By Peter Daigle, CBSPD
Surgeons rely on Sterile Processing (SP) technicians to provide clean, well-functioning instruments that will help result in good surgical outcomes. SP technicians must have knowledge, skills and understanding of how instruments are used and the critical need for proper inspection and testing prior to sterilization. This article addresses risks of electrosurgery and the importance of proper inspection and testing.
Today, laparoscopic surgical instruments come in many different shapes and styles such as graspers, scissors, hooks and probes to complete specific tasks during the procedures. These instruments can also use electricity to cauterize tissue, allowing the surgeon to ablate (remove), sculpt, sever/cut, shrink/desiccate, coagulate and modify target tissue.
A typical laparoscopic instrument consists of a handle/grip; electrosurgical attachment; 360-degree rotation knob; shaft; double-action jaw; and distal tip. When electricity is introduced to laparoscopic instruments through the electrosurgical attachment, insulation is needed on the instrument handle and shaft to ensure safety. Electricity flows through the instrument much like blood flows through veins and provides energy to the instrument’s tip; that energy is then directed to the intended targeted tissue. The type of energy present during these procedures is radio frequency (RF) electrical energy, which is measured in the unit of frequency called hertz (Hz). The current can only flow in a completed circuit. During a procedure, the electrical surgical unit is the active electrode and the patient is the return electrode. Current will always seek to complete a circuit and will always take the path of least resistance.
Understanding the risks
Although laparoscopic surgery and electrosurgical capabilities have many benefits, there are potential risks, including unintended patient burns, shock to the surgeon and potential fires in the operating room (OR). During the procedure, the surgeon can only see 5% what is being viewed on the monitor; the other 95% is out of sight during the procedure. This poses an issue when electrical current is introduced to the instrument for tissue cauterization. If even a pin hole is present in the insulation, it will have an unintended electrical discharge that can burn an organ or tissue.
Burns can cause hemorrhages, perforations in organs or intestines, contamination from leaking bowels and vessel collapse. A hole in insulation can also release a stray electrical current that poses an electrocution risk to the surgeon, and surgical fires caused by electrical arcing (typically from a breach in the surgical instrument or cord) are another significant risk. Surgical energy is the ignition source in 90% of OR fire claims.[1,2]
There are two types of electrosurgical techniques used: monopolar and bipolar. With monopolar electrosurgery, the surgeon uses a probe electrode to apply the electrosurgical energy to the target tissue to achieve the desired surgical effect (such as cutting or coagulation). The current then passes through the patient to a return pad and then back to the electrical generator to complete the circuit. With the bipolar electrosurgical technique, a bipolar device – often a set of forceps – is used. The electrical current passes from one tip of the forceps through the target tissue to the other side of the forceps, then back to the generator. The electrical current is restricted to the tissue between the forcep’s tips; therefore, the use of a return pad is not required.
Insulated forceps can wear out anywhere along the instrument. The forceps’ distal end is often out of view of the surgeon. Forceps with damaged insulation pose the same patient safety risks as laparoscopic instruments. The cord supplying the electricity to the forceps must also not be damaged because it, too, can pose a burn or fire risk.
Insulation testing is critical for safety
All laparoscopic instruments, insulated forceps and cords must have their insulation tested to ensure there are no breaches. Most of these breaches cannot be seen by the naked eye; therefore, an insulation integrity tester should be used. All electrosurgical instruments must be tested in the preparation and packaging area prior to undergoing sterilization.
Proper insulation testing takes only minutes. A laparoscopic insulation tester is a low-frequency, high-voltage generator that delivers the voltage to an inspection electrode. As the electrode moves over the insulation and a pin hole or bare spot is encountered, a small current flow will create a visible (non-hazardous) spark at the point of contact, which then triggers a visible and audible alarm in the unit. If an instrument fails insulation testing, the device must be immediately removed from service until repaired or replaced. Note: Many laparoscopic insulation testers are available on the market and it is essential that each health care facility does its research and purchases the one best suited to its needs.
It is important to never place any sharp instruments in a set that may come in contact with insulated instruments and possibly cause damage. Even if the laparoscopic instrument does not have cauterization capabilities, it also must be tested because even a small insulation crack can allow bioburden to become lodged in the instrument. Bioburden can pose a risk for a hospital-acquired infection.
Surgical procedures will not be successful without SP technicians’ knowledge of proper care and handling of surgical instruments, including electrosurgical instruments. Insulation testing must be part of every SPD’s quality assurance program. This will help drive best practice, improve safety in the OR and promote positive patient outcomes.
Peter Daigle serves as sterile processing supervisor at the University of Connecticut Health Center.
1. Overbey, DM, Townsend, NT, Chapman, BC, Bennett, DT, Foley, LS, Rau, AS, Yi, JA, Jones, EL, Stiegmann, GV, Robinson, TN. Surgical energy-based device injuries and fatalities reported to the food and drug administration. J Am Coll Surg. 2015; 221:197–205.e1
2. Smith, LP, Roy, S. Operating room fires in otolaryngology: Risk factors and prevention. Am J Otolaryngol. 2011; 32:109–14 [Article] [PubMed]
3. Association of periOperative Registered Nurses. 2010 Perioperative Standards and Recommended Practices. Recommendation XV, page 453.