Common Uses and Cited Complications of

Energy in Surgery
Ganesh Sankaranarayanan1, Rajeswara R. Resapu1, Daniel B. Jones2, Steven

Schwaitzberg3, and Suvranu De1

1
Center for Modeling, Simulation and Imaging in Medicine, Rensselaer Polytechnic

Institute, Troy, NY
2
Beth Israel Deaconess Medical Center,

Harvard Medical School, MA

3
Cambridge Health Alliance. Cambridge, MA

Harvard Medical School, Boston, MA

Running Head : Uses and Complications of Energy in Surgery

Funding: NIBIB/NIH grants # R01EB010037, # R01 EB009362, # R01 EB005807 and # R01

EB014305

Corresponding Author:

Prof. Suvranu De

JEC 2049

Department of Mechanical, Aerospace and Nuclear Engineering

Rensselaer Polytechnic Institute

110, 8th Street, Troy, NY 12180

Phone: 518-276-6096 Fax: 518-276-6025

Email: des@rpi.edu
ABSTRACT

Background: Instruments that apply energy to cut, coagulate and dissect tissue with

minimal bleeding facilitate surgery. The improper use of energy devices may increase patient

morbidity and mortality. The current article reviews various energy sources in terms of their

common uses and safe practices.

M ethods: For the purpose of this review, a general search was conducted through

NCBI, SpringerLink and Google. Articles describing laparoscopic or minimally invasive surgeries

using a single or multiple energy sources are considered, as are the articles comparing various

commercial energy devices in laboratory settings. Keywords such as 'laparoscopy', 'energy',

'laser', 'electrosurgery', 'monopolar', 'bipolar', 'harmonic', 'ultrasonic', 'cryosurgery', 'argon beam',

‘laser’, 'complications', and 'death' were used in the search.

Results and Conclusion: A review of the literature shows that the performance of

the energy devices depends upon the type of procedure. There is no consensus as to which

device is optimal for a given procedure. The technical skill level of the surgeon and the

knowledge about the devices are both important factors in deciding safe outcomes. As new

energy devices enter the market increases, surgeons should be aware of their indicated use in

laparoscopic, endoscopic and open surgery.

Keywords: minimally invasive surgery, electrosurgery, ultrasonic, harmonic scalpel,

argon beam coagulation, laser, radio frequency ablation, thermal damage, embolism, fire.
INTRODUCTION

The vast majority of surgical procedures performed throughout the world involve the use

of some device that applies energy to the tissue for cutting, coagulation, desiccation or

fulguration for the destruction or manipulation of the tissue. While various energy sources

including electricity, ultrasound, laser, argon gas, microwaves or radiofrequency waves may be

used, the fundamental principle involves tissue necrosis and hemostasis by heating. The

process of denaturation of tissue begins with the irreversible aggregation of macromolecules

and the unraveling of collagen helices around 60ºC. Protein denaturation occurs between 70ºC

and 80ºC resulting in coagulation. Further heating to 90ºC results in dehydration or dessication.

Beyond 100ºC, the intercellular water boils, eventually vaporizing the cell allowing tissue cutting.

Finally, tissue fulguration or carbonization occurs beyond 200ºC[1]. At present, there is no

standardized curriculum for surgeons that address the physics, safe use and complications

associated with these devices that promote the best outcomes for patients. In a recent study [2],

it was found that many surgeons have knowledge gaps in the safe use of widely used energy-

based devices. To address this issue, the Society of American Gastrointestinal and Endoscopic

Surgeons (SAGES) has recently initiated the Fundamental Use of Surgical Energy (FUSE)

program to develop an educational curriculum that will cover both didactic and hands-on training

approaches to the use of energy in interventional procedures in the operating room and

endoscopic procedure areas. The goals are to prevent untoward events such as operating room

fire, patient injury, surgeon/staff injury as well as promoting optimal use.

 The purpose of this paper is to summarize some of the major energy sources used in

laparoscopic surgery and discuss their relative advantages and disadvantages.

M ETHODS

The review includes a thorough search of literature concerning the physics, applications,

success, complications and comparison of various energy sources in surgery. Priority was given

to human studies and laparoscopic procedures. However, the studies involving animals (both in

vivo and in vitro) and open procedures which were unique and relevant to the assessment of the

energy sources were considered. Emphasis was placed on more recent studies covering the

latest techniques and studies conducted on live patients in the United States. The keywords

used in the search were numerous and the websites such as Medline, PubMed, SpringerLink

and Google were extensively covered along with various books published in the field.

Electrosurgery

Electrosurgery was developed by Dr. William T. Bovie in the 1920s, where a spark gap

generator was used to build the first electrosurgery tool, commonly known as RF knife or ‘Bovie’

[3]. In the 1950’s, the first bipolar unit was built by Dr. Leonard Malis, wherein two electrodes

were used for gripping and manipulating the tissue.

Mechanism of Electrosurgery

In electrosurgery, heat is generated in the tissue by the flow of radio frequency (RF)

electric current unlike electrocautery where the heat is transferred directly from the tool to the

tissue. The use of RF current (voltage in the range of 300 to 500 KHz) eliminates

neuromuscular stimulation, which ceases above 100 KHz. When the RF electrical energy is

made to concentrate in a very small area in the tissue, typically by applying the energy through
pointed or hooked tool tips, the resulting high concentration of current flow in a narrow area

increases the cellular temperature which leads to various effects on the tissue including,

coagulation, dessication or dehydration and carbonization.

The RF energy can be applied to tissue by using either monopolar or bipolar tools. In

monopolar electrosurgery, the electrical circuit is completed by the passage of current from the

active electrode at the surgical site to the dispersive electrode (or the return electrode) attached

to the body of the patient. The active electrode can be of any form (usually a point, hook or a

blade) with sharp edges and/or blunt edges. The sharp edges increase the current density (the

amount of current per unit area) and used for cutting whereas the blunt edges are used for

coagulation. The return electrode is usually a wide pad, attached to the skin of the patient,

which disperses the heat and safely leads the current out of the body. In bipolar electrosurgery

both active and return electrodes are located in the same tool and the electrical circuit is closed

by the small area of tissues that are grasped or manipulated by the tool. Bipolar tools are, thus,

usually designed as grippers or forceps. Since the current only has to travel short distances in

bipolar surgery, the voltage required for the surgery is low. Lower voltage is better for uniform

drying of the tissue which minimizes the chance of re-bleeding. Thus the bipolar devices are

more suitable for coagulation rather than cutting.

The RF energy is applied through specialized electrosurgical generators, which are RF

wave form generators with different duty cycles (percentage of time the energy is applied).

Different tissue effects such as cutting, coagulation can be achieved by selecting different duty

cycles with 100 % duty cycle enables cutting whereas lower duty cycles can be effectively used

for coagulation. Though electrosurgical generators produced by each manufacturer are

different, they usually provide selections such as pure cutting, coagulation and blended

waveforms.

The waveforms with different duty cycles can be used to produce four main effects in

electrosurgery namely, cutting, coagulation, desiccation and fulguration. The cutting is achieved
by using a continuous waveform (100 % duty cycle) applied through the active electrode of a

monopolar electrosurgical tool with a pointed tip. The narrow tip allows for large current

concentration and when placed near the tissue but not in contact, generates an arc through

which the current rushes to the tissue generating large amount of heat (greater than 100°C)

which leads to rapid tissue vaporization and induces cutting. When a blunt instrument tip is used

with contact on the tissue, the decreased current concentration due to increased surface area

leads to increase in the tissue temperature but not to point of vaporization and creates a

coagulum at temperature between 70 to 80°C and desiccation at temperature of 90°C. To

perform coagulation or desiccation, a lower duty cycle high voltage waveform is used but can

also be performed with 100 % duty cycle lower voltage cutting waveform as well. Finally in

fulguration, a lower duty cycle high voltage waveform is applied through the active electrode of a

pointed monopolar electrosurgical tool tip in non contact mode close to the tissue. With high

voltage and low duty cycle ( usually 6 %), the heat generated by the current flowing through the

arc from the tool tip heats the tissues to form coagulum and with repeated application, increases

the temperate to 200°C or more forming carbonization or fulguration.

The most commonly used electrosurgery devices are listed in Table 1. The bipolar

instruments provide compression force in addition to thermal energy, which helps in better

sealing of blood vessels and attaining better burst pressures. Thus these instruments seal larger

blood vessels as opposed to monopolar devices which are limited to smaller vessels - usually

less than 2mm [4]. The earlier generation of electrosurgical tools did not have temperature

control and hence, resulted in thermal injuries. The latest instruments (e.g., Ethicon

EndoSurgery’s ENSEAL) claim to measure temperature or impedance to provide consistent

heating to prevent injuries.

Complications and Recurrences in Electrosurgery:

Electrosurgery accounts for 80 % of all cutting and coagulation in surgeries performed

today. According to the Association of periOpertaive Registered Nurses (AORN), there are
around 40,000 patient burn cases annually due to faulty electrosurgical devices and in 1999

alone, nearly $600 million was paid in claims for those injuries [5]. Care should be taken when

operating the electrosurgical devices, particularly monopolar devices. The sparking effect at the

tool tip may cause an explosion when it comes into contact with inflammable gases that are

often used for anesthesia during the operation. Further, the current travelling through the body

can interfere with any implanted medical devices such as pacemakers [6] and defibrillators. A

metal instrument or implant that comes in the way of the current passing through the body may

create a different loop causing tissue damage in unwanted regions. Other mechanisms through

which injuries can occur during electrosurgery include insulation failure [7], direct and capacitive

coupling. Insulation of the electrosurgical tool may break due to repetitive use of the equipment,

high intensity of current flowing through the wire and in repeated sterilization process. Burns

occur at places of insulation defect and can be fatal especially when the defect is small which

leads to high current concentration. Moreover the insulation defect is often very small and will

be difficult to detect using the naked eye and an active electrode monitoring system may abate

injury [8]. Direct coupling occurs when the active electrode is either intentionally or inadvertently

touched by another tool or scope, in which case, energy can be transmitted through the other

tool to the tissues. Though in many instances, it is used intentionally, in laparoscopic

procedures, it is often dangerous since the view of surrounding organs is limited. Capacitive

coupling may occur in a laparoscopic surgery when the tools, tissues and trocars are in close

proximity creating capacitance effect (build up of charge between two conductors separated by

an insulator). This stored charge may discharge causing unintended tissue damage in the

immediate vicinity. If possible, the use of metal and hybrid (with plastic) cannula should be

avoided to eliminate injuries. This may be a particular hazard in the emerging technique of

single port laparoscopic surgery where all of the instruments are in close proximity. Though the

spread of current through the body is eliminated by the use of bipolar electrosurgery, chance of

damage to adjacent tissues still exists [9]. Apart from the common laparoscopic complications
that arise due to surgical error, the other major complication from electrosurgery is the thermal

injuries to adjacent organs. However, the complications can be both intra-operative and post-

operative and are specific to the type of procedure performed. Complicating the matter further is

that the maximum temperature and thermal spread when using energy based devices varies

based on the types of target tissue and the type of energy sources used [10] . Monopolar

electrosurgery was shown to have higher temperature and thermal spread [11-13]. Various

studies on laparoscopic procedures have shown complications while using monopolar and

bipolar electrosurgical instruments that includes conversions, failures, and recurrences [14-19].

There are cases in which death has been reported when using monopolar electrosurgical device

[20, 21]. Specifically Agarwal et al. [22] mentioned that the use of an energy source, especially

monopolar electrosurgery is the culprit for many of the injuries during laparoscopic

cholecystectomy.

Indications and Contraindications of electrosurgery

Electrosurgery has the highest number of thermal injuries, but it still is one of the most

popular techniques used in laparoscopy. Out of the two electrosurgical modalities, monopolar

electrosurgery causes the most thermal damage but bipolar devices have also shown to

produce thermal damage [11]. Studies have shown that the bipolar device has the least amount

of thermal spread among the various energy devices [11, 12, 23] and provides safe sealing and

cutting quality that are similar to other energy based devices [20]. Bipolar electrosurgery devices

have shown to have shorter dissection time, provided better seal quality, lesser blood loss,

fewer conversion rates and are more cost effective than monopolar electrosurgery [24-26]. In

laparoscopic cholecystectomy (LC), a common laparoscopic procedure which involves the use

of energy, bipolar modality is shown in one study to have performed better than monopolar

electrosurgery [27]. In a number of other studies comparing different energy devices, the

bipolar electrosurgery devices have performed better than devices using other forms of energy

sources [26, 28-30]. High success rate have also been reported in surgical outcome reports
using bipolar energy devices [14, 15, 18]. Hence the cost of bipolar electrosurgery devices may

be justified for complex surgical cases. Monopolar technique might be preferable for simpler

surgical procedures when adequate care is taken while operating in the vicinity of critical

organs. For example, making incisions on the skin before inserting the laparoscopic instruments

is a job for the monopolar tool. The risk from electrosurgery can further be reduced by limiting

the thermal damage during electrosurgery. For example, Dodde et al. [31] reported a novel

thermal management system to reduce the thermal spread during monopolar electrosurgery.

One common safety measure is the optimization of the voltage application time. Most of the

electrosurgical units come with various power settings for cutting and coagulation. The right

setting should be chosen for the specific procedure. Tissue damage is further reduced by the

introduction of a hydrating medium to keep the surgical area wet and moist. As long as the

above mentioned precautions are taken and the common risk factors are considered,

electrosurgery maybe used with confidence.

Ultrasonic energy

The use of ultrasonic energy in medicine has been reported as early as 1960, where it

was used to treat Meniers’s disease. It has been used in the cutting and coagulation of tissue in

the late 1980s [33] where Amaral [34] popularized the technique and used it successfully in over

200 patients undergoing laparoscopic cholecystectomy.

Mechanism of Ultrasonic surgery:

The basic working principle of ultrasonic surgical instruments such as ultrasonically

activated scalpel (UAS) is to use the low frequency mechanical vibrations (ultrasonic energy in

the range of 20-60 kHz) of the tool tips or the blades for tissue cutting and coagulation [32]. The

mechanical vibrations when transferred to the tissues on contact induces protein denaturation

by breaking down the hydrogen bonds in tissues due to the internal cellular friction caused by

the vibrations [33]. The mechanical vibrations are produced by the piezoelectric transducers
embedded in the tools which convert the applied electrical energy to mechanical vibrations

which are then transferred to the active blades for cutting or coagulation. The HS operate at a

frequency of 55.5 kHz whereas devices operating at various other frequencies also exist [35].

The cutting using an Ultrasonic surgical instrument is achieved by two methods. For

tissues and muscles with high protein densities, the mechanical stretching of the tissues beyond

its elastic limit due to the longitudinal motion of the sharp blades between 60 to 100 µm at 55.5

kHz is used for cutting. For tissues with low protein densities, such as liver, cavitation effect in

which intercellular water is vaporized at lower temperatures due to mechanical vibrations, there

by rupturing the cells is used for cutting. In general the cutting and coagulation in UAS depends

on various factors such as grip pressure, the shape and area of the blades in contact with the

tissues and the power settings [34].

The major advantage of using UAS is that it produces less heat compared to other

energy devices (less than 80° C compared to 100° C for electrosurgery) thereby reducing the

risk of thermal injury [35]. Due to lesser heat generation, charring and desiccation is also greatly

reduced. Since no smoke is produced, except for the mist produced due to cavitation effect

which dissipates much faster, UAS offers unobstructed view for endoscopic/ laparoscopic

procedures. The UAS does not transmit active current in the tissues and thereby eliminate any

risk of electric shock. The most commonly used ultrasonic energy devices are listed in Table 1.

Complications and Recurrences in ultrasonic surgery:

Not many complications were reported in the use of harmonic scalpel in laparoscopy.

General disadvantages of ultrasonic devices include slower coagulation compared to

electrosurgery, altering of the frequency or impedance of the surgical system itself due to blade

fatigue, temperature elevation, excessive applied pressure, or improper use. Ultrasonic energy

causes atomization of fluid, which may create a transient mist. However, overall dissection time

may be shorter with ultrasonic cavitation aspirators (UCA) or ultrasonic-activated scalpels after

the initial learning curve [36]. It has been shown in many studies that the ultrasonic devices are
not as efficient in sealing medium to large sized blood vessels [26, 37, 38]. It is also shown that

UAS produces higher average temperatures [10] and is not reliable in sealing vessels larger

than 3mm [39]. In [40] it was shown that though there is no visible injury to naked eye during

dissection experiments on a swine using a UAS, histological examination had revealed serious

injuries to various structures. Complications reported in the use of ultrasonic energy in

laparoscopic surgery includes injury to sigmoid colon [41], postoperative bleeding [42] and an

ischemic lesion [28]. Even the overheating of tissue (the non active blade of a UAS) after a

continuous activation of more than 10s resulted in histological damage to the intestinal mucosa

in a porcine [43].

Indications and Contraindications of ultrasonic energy:

The general conclusion of most studies advocating the use of ultrasonic energy is that

the minimal thermal spread leads to minimal thermal injury. However, there are studies that

contradict the statement by measuring the temperature of the tool tip instead of thermal spread

in the tissue. In [44] it was shown that at higher power settings, the ultrasonic devices

(Ultracision and Autosonix) created large thermal spread (up to 25.7 mm) and high

temperatures (140ºC at 10 mm distance) in porcine organs. In another study, the harmonic ACE

[10] is shown to have taken twice as long to cool down when compared to the other devices and

the temperatures generated by the ACE were inversely proportional to the thickness of the

tissue. Kinoshita et al. [48] says that the temperatures (150ºC) and thermal spread (10mm)

caused by ultrasonic device is far less than those caused by electrosurgery (350ºC and 22mm

respectively) in the porcine blood vessel cutting and coagulation. There are various reports of

successful laparoscopic procedures using ultrasonic energy devices. This includes

gynecological [45-48], laparoscopic cholecystectomy [49-51], laparoscopic appendectomy [52],

laparoscopic myomectomy [53, 54], laparoscopic colorectal [55], laparoscopic salpingo-

oophorectomy [56] and laparoscopic management of cornual heterotopic pregnancy [57].

Ultrasonic scalpel (Harmonic ACE) was also successfully used in division of pulmonary vessels
in video assisted lung resection [58]. Though proven to be an effective tool in gynecological

procedures, it is not a good tool for delicate reconstructive surgery for fertility due to the

cavitational effect [47]. Janssen et al. [51] showed that in laparoscopic cholecystectomy, the

learning curve of the surgeons using HS was very short compared to electrosurgery. The

general conclusion that can be drawn from the observations is that ultrasonic energy has more

advantages than disadvantages. Given the fact that more recent literature is available in the

field than other energy methods and the increasing market share of ultrasonic medical devices

[59], it can be said that ultrasonic energy may have an increasing role in the field of surgery.

Lasers

The first use of lasers in laparoscopic surgery was recorded in 1979 [60] and the regular

use of laparoscopic laser surgery has been reported as early as 1982 [61]. In a very short span

of time, lasers became very widespread in the medical field - ranging from cosmetic treatments

to highly complicated surgeries such as atrial fibrillation (AF) treatment [62, 63]. Today, lasers

are relegated mostly to gynecological procedures.

Mechanism of Laser surgery:

Lasers generate heat by applying a concentrated beam of light. In a laser system,

electromagnetic or light waves are amplified multiple fold in an optical resonator (which contains

mirrors and a gain medium) and passed out in the form of high intensity light waves. The

amount of amplification in the resonator determines the amount of energy transmitted by the

light waves which are then absorbed by the tissue. This energy absorbed by the tissue then

manifests itself into heat which cuts and coagulates the tissue. The frequency of the laser beam

determines the width of the laser beam that can be generated (the higher the frequency of the

wave, the lower the diameter of the beam) and most commercial lasers use infra-red to

ultraviolet frequencies for medical applications. The power or intensity of a laser is measured in

terms of 'irradiation' defined as the ratio of power applied to the spot-size (cross sectional area)
of the laser beam (W/m2). Though only two variables (power and spot-size) are required to

calculate the value of irradiation, two other important variables need to be considered when

using lasers in surgery – time of exposure and wave length (or frequency). The use of lasers to

generate heat for destroying tumors is known as 'photo-thermal' therapy. The changes caused

by non-thermal mechanisms while using a laser are called 'photo-chemical' processes. Usually,

in photo-chemical processes, the amount of irradiance is so low that, instead of generating heat,

it induces chemical reactions in the cells thus causing inactivity. When the amount of irradiation

is too high (108 to 109 W/cm2), plasma formation takes place and leads to a 'photo-plasmal'

process. If the electric field is too strong, the result is a small region of plasma which is

associated with dielectric breakdown, strong electric fields, shockwave formation and tissue

rupture. Once the plasma forms, the tissue properties become immaterial as all the laser energy

is absorbed by the plasma itself [64].

Lasers can be classified into contact or non-contact types – based on their interaction

with the tissue. In non-contact laser mechanism, the tip of the laser delivery device remains at a

distance from the tissue to where it is being focused. When this kind of mechanism is used in a

liquid medium, an explosive vapor bubble is formed at the tip of the tool which carries energy to

the tissue. This type of energy delivery is preferred in a few ablation processes [65]. The contact

laser is the direct contact of the tool tip with the tissue. This causes the direct transfer of energy

from the tool to the tissue. The selection of a contact or non-contact laser depends upon the

sensitivity and accessibility of the tissue being operated on. The most commonly used Laser

devices are listed in Table 1.

Complications and Recurrences in laser surgery:

Disadvantages of laparoscopic laser surgery include cost of specialized equipment,

need for advanced training in laser and laparoscopic surgery, risk of fire from flammable

materials ignited by lasers and increased operative time. The increased sedation period due to

the length of the operative time also leads to longer recovery time. Cellular damage around the
area of laser impingement can also be expected depending upon the size of the laser tip. One

of the major complications using laser as the energy source is the air embolism which can be

fatal [66-77]. Another complication with laser laparoscopic cholecystectomy is the injury to the

hepatic artery with pseudoaneurysm formation and hemobilia [78]. Hemorrhage has been

reported in other studies as well. In a review of 2344 laser laparoscopies over an 11-year period

(1982 - 1993), Ewen et al. [79] reported nine significant complications in which three cases of

intra-abdominal hemorrhage required laparotomies and one case of severe surgical

emphysema during adhesiolysis with CO2 laser was also reported.

Indications and Contraindications of laser surgery:

The efficiency of lasers in laparoscopy were reported as early as 1989, when Reddick et

al. [80] studied 25 cases of laparoscopic cholecystectomy (in the US) and found no major

complications despite having shorter recovery periods compared to open surgery. In

laparoscopy, the major use of lasers is in gynaecological procedures, where it is commonly

used in the treatment of infertility [81-86]. It is also a common source of energy in cosmetic and

eye surgeries. Success rates of more than 90% have also been reported in review of cases that

used CO2 laser along bipolar forceps in laparoscopic surgery [87, 88]. Advantages of

laparoscopic laser surgery over open techniques include minimal surgical morbidity, decreased

postoperative discomfort, and rapid, uncomplicated healing. Complications from laser

laparoscopic surgery include air embolism, hemorrhage and surgical emphysema. Moreover a

non-contact laser may do more damage than a contact laser [89].

Argon Beam Coagulation

Ward et al. [90] first reported the use of argon beam coagulation (ABC) in head and neck

surgery in 1989. The use of ABC in MIS is first reported by Low et al. [91] in 1993. Numerous

studies describing the efficiency as well as the dangers of ABC have been well documented [92-

94].
 Mechanism of argon beam coagulation:

In electrosurgery a radio frequency current is applied to tissue to cauterize and control

bleeding. In ABC, a directed beam of argon gas from the electrode tip aids in conduction of the

radio frequency current to the tissue by ionization. Like laser, this is a non-contact method

where the argon gas - which is a good conductor of electricity - acts as a means of

transportation of the current from the tool to the tissue. ABC performs faster than conventional

coagulation systems and provides a more uniform and shallower coagulation region which

results in faster dispersion thus minimizing tissue damage. It also produces less smoke than the

conventional system. Since the argon has higher density, a jet of argon gas typically move the

blood away from the surface for effective coagulation and resulting in lesser eschar. The

protection of the active electrode tip from exposure to oxygen also results in less charring [95].

The ABC system is usually connected together with an electrosurgical system where argon gas

is released from the tip of the tool to achieve hemostasis. The most commonly used ABC

devices are listed in Table 1.

Complications and Recurrences in Argon beam coagulation:

A major limitation to the use of ABC system is the potential danger of argon gas

embolism. Numerous instances of cardiac arrest were reported during the use of ABC due to

gas embolism [93, 94, 96]. Embolism (blockage of blood vessels) occurs due to the insolubility

of the argon gas in blood. The gas forms bubbles or cavities that can travel through the blood

stream and cause blockages in blood vessels. Death due to argon gas embolism has also been

reported [97-99]. Cases of non fatal argon gas embolism have been reported in [100-104].

Indications and Contraindications of Argon beam coagulation:

Despite the risks, ABC continues to be used in surgery. A number of successful cases in

the use of ABC have been reported [105-109]. Dowling et al. [110] reported that the ABC was

more effective in management of spleenic trauma compared to traditional techniques(topical

surgical, electrocautery, suture-ligation, digital pressure) in a study on ten adult pigs. Guidelines

for the safe use of ABC during laparoscopy have been tabulated by various researchers and

commercial manufacturers. Some important guidelines are, The flow rate for argon should be

chosen as low as possible to reduce the risk of argon gas embolism [111], direct contact of the

tool tip on the organ should be avoided and the electrode tip should be held at an oblique angle.

It was mentioned in a study that even at the point of longest application, the temperature

developed while using ABC was never higher than 100˚C in complete coagulation [112]. There

are other studies such as the one by Bobbio et al. [113] wherein argon beam technique is

compared with traditional surgery in the treatment of primary spontaneous pneumothorax (PSP)

using video assisted thoracic surgery (VATS) where no significant benefits of ABC were found.

The use of ABC has resulted in numerous cases of fatal and non fatal embolisms.. So, the use

of ABC must solely depend on the skill and discretion of the surgeon.

Radio Frequency (RF) Energy

Electrosurgical generators can generate EM waves in a wide range of frequencies.

Radio frequency or RF which ranges from 3 kHz to 300 MHz is the type of electromagnetic (EM)

radiation that is commonly used in electrosurgery. RF has the lowest frequency of all the EM

waves and hence takes longer than other EM waves to generate heat in the tissue. It has been

shown in a number of studies that EM in the RF range is the most effective form of radiation.

Mechanism of RF

There are two mechanisms of RF that are used in MIS. One of them is the laparoscopic

electrosurgical usage of RF. The mode of operation is the same as that of electrosurgery where

the current applied to the tissue through the scalpel falls is the RF range. RF in electrosurgery

can be used in both monopolar and bipolar modes. Apart from laparoscopy, RF can also be

used in a percutaneous setting. Percutaneous treatment involves the insertion of a needle into

the organ to be operated on via a catheter inserted through the skin of the patient. RF current is
then applied to the tissue through the needle. Though it is different from laparoscopy, it is also a

MIS procedure where the needle tip is usually guided into the body by an ultrasound positioning

system. The most commonly used RF energy devices are listed in Table 1.

Complications and Recurrences in RF

The most common usage of the RF in is radio-frequency ablation (RFA), which is also

referred to as LRFA (laparoscopic radiofrequency ablation) in the laparoscopic setting. A

number of studies show the application of LRFA in various procedures [17, 19, 114]. Beyer et al.

[114] studied minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation (AF) in

100 patients at 3 North American Institutes between 2005 and 2007 and reported postoperative

complications that includes pacemaker requirement (5%), phrenic nerve palsy (3%),

hemothorax (3%), transient ischemic attack (1%) and pulmonary embolism (1%). Case of

deaths and high morbidity has also been reported in laparoscopic cholecystectomy procedure

in Child-Pugh Class C Cirrhotic patients using a combination of HS dissection and

radiofrequency coagulation [115]. In a report submitted to the American college of physicians in

2003, it was reported that RF ablation treatment of atrial fibrillation (arrhythmias) performed

using a catheter can severely narrow the pulmonary veins due to the formation of scar tissues

[116]. In rare cases, acute renal failure associated with radiofrequency liver ablation has been

observed [117]. Most complications of RF seem to arise when it is used in the vicinity of the

heart. This is due to the interference of the electrical with the electrical activity of the heart.

Persistent inappropriate sinus tachycardia has been reported as a complication after

radiofrequency (RF) ablation of the fast atrioventricular (AV) nodal pathway [118]. In a study of

management of hepatic malignancies using RFA of malignant liver tumors in 608 patients

between 1996 and 2002 [119], hepatocellular carcinoma, followed by colorectal

adenocarcinoma were reported as a major early complications and . Symptomatic pleural

effusion was reported as the major postoperative complication. .

Indications and Contraindications of RF

 In a study on advantages of using radio frequency (RF) heating over lasers for laser

cartilage reshaping (LCR), it was shown that RF method allowed more uniform heating of larger

tissue samples but the lack of precise control of spatio-temporal distribution of heat limits the

usage of RF use in LCR [116]. The advantages of RF energy and the necessity to reduce

complications have resulted in the introduction of several new commercial devices [120, 121] .

In [122], the Gyrus Plasma Trissector (GPT), a novel bipolar RF system in laparoscopic radical

prostatectomies was shown to improve coagulation, reduce or eliminate sticking, seal large

vessels and allow secure grasping and dissecting of tissue. Ligasure, a radio-frequency-

energy-driven bipolar fusion device is used in many laparoscopic procedures [123-127]. For the

minimally invasive treatment of localized renal tumor, RFA along with cryoablation is shown to

be the most used and potentially promising therapies [128]. For the treatment of renal cell

carcinoma, it was shown in [129] that RFA assisted laparoscopic partial nephrectomy was

effective in providing hemostasis and in short term cancer control and also shown in [130] that

RFA treatment for small renal cell carcinoma found have significantly improved the quality of

life in most of the patients. In [131], it is also reported the reduction of intraoperative bleeding

and blood transfusion using RF assisted laparoscopic liver resection. However, Hompes et al.

[132] states that the laparoscopic liver resection itself is a procedure with minimal blood loss

and that radiofrequency assistance has no additional advantage. In a comparative study

between saline infused RFA and dry RFA [133], it was shown that wet RFA caused larger lesion

sizes in 10 porcine kidneys and one cycle of wet RFA was sufficient to cause irreversible cell

death compared to two cycles required using dry RFA. Although, percutaneous RFA in liver

treatments is less invasive and is considered the first choice, RFA with laparoscopic guidance is

highly recommended for patients with a relative contraindication for percutaneous RFA, such as

lesions adjacent to the gastrointestinal tract, gallbladder, bile duct and heart [134]. Similarly,

LRFA was also highly recommended for the treatment of hepatocellular carcinoma [135]. In

general, the most usage of RFA either laparoscopically or percutaneously is observed in the
liver and renal tumor ablation. However, a variety of studies featuring RFA in various surgeries

also exists. RFA is reported in the treatment of lower extremity varicosities (a minimally invasive

cosmetic procedure) where it fared better than stripping and foam sclerotherapy, although not

as effective as laser therapy [136]. A study of bipolar RF in the treatment of plantar fasciosis

[137] in patients who couldn’t be treated with conservative methods showed an improvement in

all 10 patients within a time span of 6 months to 1 year without any postoperative complications.

Com parison study

In a comparative study, it is important to understand the use of energy devices in the

context of individual procedures. In this paper, we consider the laparoscopic cholecystectomy

(LC) procedure an example (Table 2). In LC the common energy sources used are laser,

electrosurgery and ultrasonic energy. Since many of the case studies don’t explicitly state

injuries occurred while using the energy device, for LC, parameters such as mean operating

time, mean hospital stay, mean recovery time along with complications such as bile duct injury

(BDI), bile leak, conversion rate to open surgery and any reported death were collected for each

study and represented in Table 2. From the data, HC and Ultrasonically Activated Scalpel

(UAS) performed better than clip and electrosurgery methods based on operating time and bile

duct injuries. Huscher et al. [138] sates that the main advantage of UAS is the low-risk

dissection in the proximity of biliary structures. More over with UAS both cystic duct and vessels

can be separated without the need for ligature. The relative bloodless field of view when using

UAS also helps in discriminating anatomical structures. Redwan et al. [139] states that when

comparing HS and clip and electrosurgery for LC, HS performed better with lesser operating

time and the absence of major or minor bile leaks. No clear conclusion can be made regarding

laser since the operating time and injuries when compared to clip and electrosurgery varied

among the different studies and no direct comparison study exists between laser and
ultrasonically activated devices. Between monopolar and bipolar electrosurgery, though both

had comparable operating time, monopolar electrosurgery had more complications.

Discussion

A comparative study of the literature shows that the preferred source of energy in

laparoscopic surgery in the early 1990s was the monopolar electrosurgery, while bipolar and

laser was used much less frequently. However, in recent times, even with the advent of new

tools in electrosurgery, the preference is gradually shifting towards ultrasonic energy due to its

many advantages in laparoscopy. While laparoscopic laser cholecystectomy, once a popular

procedure, is rarely performed and harmonic scalpel (HS) has been used more often in recent

times. Fiber optic cables have made lasers more readily available in laparoscopy. The use of

lasers is most dominant in gynecological treatments like endometriosis. Argon beam

coagulation (ABC) is a very effective technique to attain hemostasis, and despite the large

number of deaths and intra-operative complications, it still remains in use.

In spite of significant developments, the search for an ideal energy device that will result

in perfect hemostasis with minimum damage to surrounding tissue in the most efficient manner

posing the minimum threat to the patient in terms of short and long term complications remains

elusive. Each energy method has advantages and disadvantages and a thorough knowledge of

each devices is essential in deciding which energy source for be used for a specific procedure.

Relative advantages and disadvantages of existing energy methods are presented in Table 3.

In a 2004 paper, Harrell et al. [140] mention that in a survey of 500 surgeons in 1993,

18% (of over 500 respondents) reported to have caused electrosurgical injury during

laparoscopy and 54% reported to have known of another surgeon who has caused similar

injury. Deaths were more common during early in era of laparoscopy. A brief search of the
literature shows numerous instances of deaths in the 1980s using various energy sources. The

number of deaths and even the complications in laparoscopy, have greatly reduced in recent

times. For example, complications in laparoscopic cholecystectomy, which were reported to be

around 2-4% in 1994 [141], came down to about 0.4% by 2005 [142]. Table 4 shows the various

deaths reported in laparoscopy using energy sources.

In general, most of the studies suggest that the effect of any laparoscopic procedure

depends on the skill and familiarity of the surgeon with the surgical tools. An interesting

observation while reviewing studies performed to test various instruments or methods is that

some of the results seem contradicting. Devices which have been rated high by some studies

have been rated low in others. Surgical skill and familiarity with the particular device may

certainly be a possible contributor to this apparent paradox. Further, the devices which are

shown to work well in the laboratory may not work the same way in an actual laparoscopic

procedure. Hence, there is a need for developing uniform training regimens across surgical

specialties under clinical conditions. Particularly, the fundamental understanding of how each of

the energy devices work and their effect on the tissues is very important. For example, in

electrosurgery, the understanding of different power settings and its effects on tissues is very

important. More over the knowledge of safety issues with each of the devices should also be

known so that appropriate precautions could be used to minimize injury. Solid communication

and team coordination in high fire risk setting must be introduced into practice. Examples are

the high temperature and low cooling rate of ultrasonically activated devices even after switched

off, risk of air embolism in laser from high flow rate gas cooling and venous gas embolism while

using ABC. A standardized curriculum or manual with working principles of various energy

devices and their safety issues as envisioned by the FUSE program would be a valuable tool in

increasing patient safety in surgical procedures using energy devices.

Conclusions

Each of the energy devices reviewed in this work had its own advantages and

disadvantages. When considering thermal damage, monopolar electrosurgery results in the

greatest amount of thermal damage to adjacent tissue while ultrasonic energy results in the

least. In terms of their performance, ultrasonic devices provide the highest seal strength in

smaller vessels, while electrosurgery is more efficient for larger vessels. Argon beam

coagulation results in the most effective hemostasis on irregular surfaces, however, it also leads

to gas embolism. In electrosurgery, RF is the most common form of electromagnetic radiation

used followed by microwave radiation. Lasers are very expensive and are mostly limited to

gynecological treatments in laparoscopy today, though at one time, they were widely used in

many laparoscopic procedures such as cholecystectomy. In blood vessel sealing, the

effectiveness of an energy device is dependent on the size of the blood vessel. Though there is

no clear winner in terms of operating time, in the series of study that were reviewed in this work,

the harmonic scalpel is shown to have reduced overall time compared to other energy sources

in MIS. In terms of death from complications, lasers and ABC have more reported cases than

the other methods and surgeons should be familiar in their use. Electrosurgery is still very

popular in MIS due to its familiarity with surgeons and the development of various enhanced

safety features to minimize injuries.

DISCLOSURE

Drs. Ganesh Sankaranarayanan, Rajeswara Resapu, Daniel B. Jones, Steven

Schwaitzberg, and Suvranu De have no conflicts of interest or financial ties to disclose.

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 Table 1. Most commonly used energy devices in minimally invasive surgery

Type Product Name

Monopolar electrosurgery 1. Opti4™

2. Encision AEM™
Bipolar electrosurgery 1. LigaSure™
2. Gyrus PlasmaKinectics™
3. EnSeal™
Ultrasonic energy 1. Ultracision harmonic scalpel
2. Harmonic ACE
3. Harmonic FOCUS
4. SonoSurg
5. AutoSonix
Laser energy Most commonly referred to their type than a
product name.
1. Nd: YAG laser (neodymium-doped
yttrium aluminum garnet)
2. argon laser
3. CO2 laser
Argon beam coagulator 1. System 7550™ ABC®
2. Cardioblate®
Radio Frequency (RF) energy 1. RF 3000® Radiofrequency Ablation
System
2. StarBurst®
3. Cardioblate®
 Table 2. Laparoscopic cholecystectomy using various energy devices

Author/ Number of Energy Mean Mean Mean Complications

Timeline Cases source Operating Hospital Recovery Bile duct Bile leak Conv Death
Used Time Stay Time injury ersio
(Minutes) (Days) n to
open
surge
ry
Peters et 100 Electrosur 85.27 ± 39 27.6 12.8±6.8 1 2 ( 2%) 4
al. gery hours (1%) (4%)
[143] and
1990 Neyodenu
m: yag
Laser (first
30 patients
Huscher et 461 Group 1: Group 1: Group 1: 1 (0.32%) 10 4 11
al. Ultracision 76.8 4.268 (2.17 %) (0.87 (0.21 %)
[138] HS (331 Group 2: days %)
1999 patients), 97.5 Group 2:
Group 2: 5.05 days
Ultracision
HS and
Endoloop
(130
patients)
Redwan et 160 Group 1: Group 1: Group 1: Gro
al. Harmonic 16.8±6.8 1.0 ±0.0 up 1: 8 (10
[139] Shears days %)
2008-2009 (HS) (80 Group 2: Group 2: Gro
 patients) 44.01±6.47 1.53±0.51 up 2: 11 (13
Group 2: days %0
Clip and
Electrosur
gery
(C&E, 80
patients)
Kandil et 140 Group 1: Group 1: Gr Gro G
al. Clip and 51.7±13.79 oup 1: up 1: roup
[14 Electrosur 26.95 2 1:
4] gery (C Group 2: ±8.94 (2.9 %) 2
200 &E, 70 33.21±9.6 hours (2.9
8 patients) Gr %)
Group 2: oup 2:
Harmonic 23.
Scalpel 44±2.29
(HS) hours

Tsimoyian 200 Group 1: Group 1: Group 1: Gro

nis et al. Monopolar 45±7 1.9 ±0.5 up 1:
[145] electrosur days 3
1997 gery(100 Group 2: (3
patients) 37±9 Group 2: %)
Group 2: 1.4±0.2
Ultrasonic days
ally
Activated
Shears
(UAS)
(100
patients
Edelman 80 Group 1: Group 1: Group 1 Gro
at al. Monopolar 56.9 1.4 days up 1:
[27] Electrosur 1
1993 gery Group 2: Group 2: (2.5 %)
Scissors 55.6 1.1 days
 (MEC) (40
patients)

Group 2:
Bipolar
Electrosur
gery
Scissors
(BEC) (40
patients)
Janssen et 200 Group 1: Group 1: Group 1: Group 1:
al. Harmonic 60.0 (median) 1.9 ±0.5 15 (16 %)
[51] Scalpel days
1998-2000 (Ultracisio Group 2: Group 2:
n, UC) 65.0 (median) Group 2: 51 (50 %)
1.4±0.2
(96 days
patients)

Group2:

Electrosur
gery(ES)

(103
patients)
Lane et al. 641 Group1: Group1: Group 1: Group 2: G
[146] 69.8 1.4 ±0.06 4 (0.9 %) roup
1991 (KTP/532) days 1:
laser Group 2: 2
111.8 Group 2: (1%)
(199 1.7
patients) ±0.08 G
Group2: days roup
2:
Monopolar 1
Electrosur 0 (2.3
 gery %)
(MES)

(44
2 patients)
Bordelon 103 Group1: Group 1: Group 1: G
et al. 23.6±9.56 15 roup
[147] Nd:YAG 28.84%) 1:
1990-1991 laser Group 2: 2
19.2±8.8 Group 2: (1.92
(52 8 (15.68 %) %)
patients)

Group2: G
roup
Monopolar 2:
Electrosur 1
gery
(MES) (1.96)

(51
patients)

El Nakeeb 120 Group1: Group 1: Group 1: G

et al. 45.17±10.54 1 roup
[148] Harmonic (1.6 %) 1:
2008-2009 shears Group 2: 2
(HS) (60 69.71±13.01 Group 2: (3.3
patients) 2 %)
(3.3 %)
Group2: G
Clip and roup
Electrosur 2:
gery 3
(5 %)
(C&E)

(60
 patients)

Amaral et 200 Ultrasonic 49.7±1.5 1.4 ±0.1 1 (

al. ally (without days 0.5 %)
[149] activated cholangigraph
1991-1992 scalpel y)
(UAS)
61.4±2.0 (with
cholangigraph
y)

Southern 1518 KTP laser 90.0 7 (0.46 %) 72 1 (0.07%)

Surgeons (314 (4.7
Club patients) %)
[150]
1990 Nd: YAG
laser (127
patients)

Electosurg
ery (1077
patients)

Kurauchi 1408 Type of 12 (0.9 %) 5 (0.3 %) 84 (6

et al. modality %)
[151] not
1991-1993 mentioned
 Table 3. General advantages and disadvantages of energy methods

Monopolar Electrosurgery
Advantages Disadvantages

1. Injury to patients through direct and

capacitive coupling, insulation failure
and return electrode burns.
1. Simple equipment and easy to use. 2. Interference with pacemakers and other
2. Cheaper than other energy devices. equipments during surgery.
3. Usually results in shorter operative 3. Risk from OR fire.
times. 4. Production of smoke.
4. Best method for making simple incisions 5. Higher temperatures at the tool tip and
on the skin [152] longer cool down times to a safer
temperature compared to other energy
based devices [12].
6. Large thermal spread.

Bipolar Electrosurgery
Advantages Disadvantages
1. Passage of current through only the
portion of the tissue that is operated.
1. Operational time is usually longer than
2. Smaller thermal spread ( For example,-
monopolar electrosurgery and not as
EnSeal produced a thermal spread of
effective on small blood vessels.
only 1.84 mm in medium sized (4-5 mm)
2. The amount of thermal spread usually
porcine arteries [153].
depends on the power setting and the
3. Good for coaptive vessel sealing
skill level of the user - Ligasure
4. Bipolar devices produce equal peak
produced thermal spread in the range of
temperatures on different types of
0.6 – 6 mm in porcine organs [26, 38,
tissues with various thickness [10].
154-157]
5. Bipolar devices can be available in
3. Production of smoke.
many forms – scissors, forceps, grips
etc.

Ultrasonic energy
Advantages Disadvantages
1. Produces high blade temperatures and
can damage adjacent tissues or organs
when come in contact immediately after
1. Ultrasonic energy usually produces the swictched OFF [10].
least amount of thermal spread [42, 2. Temperature produced is inversely
165]. proportional to the tissue thickness [10].
2. No smoke and only mist due to 3. Not all devices are the same -the LCS
cavitation effect. device was shown to have caused high
3. Best energy method for sealing small thermal spread – 8.5 mm in porcine
blood vessels (upto 2 mm in diameter) veins [26].
[27, 42, 166] . 4. The high power level settings of
4. Ultrasonic devices (ACE, Wave, ultrasonic devices can cause significant
CS14C) produced the best quality seals thermal spread (upto 25.7 mm) and
at lower power levels [153]. peak temperatures (upto 140°C in
5. Lesser operating time. porcine organs) [44].
5. The ultrasonic devices do not produce
effective sealing for blood vessels over
2mm in diameter [26, 38].
Laser energy
Advantages Disadvantages
1. Can be effective when right laser type
1. Very expensive equipment.
and configuration is chosen.
2. Risk of OR fire.
2. Most widely used in gynecological
3. Increased operating time in general.
procedure because of precise control of
4. Air embolism which can be fatal.
amount and depth of tissues to be
5. Either the precision or efficiency of the
affected,
laser has to be compromised – one of
3. Less scarring compared to other modes
them is usually sacrificed [158].
of energy.

Argon Beam coagulation

Advantages Disadvantages
1. Most effective form of hemostasis and is
used in procedures involving major
1. The major drawback of ABC is argon
blood loss [92, 105, 109].
gas embolism which is a result of the
2. The high efficiency of ABC also
insolubility of argon gas in blood. This
translates to faster coagulation times.
has resulted in cardiac arrests and even
3. Argon gas blows away blood and debris
death [93, 94, 96].
from the surgical field and produces a
2. Mostly used for coagulation (not used
coagulated surface that is more uniform.
for cutting).
4. ABC produces less smoke than
3. Involves the use of electricity, hence the
conventional electrosurgery.
risk of interference with surgical
5. It has shown that the thermal spread of
equipment exists.
the ABC system is constant (2-3 mm)
[140].
!
 Table 4. Deaths due to laparoscopic use of energy sources

Author Energy source Description

Deaths of two women in 1978 and 1979 due
Peterson et al. to the damage to the bowel during the
(1981) Electrosurgery laparoscopic sterilization procedure using
[16] monopolar electrocoagulation. The
complications were post-operative.
Willson et al. Death due to thermal injury to the colon
(1994) Electrosurgery occurring beyond the field of view during
[175] laparoscopic cholecystectomy.
Death of two patients (one with severe liver
failure and one with sepsis ) due to the
Curro et al. failure of laparoscopic cholecystectomy in
(2005) Harmonic Scalpel treatment of Child Pugh C cirrhosis using
[47] the harmonic scalpel. The result is more of
the case of ineffective procedure rather than
a surgical complication.
Death of two patients with embolic cardiac
Tellides et al. and neurologic complications after
(1998) Laser bronchoscopic Nd: YAG laser tumor
[69] ablation. The embolism was caused due to
the use of laser fiber air coolant at high flow.
Death of two patients due to venous
embolization leading to cardiovascular
Baggish et al.
collapose while undergoing intrauterine
(1989) Laser
surgery with the Nd:YAG laser delivered by
[66]
the artificial sapphire tip. Use of sapphire tip
and gas cooling was stated as the reason
Death of one patient due to venous air
embolism while undergoing laser
Challener et al. endometrial ablation with the sheathed
(1990) Laser quartz fiber Nd: YAG laser. The embolism
[67] was caused by the entry of compressed air
to the endometrical cavity while reinserting
the hysteroscope
Death of one patient due to air embolism
Schroder et al. while undergoing laser thermia with the
(1989) Laser Nd:YAG laser delivered by artificial sapphire
[76] tip. Coaxial air flow for cooling was stated
as the reason
 Death of one patient due to venous gas
embolism while undergoing bilateral
Yuan et al.
choanal stenosis with the Nd:YAG laser
(1993) Laser
delivered by artificial sapphire tip. Coxial
[73]
cooling system with N2 gas was stated as
the reason
Peachy et al. Death of one patient due to systemic air
(1988) Laser embolism while undergoing resection of a
[71] bronchial carcinoma with Nd:YAG laser.
Death of one patient due to postoperative
Lang et al.
myocardial infarction because of air
(1991) Laser
embolism while undergoing treatment for
[69]
endobronchial carcinoma with Nd:YAG laser
Sezeur et al.
The death of a 20 year old man undergoing
(2008)
ABC laparoscopic partial splenectomy for the
[97]
removal of a benign cyst.
Death of one patient from complications of a
ECRI report.
gas embolism caused by intra-abdominal
(1994) ABC
overpressurization during a laparoscopic
[98]
cholecystectomy.
Ousmane at al.
Death of one patient from complications of a
(2002) ABC
gas embolism during liver surgery
[99]