continuously cleared by the suction
at the tip.
Ultrasonic scalpels use solid tips or blades. When the tips vibrate, thermal heat is produced by the edge of the blade.
This technology allows surgeons to coagulate and divide tissue. The tip vibrates at a frequency of 55,000 times per
second, stimulating collagen molecules to denature and form a coagulum.55 The motion of the tip produces a vapor
which, because of lower tip temperatures, could carry infectious aerosols.56 Even though the ultrasonic scalpel tip
produces less heat than monopolar electrosurgery, heat is produced and there is thermal spread to adjacent
tissues.57 Surgeons must be aware of heat production and the potential transfer of the heat to unintended structures.
Both types of ultrasonic devices produce rapid mechanical motion with transducers within the hand pieces. Two
types of transducers are used piezoelectric crystals and magnetostrictive laminations. The piezoelectric ceramic
transducer is composed of a series of ceramic discs mounted together. When electrical energy is applied, the discs
change shape and cause the tip to vibrate. The ceramic discs are air cooled, so the hand piece is lighter. It is also
more fragile and may break if dropped.
The magnetostrictive transducer has 22-24 nickel alloy laminations that are layered together. The electrical energy
stimulates the laminations to lengthen and shorten creating tip excursion. The laminations do get hot, but the heat is
dissipated via an internal, closed, continuous cooling water system. Magnetostrictive transducers are capable of
higher amplitudes and are more durable.
Active electrode monitoring can minimize concerns about insulation failure and capacitive coupling. The system
monitors and shields against stray electrosurgical current.
ENDOSURGICAL SMOKE PLUME
Surgical smoke can represent a risk for patients during laparoscopic surgery. Not only can smoke reduce visibility
within the abdomen impeding procedure progress, the patient can experience other dangerous side effects. Weld
and colleagues studied smoke produced by various energy sources and determined that monopolar electrosurgery
produces particle distributions that degrade visibility the most, documenting the need to effectively evacuate and
filter smoke within the abdominal cavity.58
A study out of the University of Minnesota measured levels of carbon monoxide inside the peritoneal cavity during
laparoscopic cholecystectomy. The study found that carbon monoxide was present in the abdomen five minutes after
the use of electrosurgery at a median concentration of 345 parts per million (ppm). By the end of the procedure the
median concentration had risen to 475 ppm. This was in excess of the 35 ppm upper limit for a one-hour exposure
set by the Environmental Protection Agency.59
The danger of smoke inside the abdomen has also been documented at the Mercer University School of
Engineering by Ott and colleagues. They found as smoke is produced inside the abdomen it is absorbed through
the peritoneal membrane. The subsequent result in the patients bloodstream is an increase in the methemoglobin
and carboxyhemoglobin concentrations, which reduces the oxygen-carrying capacity of red blood cells.60 The
potential hazard for the patient is falsely elevated pulse oximeter readings. Pulse oximeter readings are
compromised in the presence of dyshemoglobinemia both carboxyhemoglobin and methemoglobin are
dsyshemoglobinemias and give a falsely elevated oxygen reading, which could result in unrecognized patient
hypoxia.61

27

An additional risk to the patient resulting from the production of surgical smoke inside the abdomen is port-site
metastases. If malignant tissue is cauterized and aerosolized inside the abdomen, the cancerous cells can seed at
another site. A study conducted by Fletcher and colleagues in Canada found that when electrosurgery is used on
melanoma cells they are released into the plume. They concluded that the cells were viable and could be grown in
culture. This could explain port metastases at sites that were not in direct contact with the tumor.62 Evacuation and
appropriate filtration of endosurgical smoke is of patient benefit and can be done with a variety of devices designed
specifically for use during laparoscopy.
CONCLUSIONS
Minimally invasive procedures have progressed in recent years and as the tools improve, so too will the procedures.
It is of utmost importance that procedures and systems are designed with patient safety in mind. Creating a culture of
safety is the responsibility of every surgical team member. The recommendations of Dr. John C. Clarke and others
who specialize in promoting safe systems can improve overall team function:
1. Ensure equipment works and that team members are trained to use it
2. Use of checklists can reduce errors
3. Standardize around best practice and equipment
4. Improve electrosurgical safety
5. Practice teamwork
6. Critique care and register problems
7. Continue to improve equipment41
Best practices during minimally invasive procedures should be evidence-based and supported by professional
standards. Organizations such as the Association of periOperative Registered Nurses (AORN) publish recommended
practices that when followed contribute to positive patient outcomes.48

28

GLOSSARY
Active Electrode

An electrosurgical instrument or accessory that concentrates the electric

(therapeutic) current at the surgical site.

Aerosols

Suspension of fine, solid or liquid particles in air as smoke, fog or mist.

Alternating Current

A flow of electrons that reverses direction at regular intervals.

Bipolar Electrosurgery

Electrosurgery in which current flows between two bipolar electrodes positioned

around tissue to create a surgical effect (usually desiccation). Current passes
from one electrode through the desired tissue to another electrode, thus
completing the circuit without entering any other part of the patients body.

Bloodborne Pathogens

Pathogenic microorganisms that are present in human blood and can cause
disease in humans. May include, but are not limited to HIV, HPV or hepatitis B.

Breathing Zone

The two-foot radius area around a persons nose and mouth from which air is
drawn in during inhalation.

Cautery

The use of heat or caustic substances to destroy tissue or coagulate blood.

Coagulation

The clotting of blood or destruction of tissue with no cutting effect,

electrosurgical fulguration and desiccation.

Current

The number of electrons moving past a given point per second, measured in
amperes.

Cut

A low-voltage, continuous waveform optimized for electrosurgical cutting.

Cutting

Use of the cut waveform to achieve an electrosurgical effect that results from
high-current density in the tissue causing cellular fluid to burst into steam and
disrupt the structure. Voltage is low and current flow is high.

Desiccation

The electrosurgical effect of tissue dehydration and protein denaturation caused

by direct contact between the electrosurgical electrode and tissue. Lower
current density/concentration than cutting.

Diathermy

The healing of body tissue generated by resistance to the flow of highfrequency electric current.

Direct Current

A flow of electrons in only one direction.

Electrosurgery

The passage of high-frequency electrical current through tissue to create a

desired clinical effect.

Endo-roticular

Laparoscopic instruments that rotate and articulate at various degrees to

facilitate endoscopic procedures.

ESU

Electrosurgical unit.

Exposure

The fact or condition of being exposed.

Fulguration

Using electrical arcs (sparks) to coagulate tissue. The sparks jump from the
electrode across an air gap to the tissue.

Generator

The machine that coverts low-frequency alternating current to high-frequency

electrosurgical current.

Hypoxia

Subnormal levels of oxygen in the air, blood or tissue.

Laparoscopy

A technique in which a lighted tube or scope is inserted into the abdomen.

29

Minimally invasive surgery (MIS)

Procedures that use small incisions or openings to gain access to the bodys
internal organs or tissues.

Monopolar Electrosurgery

A surgical procedure in which only the active electrode is in the surgical wound;
electrosurgery that directs current through the patients body and requires the
use of a patient return electrode.

Natural orifice translumenal

endoscopic surgery

Referred to as NOTES or NOSCAR surgery. An advanced experimental

technique referred to as scarless because access to the abdominal cavity is
through natural body orifices, such as the mouth, urethra and anus.

Occupational Exposure

Reasonably anticipated skin, eye, mucous membrane or parenteral contact with

blood or other potentially infectious materials that may occur as a result of the
performance of an employees duties.

Pad

A patient return electrode.

Patient Return Electrode

A conductive plate or pad (dispersive electrode) that recovers the therapeutic

current from the patient during electrosurgery, disperses it over a wide surface
area and returns it to the electrosurgical generator.

Personal Protective Equipment

Specialized clothing or equipment worn by an employee for protection.

Plume

Cellular debris created as a result of the mechanical division or heat-generated

pyrolysis of human tissue. Also called surgical smoke or smoke plume.

Power

The amount of heat energy produced per second, measured in watts.

Radiofrequency

Frequencies above 100 kHz; the high-frequency current used in electrosurgery.

Respirator

A specially fitted device worn over the mouth or nose or both to protect the
respiratory tract.

RF

Radiofrequency.

Single-incision laparoscopic
surgery (SILS)

An advanced minimally invasive technique in which the surgeon operates

primarily through a single entry point, such as the navel.

Standard Precautions

Work practice that treats all human blood and certain body fluids as if known to
be infectious for HIV, HPV and other bloodborne pathogens.

Smoke Evacuator

A high-flow vacuum source used to capture and filter surgical smoke aerosols
and gases generated during the use of heat-producing devices during surgical
and invasive procedures (e.g., lasers and electrosurgical units).

Surgical Smoke

Cellular debris created as a byproduct of the pyrolysis of human tissue. Also

called plume or smoke plume.

Tissue Response Technology

An electrosurgical generator technology that continuously measures the

impedance/resistance of the tissue in contact with the electrode and
automatically adjusts the output accordingly to achieve a consistent tissue
effect.

Tissue Fusion Technology

An electrosurgical technology that combines a modified form of electrosurgery

with a regulated optimal pressure delivery by instruments to fuse vessel walls
and create a permanent seal.

Transcolonic

Access to the abdominal cavity through the anus.

Transgastric

Access to the abdominal cavity through the mouth.

Transvaginal

Access to the abdominal cavity through the vagina.

Transvesical

Access to the abdominal cavity through the urethra and bladder.

30

Volt

The unit of measurement for voltage.

Voltage

The force that pushes electric current through resistance; electromotive force or
potential difference expressed in volts.

Watt

The unit of measurement for power.

Waveform

A graphic depiction of electrical activity that can show how voltage varies over
time.

31

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Post-Test and Evaluation

35