Electrosurgery Paper

7/24/2019 Electrosurgery Paper

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Electrosurgery Part II. Technology, applications, and safety of electrosurgical devices

Arash Taheri, MD,a Parisa Mansoori, MD,b L aura F. Sandoval, DO,a Steven R . Feldman, MD, PhD,a,b,c

Daniel Pearce, MD,a and Phillip M. Williford, MDa

Winston-Salem, North Carolina

CME INSTRUCTIONS

Thefollowing isa journal-based CMEactivitypresented bythe AmericanAcademy of

Dermatology and is made up of four phases:

1. Reading of the CME Information (delineated below)

2. Reading of the Source Article

3. Achievement of a 70% or higher on the online Case-based Post Test

4. Completion of the Journal CME Evaluation

CME INFORMATION AND DISCLOSURES

Statement of Need:

The American Academy of Dermatology bases its CME activities on the Academy’s

core curriculum, identified professional practice gaps, the educational needs which

underlie these gaps, and emerging clinical research findings. Learners should reflectupon clinical and scientific information presented in the article and determine the

need for further study.

Target Audience:

Dermatologists and others involved in the delivery of dermatologic care.

Accreditation

The American Academy of Dermatology is accredited by the Accreditation Council

for Continuing Medical Education to provide continuing medical education for

physicians.

AMA PRA Credit Designation

The American Academy of Dermatology designates this journal-based CME activity

for a maximum of 1 AMA PRA Category 1 Credits . Physicians should claim only the

credit commensurate with the extent of their participation in the activity.

AAD Recognized Credit

This journal-based CME activity is recognized by the American Academy of

Dermatology for 1 AAD Credit and may be used toward the American Academy of

Dermatology’s Continuing Medical Education Award.

Disclaimer:

The American Academy of Dermatology is not responsible for statements made

by the author(s). Statements or opinions expressed in this activity reflect the

views of the author(s) and do not reflect the official policy of the America n

Academy of Dermatolog y. The informati on provided in this CME activity is for

continuing education purposes only and is not meant to substitute for the

independent medical judgment of a healthcare provider relative to the

diagnostic, management and treatment options of a specific patient’s medical

condition.

Disclosures

Editors

The editors involved with this CME activity and all content validation/peer reviewers

of this journal-based CME activity have reported no relevant financial relationships

with commercial interest(s).

Authors

Dr Feldman is a consultant and speaker, has received grants, or has stock options in

Abbott Labs, Amgen, Anacor Pharmaceuticals, Inc, Astellas, Caremark, Causa

Research, Celgene, Centocor Ortho Biotech Inc, Coria Laboratories, Dermatology

Foundation, Doak, Galderma, Gerson Lehrman Group, Hanall Pharmaceutical Co

Ltd, Informa Healthcare, Kikaku, Leo Pharma Inc, Medical Quality Enhancement

Corporation, MedicisPharmaceutical Corporation, Medscape, Merck& Co, Inc, Merz

Pharmaceuticals, Novan, Novartis Pharmaceuticals Corporation, Peplin Inc, Pfizer

Inc, Pharmaderm, Photomedex, Reader’s Digest, Sanofi-Aventis, SkinMedica, Inc,

Stiefel/GSK, Suncare Research, Taro, US Department of Justice, and Xlibris. Drs

Taheri, Mansoori, Sandoval, Williford, and Pearce have no conflicts of interest to

declare.

Planners

The planners involved withthis journal-based CMEactivity havereportedno relevant

financial relationships with commercial interest(s). The editorial and education staff

involved with this journal-based CME activity have reported no relevant financial

relationships with commercial interest(s).

Resolution of Conflicts of Interest

In accordance with the ACCME Standards for Commercial Support of CME, the

American Academy of Dermatology has implemented mechanisms, prior to the

planning and implementation of this Journal-based CME activity, to identify and

mitigate conflicts of interest for all individuals in a position to control the content of

this Journal-based CME activity.

Learning objectives

After completing this learning activity, participants should be able to compare and

contrast electrosurgery with other surgical methods; describe the different technol-

ogies used in different electrosurgical units for controlling the output power, tissue

effect, and patient and operator safety; and delineate the contraindications and

limitations of electrosurgery.

Date of release: April 2014

Expiration date: April 2017

2013 by the American Academy of Dermatology, Inc.

http://dx.doi.org/10.1016/j.jaad.2013.09.055

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607.e1


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Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminalmodes, with the primary difference between these modes being their safety profiles. A monopolarelectrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is nodispersive electrode connected to the patient’s body and instead the earth acts as the return electrode.Biterminal mode uses a dispersive electrode connected to the patient’s body, has a higher maximum

power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have differenttechnologies for controlling the output power and for providing safety. A thorough understanding of thesetechnologies helps with a better selection of the appropriate surgical generator and modes. ( J Am AcadDermatol 2014;70:607.e1-12.)

Key words: bipolar; biterminal; electrosurgery; high frequency; monopolar; monoterminal; power;radiofrequency.

INTRODUCTIONThe term electrosurgery (radiofrequency surgery)

refers to the passage of high-frequency electrical

current through the tissue in order to achieve aspecific surgical effect. Previous generations of electrosurgical generators used a spark gap and/ora vacuum tube to make the desired high-frequency electrosurgical currents. However, modern units usetransistors to make high-frequency currents with a variety of waveforms. The shape of an electrosur-gical current waveform does not have any directeffect on the final tissue results of the current. Theonly variables that determine the final tissue effectsof a current are the rate and depth at which heat isproduced.1-3 In electrosection, the ratio of peak to

average voltage of a current affects the depth of coagulation on the incision walls; with higher-peaked voltages there is deeper coagulation.2,4-6

Electrosurgical currents can be delivered to thetissue in monopolar or bipolar and monoterminalor biterminal modes, with the primary differencebetween these modes being their safety profiles.Different electrosurgical generators may havedifferent current waveforms, different technologiesfor the control of output power, and different safety technologies. A better understanding of thesetechnologies and their applications and an aware-

ness of potential complications of electrosurgery

helps to improve efficacy and safety of surgicalprocedures.

BIPOLAR VERSUS MONOPOLAR ELECTROSURGERY Key pointsd In monopolar electrosurgery, there is an

active electrode and a dispersive electrode, while in bipolar mode there are 2 activeelectrodes

d In bipolar mode, electrical current passesonly through the tissue grasped between thetips of the bipolar forceps

In electrosurgery, the prefixes mono- and bi-

polar refer to the number of active electrodes. Inmonopolar electrosurgery, an active electrodecarries current to the tissue (Fig 1). Current thenspreads through the body to be collected andreturned to the electrosurgery unit by a large-surface dispersive electrode. The dispersive elec-trode is also known as the return, neutral, passive, orpatient plate electrode.

Two types of dispersive electrodes are in commonuse today: conductive and capacitive. With theconductive type, a metallic foil or conductive poly-mer is attached to the patient’s skin. With the

capacitive type, the conductive foil has an insulating

From the Center for Dermatology Research, Departments of

Dermatology,a Pathology,b and Public Health Sciences,c Wake

Forest School of Medicine.

The Center for Dermatology Research is supported by an unre-

stricted educational grant from Galderma Laboratories, L.P.

Dr Feldman is a consultant and speaker, has received grants, or

has stock options in Abbott Labs, Amgen, Anacor Pharmaceu-

ticals, Inc, Astellas, Caremark, Causa Research, Celgene, Cen-

tocor Ortho Biotech Inc, Coria Laboratories, Dermatology

Foundation, Doak, Galderma, Gerson Lehrman Group, Hanall

Pharmaceutical Co Ltd, Informa Healthcare, Kikaku, Leo Pharma

Inc, Medical Quality Enhancement Corporation, Medicis

Pharmaceutical Corporation, Medscape, Merck & Co, Inc, Merz

Pharmaceuticals, Novan, Novartis Pharmaceuticals Corporation,

Peplin Inc, Pfizer Inc, Pharmaderm, Photomedex, Reader’s

Digest, Sanofi-Aventis, SkinMedica, Inc, Stiefel/GSK, Suncare

Research, Taro, US Department of Justice, and Xlibris. Drs

Taheri, Mansoori, Sandoval, Williford, and Pearce have no

conflicts of interest to declare.

Reprint requests: Arash Taheri, MD, Department of Dermatology,

Wake Forest School of Medicine, 4618 Country Club Rd,

Winston-Salem, NC 27104. E-mail: [email protected].

0190-9622/$36.00

J A M A CAD DERMATOL

A PRIL 2014607.e2 Taheri et al

mailto:[email protected]

mailto:[email protected]



layer on the outside that prevents direct contact withthe patient’s skin. The insulated electrode and thepatient’s skin form a capacitor that passes a capac-itive current.7 Both types of dispersive electrodes

have specific advantages and disadvantages.Electrode failures and subsequent patient injury can be attributed mostly to improper application,electrode dislodgment, and electrode defects ratherthan to electrode design.7

Monopolar electrosurgery should be performed with caution on an extremity such as a finger or penisbecause there is limited cross-sectional area for thereturn current to spread across. Theoretically, thismay result in a higher current density and someheating throughout the volume of the extremity,leading to unintentional thermal damage if a high

power is used for a relatively long activation time.

Unlike monopolar electrosurgery, where the pa-tient’s body forms a major part of the electricalcircuit, in bipolar electrosurgery, only the tissuegrasped between the tips of a bipolar forceps isincluded in the electrical circuit (Fig 2). These bipolarforceps act as 2 active electrodes.8,9

The bipolar mode is used primarily for thecoagulation of pedunculated benign tumors or he-mostasis of blood vessels. It potentially causes lessdamage to surrounding tissue and reduces risk of distant site burn to the patient compared to monop-olar electrosurgery.8,9

BITERMINAL VERSUS MONOTERMINAL ELECTROSURGERY Key pointsd In monoterminal electrosurgery, no dispersive

electrode is connected to thepatient’s body andthe earth acts as the return electrode. Mono-terminal mode can only be performed usingearth-referenced electrosurgical units, which have a return electrode connected to earth

d In isolated electrosurgical units, the return electrode is not connected to earth. There-fore, there will be no current flow and nothermal effect unless the dispersive elec-trode is attached to the patient’s body (biter-minal mode)

d Biterminal mode has a higher maximum power and theoretically may be safer than monoterminal mode in certain settings

d Coagulation, fulguration, and electrosection can be performed in either biterminal or monoterminal mode; however, biterminal mode is the preferred mode for electrosection

d Inadequate contact of the dispersive elec-trode with the patient’s body may result in a burn at this site. A contact quality moni-toring system can disable the power if thedispersive electrode is not in adequate con-tact with patient’s skin

The prefixes mono- and biterminal refer to thenumber of electrodes that are in contact with thepatient’s body (Figs 1 and 3). Bipolar electrosurgery is always biterminal; monopolar electrosurgery could be monoterminal or biterminal.

In so-called ‘‘earth-referenced’’ electrosurgicalunits, the return electrode is connected to earth(usually through the power supply cable), andtherefore the earth and all conductive objects aroundthe patient’s body can act as a capacitive dispersiveelectrode (Fig 3). Electrosurgery can be performedusing these units regardless of whether a dispersive

electrode is attached to the patient. Performing

Fig 2. A bipolar electrosurgery circuit. The electric currentflows from 1 forceps tine through the tissue placedbetween the tips to the other forceps tine, and then backto the electrosurgical generator. The bipolar mode is saferthan the monopolar mode with regard to the potentialextent of injury and possibility of distant site burns.

Fig 1. A monopolar, biterminal electrosurgery circuit.High-frequency electric current flows from the activeelectrode, through the patient’s body, and then to the return(dispersive) electrode. Heat generation is practically limitedto the area of high current density, meaning adjacent to theactive electrode. The arrows indicate the direction of theelectricity in 1 phase of current. In the next phase, thecurrent will flow in the opposite direction. (Reprinted with

permission from Taheri A, Mansoori P, Sandoval LF, Feld-man SR, Pearce D, Williford PM. Electrosurgery. PartI: Basicsand principles. J Am Acad Dermatol 2014;70:591-604.)


V OLUME 70, NUMBER 4Taheri et al 607.e3



monopolar electrosurgery without using a dispersive

electrode is called monoterminal or single-electrodeelectrosurgery (Fig 3). Because the maximum outputpower is far lower when the dispersive electrode isnot used, only relatively low-powered electrosur-gery can be performed in monoterminal mode.5

Monoterminal mode reduces the power but not thepeak voltage; therefore, a pure cut cannot beperformed using this mode. Biterminal is thepreferred mode for electrosection.4-6

During monoterminal electrosurgery with anearth-referenced unit, if an electrically conductiveobject—such as a metal table, electrocardiogram

electrode, or surgical staff—comes into contact with the patient’s body, some current may selectthe object as a low-resistance return pathway to theground. If the contact area is small, current concen-tration at this point may result in a burn at this site(Table I). For this reason, monoterminal mode canbe safely used only on conscious patients who would be aware of such complications, and only on carefully insulated tables with no exposedmetallic parts near the patient’s body. Using a goodreturn electrode ensures that current returns to thepath of least resistance and does not take any

alternative path through operators or environmentalobjects. Therefore, use of the return electrode,although not technically necessary for operation of an earth-referenced unit, will enhance the powerand potentially safety of the electrosurgical appa-ratus. Earth referenced electrosurgery units are notcommonly used in operating rooms today. However,many surgeons still prefer them for outpatient,office-based minor surgical procedures, avoidingthe additional time and cost associated with the useof a dispersive electrode.

The type of electrosurgical unit commonly used in

operating rooms today is known as floating or

isolated. In contrast to the earth-referenced units,the dispersive electrode is isolated from earth. Thismeans that the current can return to the electrosur-gery unit only via the dispersive electrode. Anisolated generator will not work unless the disper-sive electrode is attached to the patient—a safety feature of these units.3 During activation, if thepatient’s body comes in contact with an environ-mental object, very low or no current passes throughthe object and the risk of a burn is low. The surgeoncan touch an active electrode and not be burned solong as he or she does not touch the patient ordispersive electrode with the other hand.Unfortunately, the isolation of these units from earthor environmental objects is never complete, becausea high-frequency current is not always completely confined by insulation. Current leakage does occurby forming a capacitor between electrode cables and

the floor of operating room or conductive environ-mental objects.3,4 There is still therefore a potentialfor distant site burns.

Although a good dispersive electrode reduces therisk of distant site burns, inadequate contact of thedispersive electrode with the patient’s body may result in a smaller contact area and current concen-tration at this point that may lead to a burn at thissite.1,3,18,19 Most modern electrosurgery units includea contact quality monitor for the dispersive electrodethat measures the quality of the contact between thepatient’s skin and dispersive electrode and also

between the electrode and the generator (Fig 4). If the dispersive electrode becomes dislodged or thereis a high resistance between the dispersive electrodeand the patient’s skin, the unit will sound an alarmand the power will be disabled. Theoretically, thistechnology reduces the risk of burns at the dispersiveelectrode, but there is no clinical evidence support-ing this idea.20 There also have not been any clinicaltrials comparing the rate of side effects between anearth-referenced monoterminal device and a biter-minal isolated device with or without a contactquality monitor.

The best location for placement of the dispersiveelectrode is a muscular site well supplied with blood vessels and adjacent to the surgical field. If there isany metal in patient’s body, the dispersive padshould be placed between the metal and the surgicalsite to prevent current from passing selectively through the metal.

CONTROLLING THE OUTPUT POWER OFELECTROSURGICAL DEVICESKey pointsd In constant voltage electrosurgical genera-

tors, voltage is the output variable that can

Fig 3. Monoterminal electrosurgery using an earth-referenced unit. The return electrode is connected to theearth. Therefore, the earth and all conductive objectsaround the patient’s body can act as a capacitive returnelectrode. The current passes through the earth and comesback to the generator.





be adjusted on the display panel. The power deployed in tissue is not only dependent on this voltage but also on the resistance in theelectrodeetissue contact area

d When working with a constant voltage, thequality of surgical effect is dependent on thetype of tissue and its electrical resistance, but not on the size of the electrode used

d In some devices, an automatic power adjust-ment mode provides a constant output power regardless of tissue resistance. In thismode, the quality of surgical effect is depen-dent on the size of the electrode used, but not on the type of tissue or its electrical resistance, as long as the power remainsconstant

There are 2 types of electrosurgical generatorsregarding the output-power control system: constant voltage and automatic power adjustment (Fig 5).3,7

Most conventional electrosurgical generators use aconstant voltage output system. In these generators, voltage is the output variable that can be adjusted onthe display panel. The dial setting for control of voltage in these units is usually calibrated usingnumbers from 1 to 10. These generators deliver lesspower to the tissue with higher resistance comparedto the tissue with lower resistance, using the same voltage setting (W = V 2/R; where W = power, V =

voltage, and R = resistance).

3,4,7

Therefore, working

on a dried hyperkeratotic epidermis may need ahigher voltage setting than when working on thedermis to achieve the same effect.

More recent constant voltage generators aresupplemented with an arbitrary dial setting with adisplay calibrated in watts. The indicated powerrefers to the maximum power that can be deliveredto the nominal resistance in the circuit (Fig 5). A resistance in the circuit that is higher or lower thanthe nominal resistance leads to an output powerlower than maximum power. Therefore, the power

actually delivered to the tissue is usually lower thanthis maximum. This type of display has the advan-tage of allowing a limited degree of comparison to bemade between different units or modes.

In electrosurgical generators with an automaticpower adjustment system (tissue-responsive ortissue-adaptive generators), power is the output variable that can be adjusted on the display panel, with the dial setting calibrated in watts. Thesegenerators can provide a constant power in a widerange of resistances in the circuit (Fig 5, C ). They canprovide the same surgical effect in different tissues

with different electrical resistances at the same

Fig 4. An electrosurgery unit with a contact quality monitor for the dispersive electrode. Contact quality is

monitored by splitting the return electrode into 2 parts andmeasuring the resistance between the parts. If both partsare in good contact with the skin, the resistance betweenthem will be low. If one or both parts are not in goodcontact with skin, the resistance will be high and themonitoring system will disable the power.

0

10

20

30

40

50

60

70

80

0 200 400 600 800 1000 1200 1400 1600 1800 2000

Res i s tanc e in Ohms

s t t a W

n i

r e w o P

B

A

C

→←Large electrodes Small electrodes

Fig 5. Power-resistance curves of an electrosurgical unit. A , Constant-voltage mode with a nominal load of 200ohms, when the maximum power is set at 30 watts. B, Thesame mode when the maximum power is set at 70 watts.

Increasing the size of the electrode leads to lowerresistance and higher power. Therefore, current density at the electrodeetissue interface and quality of tissue effect(except for the depth of effect) will not change signifi-cantly with changing the size of electrode. However, a very large electrodeetissue contact area with \200 ohmsresistance leads to a reduction in power and possibly aninability to achieve the desired surgical effect. C, Auto-matic power adjustment mode provides a constant outputpower between 200 and 1400 ohms. These units do notautomatically adjust the power according to the electrodesize.





power setting.3,7 However, if the electrodeetissuecontact area is increased, power is not increased inproportion with the contact area. Therefore, thepower setting should be increased manually toprovide enough power to warm up a larger areaand create the same surgical effect. Both technolo-gies have specific advantages and disadvantages.The choice of one technology may depend on thesurgeon’s preferences and the price of the unit(Table II).

CLINICAL CONSIDERATIONS INELECTROSURGERY Key pointsd Electrosection results in the histologic

distortion of surgical margins. For speci-mens requiring histopathologic analysis,

scalpel surgery is preferredd Hemostasis of a bleeding vessel can be per-

formed by clamping the vessel and passing a relatively low-power continuous current (cutting mode) through the clamp. Current flow should be stopped when a poppingsound is heard or spark is seen

d For hemostasis of an oozing surface, con-tact coagulation is the preferred mode.Fulguration usually is less efficient becauseit results in fragmentation of the coagulatedlayer

d

Penetrating proximally insulated electrosur-gical electrodes can be used for coagulation of subcutaneous targets, such as tumors or varicose veins

d Fractional radiofrequency skin rejuvenation devices which use penetrating electrodes are used for fractional heating of the dermis andcollagen remolding while preserving theepidermis

Electrosection versus scalpel surgery Electrosection results in more collateral tissue

damage compared to scalpel surgery, creating

some histologic distortion of surgical margins.Thermal damage causes carbonization at the exci-sion margin, vessel thrombosis, and collagen dena-turation.22,23 Cellular changes may include vacuolardegeneration, shrunken and shriveled cell outlines with condensation and elongation of the nuclei, orfusion of cells into a structureless homogeneousmass with a hyalinized appearance.24 In frozensections, normal structures may mimic tumors, suchas basal cell carcinaoma.25 It also may make itimpossible to distinguish squamous and melanocyticneoplasms. For specimens requiring histopathologic

analysis—especially during the excision of tumors T a b l e I I .

T h e c h o i c e o f t h e e l e c t r o s u r g i c a l u n i t b a s e d o n t h e s u r g i c a l

s e t t i n g

S e t t i n g a n d i n d i c a t i o n s

C o m m o n l y u s e d d e v i c e s

A d v a n t a g e s

D i s a d v a n t a g e s

M a j o r s u r g e r i e s a n d e n d o s c o p i c

( u r o l o g i c ) p r o c e d u r e s i n o p e r a t i n g

r o o m s

H i g h p o w e r ( u s u a l l y 2 0 0

- 4 0 0 w a t t s ) ,

i s o l a t e d g e n e r a t o r s

, w i t h c o n s t a n t -

v o l t a g e o r a u t o m a t i c p o w e r

a d j u s t m e n t m o d e

M o r e a v a i l a b l e m o d e s a n d f l e x i b i l i t i e s

E x p e n s i v e ; s o m e d e v i c e

s m a y l a c k a n

a b i l i t y t o p r o v i d e a v

e r y l o w

o u t p u t

p o w e r f o r v e r y s u p e r

f i c i a l m i n o r

d e s t r u c t i o n s

M i n o r d e r m a t o l o g i c p r o c e d u r e s o n

c o n s c i o u s p a t i e n t s

L o w

p o w e r ( u s u a l l y a r o u n d 4 0

- 1 0

0

w a t t s ) , e a r t h - r e

f e r e n c e d u n i t s , w

i t h

c o n s t a n t - v o l t a g e o u t p u t m o d e

M o r e c o s t - e f f e c t i v e a n d c o n v e n i e n t t o

u s e

L o w e r s a f e t y p r o f i l e ; m a y h a v e f e w e r

a v a i l a b l e m o d e s a n d

f l e x i b i l i t i e s ; s o m e

h a v e o n l y 1 i n t e r r u p t e d c u r r e n t f o r

c o a g u l a t i o n a n d f u l g

u r a t i o n

M o s t d e r m a t o l o g i c p r o c e d u r e s

L o w

p o w e r ( u s u a l l y a r o u n d 7 0

- 2 0

0

w a t t s ) , i s o l a t e d u n i t s , w i t h c o n s t a n t -

v o l t a g e o u t p u t m o d e

S a f e s t p r o f i l e

M a y b e l e s s c o n v e n i e n t t o u s e t h a n

e a r t h - r e

f e r e n c e d u n i t s

N o t e :

S o m e e l e c t r o s u r g i c a l u n i t s s h o w a n i n d e x n a m e d ‘ ‘ c r e s t f a c t o r ’ ’ t h a t i s t h e r a t i o o f

p e a k v o l t a g e t o a v e r a g e v o l t a g e o f t h e i r c o n t i n u o u s c u t t i n g c u r r e n t . G e n e r a t o r s w i t h l o w e r c r e s t f a c t o r s a r e

a b l e t o p r o v i d e c l e a n e r c u t s w i t h l e s s c o l l a t e r a l d a m a g e a n d l e s s h e m o s t a s i s i n p u r e c u t t i n g m o d e

. M o s t a v a i l a b l e e l e c t r o s u r g i c a l u n i t s i n t h e m a r k e t h a v e a n o u t p u t f r e q u e n c y o

f 0

. 3 - 5

M H z

. T h e r e i s

n o s t r o n g e v i d e n c e s h o w i n g a n y r e l a t i o n b e t w e e n f r e q u e n c y o f e l e c t r o s u r g i c a l c u r r e n t s a n d t h e i r e f f e c t s o n t i s s u e

. A f e w s t u d i e s a r e

a v a i l a b l e b u t c a n b e c r i t i c i z e d b e c a u s e o f p o

o r s t u d y m e t h o d s .

2 1





that require the margins to be assessed—scalpelsurgery is preferred. Electrosection in pure cuttingmode may cause less thermal damage artifact thanusing a blend cut.26,27

Electrosection often serves as an alternative toscalpel surgery; however, there is conflicting evidencein studies comparing these modalities with respect tooutcomes, such as postoperative pain, infection, wound healing, and scar formation. While many studiessupport better outcomes using scalpelsurger y,there is also literature favoring electrosection.26,28-30 A general concept is to avoid electrosection for cuttingskin when a primary closure is planned.

Electrosection versus CO2 laser surgery Like electrosection, CO2 laser can provide coag-

ulation of the incision walls and hemostasis. Bothtechniques, especially electrosection, are operator-

dependent and cannot be standardized. Therefore, itis not easy to compare these methods in clinicalsettings. There is conflicting evidence in studiescomparing the depth of collateral injury and finalresults of surgery using these modalities. While somestudies show more collateral coagulation using aCO2 laser, others report the opposite results.27,29-36

Compared to CO2 lasers, electrosurgery generally isless expensive, does not require eye protection, andis more accessible.

Electrocoagulation for achieving hemostasis

Hemostasis of a bleeding vessel can be performedby clamping the vessel and passing a monopolarcurrent through the clamp or using a bipolar elec-trode.37 Care should be taken to prevent spark for-mation andtissuefragmentation or charring at the endof coagulation. A relatively low-power continuouscurrent (cuttingmode) is thepreferred current in orderto prevent large spark formation. A popping soundmay be heard or a spark may be seen at the time of desiccation, and at this time current flow should bestopped.5 For hemostasis of an oozing surface, contactcoagulation is thepreferredmode. Fulguration usually

is less efficient because it results in fragmentation of the coagulated layer. Wiping of the coagulated areashould be avoided if possible, because it can causedisruption of the coagulated layer and result inmore bleeding. One should remember that coagula-tion of a surface for achieving hemostasis results indamage to the surface that may adversely affectpostoperative and aesthetic outcomes.4-6,38

To optimize hemostasis, the operative fieldshould be dry, because blood diffuses the currentflowing from the electrode. A dry operative field isalso essential for cutting and coagulation. Proximally

insulated bipolar electrodes can help with more

effective hemostasis in wet environments.Electrocautery, as opposed to high-frequency elec-trosurgery, may function in wet environments,although not as effectively as in dry fields.

Electrosurgery for hair removal Hair removal can be performed using a needle

electrode that enters the hair follicle and applies adirect electrical current (galvanic current). Theresulting chemical reaction (electrolysis) aroundthe electrode destroys the hair follicle. The processis relatively slow and time-consuming. Using anelectrosurgical alternating current, the follicle canbe destroyed using thermal damage (thermolysis).This process is faster than electrolysis; however,there is a greater risk of damage to the dermis aroundthe hair follicle and scar formation.39-41

Electrosurgery in the treatment of malignant skin tumors

Curettage and electrodesiccation has been usedsuccessfully in the treatment of many differentbenign and malignant skin tumors.42-44 For treatmentof cancers, this procedure is usually repeated $ 2times in an attempt to remove any small tumorextensions. The procedure may be less morbid,faster, and more cost-effective to perform thanexcision and repair in certain cases with certaintumors. A great advantage of curettage over surgical

excision arises from the ability of a semisharp curetteto differentiate and remove friable abnormal tissuefrom the normal surrounding tissue with minimalsacrifice of normal skin.44 However, this method isoperator-dependent and cannot be easily standard-ized because the depth of coagulation achieved isdependent on many factors, such as size of theelectrode and power used.45 Treatment of basal cellcarcinoma with curettage and electrodesiccationresults in cure rates ranging from 88% to 99%depending on the location and size of tumor andthe surgical method used. Studies that reported the

highest cure rates destroyed a wider peripheralmargin around the initial curettage, ranging from 2to 8 mm.6,46-50

Electrosurgery in the treatment of benign superficial skin tumors

Upon a mild thermal coagulation, the epidermisand papillary dermis turns to a soft material (lique-faction) that can be easily wiped off of the surface of the skin surface. However, the reticular dermis doesnot respond in the same way; instead, it maintains itsdurability and remains solid and cannot be wiped off

after coagulation or desiccation.

51

This phenomenon





helps the surgeon to distinguish the papillary fromthe reticular dermis.

For the treatment of superficial epidermal over-growths, such as seborrheic keratoses or plane warts,a very superficial coagulation using a fine-tip elec-trode or electrofulguration with a low output powercan be performed. The area may be wiped off aftercoagulation to see if any epidermal tissue remains inplace that requires a second pass of superficialcoagulation.

To achieve a very superficial coagulation using afine-tip electrode, a very low power should bechosen. Spark formation that occurs at the time of desiccation indicates the occurrence of deeper injury and should be avoided by reducing voltage, power,and/or contact time.

Penetrating insulated electrosurgical electrode

for the destruction of subcutaneous targetsElectrocoagulation of a variety of tumors in inter-

nal organs has been performed using penetrating,proximally insulated electrodes.52,53 Recently, thisapproach has been used for the treatment of thedeeper component of infantile hemangioma of theskin.54

Endovascular thermal ablation of varicose veinsusing a long, flexible electrosurgical electrode withinsulation on the proximal parts is used as a lessinvasive alternative to traditional surgery.55,56

Compared to surgery, this approach provides the

same efficacy with less postoperati ve morbidity and a lower rate of adverse events.57 Proximally insulated needles can also be used for treatingtelangiectasias.58

Penetrating insulated electrodes have also beenused for ablation or denervation of corrugator super-cilii muscle for treatment of hyperdynamic verticalglabellar furrows.59-61

Electrosurgical currents in aesthetic medicineand skin rejuvenation

High-frequency electrical currents (radiofrequency

technology) has been used for the treatment of cellulite, acne scar, inflammatory acne, skin resurfac-ing, and nonablative tightening of skin to improvelaxity and reduce wrinkles.62-70 Most of the devicesmarketed for these purposes use $ 1 electrodes todeliver the current to the skin surface (epidermis).However, the manner in which some of these devices work is not completely understood.71 For skin tight-ening, the most acceptable explanation is that theheating of dermal tissue by high-frequency (radio-frequency) currents results in remodeling of collagenfibers and subsequent neocollagenesis.66,72 Most of

these methods have struggled to gain attention in the

scientific literature, and there is a paucity of well-conducted randomized trials supporting their effi-cacy.72 There is evidence, however, of the success of fractional radiofrequency systems with penetratingelectrodes in dermal heating and collagen remodel-ing. In contrast with the devices that deliver thecurrent to the epidermis, these devices deploy energy directlyto the dermis.73-77 Multielectrode pins of thesedevices provide heating of the areas that are directly targeted by the electrodes, leaving intact or only slightlyaffected zones betweenthe targeted areas.73-77

The preserved tissue serves as a pool of cells thatpromote rapid wound healing.

Depending on the technology used, when anelectrode of a fractional radiofrequency device entersthe skin, the maximum heating effect can be aroundthe tip of the electrode in dermis because high-frequency electrical currents have a tendency to

propagate toward the center of the bulk of tissue.78

This phenomenon can preserve the epidermis duringdermal heating and reduce the risk of postproceduralside effects, including postinflammatory dyspigmen-tation. By insulating the proximal end of the pene-trating electrode, the epidermis will escape injury more efficiently during heating of the dermis.79 Incontrast to radiofrequency currents, laser-based frac-tional resurfacing may produce greater tissue injury on the surface of the skin (epidermis) than in thereticular dermis.80,81 However, to our knowledgethere is no clinical trial comparing these modalities.

Electrosurgery and implantable electronicdevices

Electrosurgery has been reported to causedestruction, reprogramming, depleted battery, andinhibition or activation of implantable electronicdevices. Skipped beats, asystole, bradycardia, ven-tricular fibrillation, and unspecified tachyarrhythmiahave been reported with use of electrosurgery inpatients with cardiac implantable electronic devices.82-84 The incidence of interference is higher when using the monopolar rather than bipolar

mode, using a higher power, working near theimplanted device, or having the pacemaker betweenthe active and dispersive electrode.82 Recent im-provements in electrical shielding and filtering sys-tems have made implanted electronic devices moreresistant to outside electrical interference.84 Heatelectrocautery is a safe alternative to electrosurgery in patients with implanted electronic devices.

Practical differences between different electrosurgical units

Electrosurgical units have different output power,

output frequency, and can provide different modes.





The choice of the unit depends on the surgical settingand the desired applications (Table II).

CONCLUSIONSBipolar electrosurgery is primarily used for the

coagulation and hemostasis of small- to medium-

sized blood vessels or in certain situations, such assurgery on a finger or a patient with an implantableelectronic device. The bipolar mode theoretically can be safer than the monopolar mode with regard tothe potential extent of injury and possibility of distantsite burns.

With regard to safety, the monoterminal modemay be limited in electrosurgery, especially whenusing a high power on an unconscious patient or apatient with neuropathy who cannot sense the painof possible burns. However, if an earth-referenceddevice cannot provide a very low power for a fine

coagulation, the monoterminal mode can be used toreduce output power. The correct use of a returnelectrode increases the power and safety of theelectrosurgical device.

Although the application of electricity insurgery dates back 100 years, progress in technol-ogy still leads to the introduction of new methodsand indications. More recent applications of electrosurgery include the treatment of varicose veins, treatment of benign subcutaneous tumors,and fractional skin rejuvenation. A thoroughunderstanding of the technology and its possiblecomplications can promote effective applicationof electrosurgical techniques and improvedoutcomes.

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