burns it. That's a direct application injury."
The most common risk is associated with dam-
aged or incorrectly handled electrosurgery instru-
ments, which can burn through a patient's bowel to
cause leaks, sepsis, ICU stays and even death. These
burns can occur when insulation in the instrument's
shaft has a breach — because of mishandling, or sim-
ply the result of the instrument being reprocessed
many times over — the surgeon doesn't know about.
These breaches can spread stray energy to areas of
the patient the surgeon isn't even looking at.
"We call them perforations and leaks, but we for-
get they were probably caused by our energy set-
tings, the energy we were using or just how we
manipulate our instruments," says Dr. Jones.
As a result, Dr. Jones says electrosurgery instru-
ments should at the very least be visually inspected
before every case. Surgeons and other staff mem-
bers will usually spot a large hole or crack on an
instrument, but the dangerous thing about electro-
surgery is that the smaller the hole, the more pow-
erful the stray energy streams. "If you see a big
hole, you say, 'Well, that instrument is broken, we
can't use it,'" says Dr. Jones. "It's really the holes
you can't see that can cause more damage."
To find these tough-to-see cracks and evaluate
the insulation integrity of electrosurgery instru-
ments, use a porosity detector. "These determine if
energy leaks across the insulation of a laparoscopic
instrument," says Dr. Robinson. "If energy travels
across the insulation to the porosity detector's ring,
it signals a tone which represents the presence of
an insulation defect."
But porosity detectors, which Dr. Robinson esti-
mates about half of hospitals use, aren't foolproof
and require close attention. When his team visited
four large medical centers around Denver, he
found 19% of their laparoscopic instrument sets
had one or more insulation defects. Dr. Robinson
says two of the centers used porosity detectors but
didn't perform any better on the inspections than
the ones that didn't.
Insulation can usually be repaired, and Dr.
Robinson says vendors are capable of improving its
durability using different thicknesses and laminates.
He notes to pay particular attention to L-hooks and
spatulas that deliver energy. "You need to be look-
ing disproportionately at the instruments you're
passing energy through before every case. Routine
inspection of laparoscopic insulation is simple to
do, but I think most surgeons aren't aware insula-
tion defects are an issue."
Stray energy is the most common safety problem
associated with surgical energy devices, but not the
3 4 • S U P P L E M E N T
T O O U T P A T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 2 0
RARE BUT CATASTROPHIC While surgical fires are exceedingly rare, they could happen at any time, and can greatly injure patients like this one.
