SCIENTIFIC PAPER

Principles and Safety Measures of Electrosurgery

in Laparoscopy
Ibrahim Alkatout, MD, MA, Thoralf Schollmeyer, MD, Nusrat A. Hawaldar, MS,
Nidhi Sharma, MS, Liselotte Mettler, PhD

ABSTRACT INTRODUCTION
Background: Electrosurgical units are the most common A basic understanding of electricity is needed to safely
type of electrical equipment in the operating room. A apply electrosurgical technology for patient care.1 Electro-
basic understanding of electricity is needed to safely apply surgery is one of the most commonly used energy systems
electrosurgical technology for patient care. in laparoscopic surgery.2 The surgical team should have a
good understanding of the principles of electrosurgery
Methods: We reviewed the literature concerning the es-
and tissue effects to avoid complications. The risk of
sential biophysics, the incidence of electrosurgical inju-
complications is linked to the surgeon’s fundamental
ries, and the possible mechanisms for injury. Various
knowledge of instruments, surgical technique, biophysics,
safety guidelines pertaining to avoidance of injuries were
relevant anatomy, and safe technical equipment. The risk
also reviewed.
of complications is linked to fundamental surgical knowl-
Results: Electrothermal injury may result from direct ap- edge of instruments, surgical technique, biophysics, and
plication, insulation failure, direct coupling, capacitive relevant anatomy. Appropriately applied, electrosurgery is
coupling, and so forth. safe and effective. Electrothermal injury may result from
direct application, insulation failure, direct coupling, and
Conclusion: A thorough knowledge of the fundamentals capacitive coupling.3
of electrosurgery by the entire team in the operating room
is essential for patient safety and for recognizing potential
History
complications. Newer hemostatic technologies can be
used to decrease the incidence of complications. The conception of electrosurgery began in the early 19th
century when the French physicist Becquerel first used
Key Words: Electrosurgery, Electrosurgical safety, Lapa- electrocautery. Rather than using boiled oil to achieve
roscopic electrosurgery. hemostasis, he passed direct current through a wire
thereby heating it and effectively cauterizing tissue upon
contact. In 1881, D. Arsonoval pioneered the use of alter-
nating current.
It was not until the late 1920s that collaboration between
the physicist, William T. Bovie and the neurosurgeon
Harvey Cushing resulted in the predecessor of today’s
electrosurgical unit. This model was used until 1968 when
a smaller model was developed by Valleylab, which has
since produced today’s platform of electrosurgical units.3

BASIC PRINCIPLES OF ELECTROSURGERY

Energy in wattage (power) is the product of current and
Department of Obstetrics and Gynaecology, University Hospitals Schleswig-Hol- voltage. Power is the amount of current times the voltage
stein, Campus Kiel, Germany (all authors).
level at a given point measured in wattage or watts (W). It
Conflict of interest: The authors declare that they have no conflict of interest.
corresponds to the rate of work being performed, W⫽V⫻I.
Address correspondence to: Professor Liselotte Mettler, Department of Obstetrics
and Gynaecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold- Ohm’s law, I⫽V/R, shows the relationship between the
Heller-Str. 3, House 24, 24105 Kiel, Germany. E-mail: [email protected]
properties of electrosurgical energy.
DOI: 10.4293/108680812X13291597716348
© 2012 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by Current (I) is what flows on a wire or conductor like water
the Society of Laparoendoscopic Surgeons, Inc. flowing down a river. Current flows from negative to

130 JSLS (2012)16:130 –139

positive on the surface of a conductor. Current is mea- surgical generator, the active electrode and the return
sured in amperes (A) or amps. electrodes. The electrosurgical unit is the source of the
voltage.4 – 6
Voltage (V) is the difference in electrical potential between 2
points in a circuit. It is the push or pressure behind current Electrical energy is converted to heat in tissue as the tissue
flow through a circuit and is measured in volts (V). resists the flow of current from the electrode. Three tissue
effects are possible with today’s electrosurgical units—
Resistance determines how much current will flow
cutting, desiccation, and fulguration.7 Achieving these ef-
through a component. Resistors are used to control volt-
fects depends on the following factors: current density,
age and current levels. A very high resistance allows a
time, electrode size, tissue conductivity, and current
small amount of current to flow. A very low resistance
waveform.6,8
allows a large amount of current to flow. Resistance is
measured in ⍀ ohms.
1. Current density
Principles of Electrosurgery As expected, the greater the current that passes through
an area, the greater the effect will be on the tissue.4
Often “electrocautery” is used to describe electrosurgery.
This is incorrect. Electrocautery refers to direct current
2. Time
(electrons flowing in one direction), whereas electrosur-
gery uses alternating current (Figure 1). Modern day elec- The length of time a surgeon uses an active electrode deter-
trosurgery is the utilization of alternating current at radiofre- mines the tissue effect. Too long an activation will produce
quency levels. During electrocautery, current does not enter wider and deeper tissue damage. Too short an activation will
the patient’s body. Only the heated wire comes in contact result in absence of the desired tissue effect.9
with tissue. In electrosurgery, the patient is included in the
circuit and current enters the patient’s body. 3. Electrode Size
Electrical current flows when electrons from one atom With respect to electrode size, smaller electrodes provide
move to an adjacent atom through a circuit. Heat is pro- a higher current density and result in a concentrated
duced when electrons encounter resistance. For current to heating effect at the site of tissue contact. Following the
flow, a continuous circuit is needed. In the operating same principle, the patient return electrode used in mo-
room, the circuit is composed of the patient, the electro- nopolar electrosurgery is large in relation to the active

Figure 1. Direct and alternating current.

JSLS (2012)16:130 –139 131

Principles and Safety Measures of Electrosurgery in Laparoscopy, Alkatout I et al.

electrode in order to disperse the current returning to the away from the tissue to create a spark gap or steam
electrosurgical unit and minimize heat production at this envelope through which the current arcs to the tissue.
return electrode site.6 – 8 This spark gap results from heating up the atmosphere
between the electrode and the tissue.13 The coagulation
4. Tissue Conductivity current is effective with the power settings in the range of
30W and 50W.6
Various tissue types have a different electrical resistance,
which affects the rate of heating. Adipose tissue and bone Fulguration (Spray) is a noncontact coagulation that also
have high resistance and are poor conductors of electric- utilizes spark gap to mediate tissue effects, which results
ity, whereas muscle and skin are good conductors of in heating and necrosis as well as greater thermal spread.
electricity and have low resistance.7,10 Desiccation (Deep) is another form of coagulation in
which direct contact is made with the tissue, resulting in
5. Current Waveforms electrical energy being converted into heat within the
The final determinant of how tissue responds to elec- tissue. The end result is deeper necrosis and greater ther-
trosurgery is the current type. Electrosurgical units pro- mal spread.9
duce 3 different waveforms: cut, blend, and coagulation Table 1 is giving an overview of the tissue effects of the
(Figure 2).9 two traditional and two innovative energy modalities.
A pure cutting (vaporization) waveform is continuous,
In monopolar electrodes, radiofrequency current flows from
unmodulated, and undamped. A coagulation waveform is
the generator through the active electrode, into the target
interrupted, modulated, and damped current.11,12 A blend
tissue, through the patient, the dispersive electrode and then
waveform is a modification of the cutting waveform and is
returns to the generator.13 The most common site of injury is
used when hemostasis is needed while cutting.5,6 This
at the patient return electrode. The return electrode must be
waveform type consists of a combination of both cutting
of low resistance with a large enough surface area to dis-
and coagulation waveforms.4 Higher blend settings trans-
perse the electrical current without generating heat. If the
late into more time between bursts of current and greater
patient’s return electrode is not large enough or is not com-
coagulation, as seen in the following examples: Blend 1
pletely in contact with the patient’s skin, then the current
(80% cut, 20% coagulation); Blend 2 (60% cut, 40% coag-
exiting the body can have enough density to produce unin-
ulation); and Blend 3 (50% cut, 50% coagulation).9
tended burns. Excessive hair, adipose tissue, bony promi-
A cutting current power setting must be between 50W and nences, and the presence of fluid and scar tissue compro-
80W to be effective. Ideally, the electrode is held slightly mise the quality of contact. To avoid this type of injury,

Figure 2. Wave forms of electrosurgical units with different tissue effects.

132 JSLS (2012)16:130 –139

 Table 1.
Comparison of Tissue Effects of 4 Energy Modalities4
Monopolar Traditional Bipolar Advanced Bipolar Ultrasonic

Tissue Effect Cutting, Coagulation Coagulation Cutting, coagulation Cutting, coagulation

Power Setting 50–80 W 30–50W DEFAULT 55,000 Hz frequency
Thermal Spread Not well assessed 2–6mm 1–4mm 1–4mm
Maximum Temperature ⬎100°C ⬎100°C Not well assessed ⬍80°C
Vessel Sealing Ability Not applicable Not applicable Seals vessels ⱕ7mm Seals vessels ⱕ5mm
Technique Not applicable Not applicable Tension free application Tension free application

Figure 4. In bipolar electrosurgery, the 2 tines of the forceps

form the active and return electrode functions.

Figure 3. Monopolar circuit.

contact quality monitoring systems were introduced in 1981.

This system inactivates the generator if a condition develops
at the patient return electrode site that could result in a burn
(Figure 3 and Table 1).
In bipolar electrosurgery the active and return electrodes
are located at the site of surgery, typically within the
instrument tip. The classical example is the 2 tines of
forceps that are the active and return electrode and repre-
sent the entire circuit.9 Most bipolar units use a lower voltage Figure 5. Tissue charring and thermal spread are inversly related
waveform to achieve hemostasis and avoid collateral tissue to the voltage setting.
damage.4 Bipolar electrosurgery has a more limited area of
thermal spread compared with that of monopolar electrosur-
gery, and is similar to that of a laser.14,15 The maximal lateral Complications of Electrosurgery
thermal spread is within 5mm and the depth limited to the
serosal layer (Figure 4 and Table 1).15 Electrothermal injury may result from the following situ-
ations: direct application, direct coupling, insulation fail-
Disadvantages of bipolar electrosurgery include the in- ure, capacitive coupling, and so forth.
creased time needed for coagulation due to a low power
setting, charring, and tissue adherence with incidental
tearing of adjacent blood vessels (Figure 5).16 Direct Application
This may be due to unintended activation of the electro-
Incidence of Electrothermal Injuries
surgical probe, eg, moving from the intended operating
Injury from inadvertent energy transfer has a reported area to an iliac artery or vein on the pelvic sidewall, or
incidence of 1 to 5 recognized injuries per 1,000 cases.17,18 operating on a moving ovarian cyst.17

JSLS (2012)16:130 –139 133

Principles and Safety Measures of Electrosurgery in Laparoscopy, Alkatout I et al.

Direct Coupling instrument, which is outside the view of the monitor but
distal to the protective cannula, carries the highest risk for
Direct coupling occurs when the electrosurgical unit is
creating an injury that even the most attentive surgeon is
accidentally activated while the active electrode is in close
unable to detect. Disposable instruments have a lower
proximity to another metal instrument. Current from the
incidence of insulation failure compared with reusable
active electrode flows through the adjacent instrument
instruments. The distal third of laparoscopic instruments is
through the pathway of least resistance, and potentially
the most common site of insulation failure (Figure 7).20
damages adjacent structures or organs not within the vi-
sual field that are in direct contact with the secondary
Capacitive Coupling
instrument.6 It can be prevented with visualization of the
electrode in contact with the target tissue and avoiding Capacitive coupling is electrical current that is established
contact with any other conductive instruments prior to in tissue or in metal instruments running parallel to but not
activating the electrode (Figure 6).4 directly in contact with the active electrode. This occurs
when electric current is transferred from one conductor
Insulation Failure (the active electrode) through intact insulation and into
adjacent conductive materials (eg, bowel) without direct
This is now thought to be a main cause of laparoscopic
contact.21
electrosurgical injuries. It is defined as a break or defect in
the insulation that coats the instrument. Insulation failure In monopolar mode, an alternate current flowing through
is caused by excessive use of reusable instruments, par- an active monopolar electrode and back to the electrosur-
ticularly with repetitive passage through trocars and fre- gical generator through the patient and the return pad
quent mechanized sterilization.19 By lowering the concen- induces an unintended current in any conductors in close
tration of the current used, coagulation with cutting proximity. The degree of current induced will depend on
current and use of an active electrode monitoring system, the proximity of the conductors, the voltage, and the
the risk of accidental burns can be reduced.6 insulation. Any conductor in the operating room is at risk
of inheriting a stray current by becoming capacitively
Eighteen percent of insulation defects are located in the
coupled to the current coming from the active electrode.
section of the instrument most likely to create a cata-
strophic electrosurgical injury. Originally described as
‘‘Zone 2 ” by Voyles and Tucker, the location along the

Figure 6. Direct coupling occurs when an active electrode

makes an unintended contact with another electrode or conduc- Figure 7. Insulation failures. Any break in the insulation may
tive instrument. provide an alternate pathway for the flow of current.

134 JSLS (2012)16:130 –139

If an injury is to occur it is often away from the surgeons With direct traumatic perforation, symptoms usually occur
visual field and involves body structures. Ironically, the within 12 hours to 36 hours, although their occurrence up
use of metal trocars can actually reduce this risk by allow- to 11 days later has been reported.24,25 The time delay
ing the stored energy from a capacitor to dissipate over from burn to perforation would appear to be related to the
the large surface area of the patient’s skin, thereby severity of the coagulation necrosis.26 Features of electri-
making the electrical energy less concentrated and less cal injuries are distinguished by an area of coagulative
dangerous. The use of an active electrode monitoring necrosis, absence of capillary ingrowth of fibroblastic
system and limiting the amount of time that a high muscle coat reconstruction, and absence of white cell
voltage setting is used can also eliminate concerns about infiltration, except in focal areas at the viable borders of
capacitive coupling (Figure 8).4,6,16,22 injury.24,25

Clinicopathological Findings Safety measures for prevention of electrosurgical compli-

cations:
Most electrothermal injuries to the bowel (approximately
75%) are unrecognized at the time of occurrence.16 The 1. Inspect insulation carefully
result of an unrecognized bowel injury is usually serious, 2. Use the lowest possible power setting
often leading to long-term complications. The small
bowel, especially the ileum, is most frequently involved, 3. Use a low-voltage waveform (cut)
and the injury may not cause clear-cut or rapid symptoms
4. Use brief intermittent activation
and abnormal laboratory values.23 Generally speaking,
symptoms of bowel perforation following electrothermal 5. Do not activate in open circuit
injury are usually seen 4 to 10 days after the procedure.
6. Do not activate in close proximity or direct contact with
another instrument
7. Use bipolar electrosurgery when appropriate
8. Select an all metal cannula system as the safest choice
9. Utilize available technology (tissue response generator,
active electrode monitoring) to eliminate concerns about
insulation failure and capacitive coupling.27

NEWER TECHNOLOGIES

Active Electrode Monitoring Systems

In an effort to minimize the risks of insulation failure and

capacitive coupling, active electrode monitoring systems
now exist. When interfaced with electrosurgical units,
these systems continuously monitor and shield against the
occurrence of stray electrosurgical currents. Critical to the
success of these systems are the integrated laparoscopic
instruments that have a secondary conductor within the
shaft that provides coaxial shielding.9

Tissue Response Generator

Figure 8. Capacitive Coupling. A capacitively coupled current Tissue response generators are the next step in the evo-
typically returns through a metal trocar sheath to the grounding lution of electrosurgical generators. By using a computer-
pad. If a plastic trocar sheath is used, the current will accumulate controlled tissue feedback system that senses tissue im-
at the junction of the plastic and metal and seek an alternate pedance or resistance, a consistent electrosurgical clinical
path. effect is obtained through all tissue types.6,27

JSLS (2012)16:130 –139 135

Principles and Safety Measures of Electrosurgery in Laparoscopy, Alkatout I et al.

Vessel Sealing Technology Its higher cost is a significant handicap for its use in
surgery in developing countries.
The most recent advancement in electrosurgery has been
the introduction of vessel sealing technology. Core to this The EnSeal instruments adjust dose energy simultaneously
technology is the use of bipolar electrosurgery that relies to various tissue types in a tissue bundle each with its own
on tissue response generators. This advanced electrical impedance characteristics. Less heat is required to accom-
current is combined with optimal mechanical pressure plish fusion, as the tissue volume is minimized through
delivery by the instruments to fuse vessel walls and create compression; energy is focused on the captured segment;
a seal. Specifically, high current and low voltage are de- and the vessel walls are fused through compression, pro-
livered to the targeted tissue and denature the collagen tein denaturation, and then renaturation.
and elastin in the vessel wall while the mechanical pres-
sure from the instrument allows the denatured protein to Ultrasonic Technology
form a coagulum.28 Vessels up to 7mm in diameter and
large tissue bundles can now be surgically ligated. Addi- The Harmonic scalpel is an ultrasonic surgical instrument
tionally, thermal spread appears to be reduced compared for cutting and coagulating tissue, operating at a fre-
to traditional bipolar electrosurgical systems. Unlike tra- quency of 55.5 kHz/second or 55,500 cycles per second
ditional electrosurgical instruments, these devices re- (Figure 9 and Table 1).34
quire a tension-free application to tissue bundles to There is no electrosurgical current generated. The combi-
successfully obtain the desired tissue effect. Valleylab, nation of mechanical energy and the heat that is generated
Gyrus ACMI, and SurgRx, Inc. are 3 companies that causes protein denaturation and formation of a coagulum
have developed devices for both open and laparo- that seals small blood vessels. Typically, this energy mo-
scopic applications.6,8,28 –31 dality is effective for blood vessels between 2mm and
3mm, although a newer device has demonstrated the
The LigaSure system produces supraphysiological seals ability to coagulate blood vessels up to 5mm in diameter
with significantly higher bursting pressures than the with less heat, charring, and thermal injury to surrounding
plasma kinetics sealer (PK, Gyrus Medical, Maple Grove, tissues.35–37
MN) in vessels ranging from 4mm to 7mm. The plasma
kinetics (PK) seal becomes progressively weaker while The 2 cutting mechanisms of the Harmonic scalpel are
the LigaSure seal increases in strength as the vessel size different from that observed with electrosurgery or laser
increases.32 surgery. The first mechanism is cavitational cutting and
fragmentation. As the blade tip vibrates, it produces large
The LigaSure vessel sealing system is a safe alternative for transient pressure changes, which causes cellular water to
securing pedicles in vaginal hysterectomy compared with vaporize at low temperature, rupturing cells, leading to
conventional suture ligation.33 The LigaSure system re- very precise cutting and dissection. The second mecha-
duces the operating time (by reducing pedicle-securing nism for cutting by Harmonic scalpel is the actual power
time) and blood loss without increasing the postoperative cutting offered by a relatively large blade vibrating 55,500
complication rates of vaginal hysterectomy. This benefi- times per second. The blade edge cuts tissue by stretching
cial effect was more pronounced in difficult procedures. it beyond its elastic limit and on a more microscopic level,

Figure 9. Principles of ultracision technology in surgery.

136 JSLS (2012)16:130 –139

by breaking molecular bands. The heat generated from that can extend into the subcutaneous fat even when the
friction of tissue is typically ⬍80°C. This minimizes tissue optical tip is not in direct contact with the skin.39
charring, desiccation, and the zone of thermal injury.34
Disadvantages of this technology are the formation of Burns
aerosolized fatty droplets from the tissue being treated,
which can interfere with visualization through a laparo- Burns to the patient and perioperative personnel can
scope.28,38 occur when the cautery tip is not placed in its insulated
container on the surgical field. Patients can also be burned
at the site of the dispersive pad. Alternative site burns
Laparosonic Coagulating Shears (LCS) occur when the patient’s skin is in contact with metal or
Unsupported tissue, such as a transected bleeding vessel other conductive materials and the electric currents return
in a mesentry that cannot be compressed against a firm to the ground or the electrosurgical unit through this
surface, is difficult to coagulate with a dissecting hook site.39
blade. To obviate this problem, the LCS was developed to
include a vibrating blade with a sharp and blunt edge as Shocks
well as passive tissue pad with which tissue is pressed
Shocks from the electrosurgical unit have occurred, which
against the active vibrating blade. This device allows un-
are frequently mistaken for burns and usually occur when
supported tissue to be grasped and coagulated without
the surgeon is holding the instrument on the tissue to be
difficulty, or cut and coagulated like a pair of scissors.34
cauterized. To prevent the shock, the active electrode
With the advent of new technology, it is crucial to should be placed on the region of interest before activa-
understand the mechanics of how instruments work to fully tion.40
be able to utilize them and prevent injury. The LigaSure has the
highest burst pressure and fastest sealing time and was Surgical Smoke
the highest rated overall. The Harmonic scalpel produced The National Institute of Occupational Safety and Health
the lowest thermal spread and smoke but had the lowest (NIOSH) and the Centers for Disease Control (CDC) have
mean burst pressure. The Gyrus plasma kinetics had the studied electrosurgical smoke at length. They state, “Re-
highest smoke production and variable burst pressures. search studies have confirmed that this smoke plume can
Despite using nanotechnology, the Enseal device was the contain toxic gases and vapors, such as benzene, hydro-
slowest and had variable burst pressures.32 gen cyanide, formaldehyde, bioaerosols, dead and live
All of these partly or fully disposable instruments contrib- cellular material and viruses.”
ute to the quality of the surgery but also to the costs. These The Occupational Safety and Health Administration rec-
can be considerable; however, if we board a plane we ommends that smoke evacuation systems be used to re-
expect the highest safety standards available and the same duce potential acute and chronic health risks to patients
applies to surgical situations. and personnel.41

Thermal Injury Secondary to Fiberoptic Cables CONCLUSION

Laparoscopy requires a reliable light source to provide Principles of electrosurgery must be thoroughly under-
adequate visualization. Thermal damage may however stood by all operating room personnel. This forms the
occur secondary to the fiberoptic light source.39 basis for patient safety and helps in early recognition of
possible complications.42 The advantages and disadvan-
In a study conducted by Hindle et al,39 it was found that
tages of various forms of electrosurgery must be born in
the maximum temperature at the optical cable was be-
mind while using a particular modality. Newer technolo-
tween 119.50 C and 268.60 C. They also found that when
gies with more efficient hemostatic properties must be
surgical drapes were exposed to the tip of the light source,
used whenever appropriate.
the time to char was 3 seconds to 6 seconds, and signifi-
cant injury was recorded with the optical cable 3mm from
the skin. Hindle et al concluded that the temperature at References:
the tip of the optical light cord can induce extreme dam- 1. Christopher MJ, Ketsia BP, Ian BN, et al. Electro surgery. Cur
age and can produce immediate superficial tissue necrosis Surg. 2006;63:458.

JSLS (2012)16:130 –139 137

Principles and Safety Measures of Electrosurgery in Laparoscopy, Alkatout I et al.

2. Wu MP, Ou CS, Chen SL, Yen EYT, Rowbotham R. Compli- 19. Vancaillie TG. Active electrode monitoring. How to prevent
cations and recommended practices for electrosurgery in lapa- unintentional thermal injury associated with monopolar electro-
roscopy. Am J Surg. 2000;179:67–73. surgery at laparoscopy. Surg Endosc. 1998;12:1009 –1012.
3. Nezhat CH, Nezhat F, Brill I, Nezhat C. Normal variations of 20. Montero PN, Robinson TN, Weaver JS, Stiegmann GV. Insu-
abdominal and pelvic anatomy evaluated at laparoscopy. Obstet lation failure in laparoscopic instruments. Surg Endosc. 2010;24:
Gynecol. 1999;94:238 –242. 462– 465.

4. Jones CM, Pierre KB, Nicoud B, Stain SC, Melvin WV. Elec- 21. Odell RC. Electrosurgery: biophysics, safety and efficacy. In:
trosurgery. Curr Surg. 2006;63:458 – 463. Mann WJ T, Stovall G, eds. Mann/Stovall Gynecologic Surgery.
New York: Churchill Livingstone; 1996;55– 67.
5. Van Way CW, Hinrichs CS. Technology focus: electrosurgery
201:basic electrical principles. Curr Surg. 2000;57:261–264. 22. Vilos G, Latendresse K, Gan BS. Electrophysical properties
of electrosurgery and capacitive induced current. Am J Surg.
6. Valleylab. Principles of electrosurgery. 1999;1–23. 2001;182:222–225.
7. Advincula AP, Wang K. The evolutionary state of electrosur- 23. Soderstrom RM. Bowel injury litigation after laparoscopy.
gery: where are we now? Curr Opin Obstet Gynecol. 2008;20(4): J Am Assoc Gynecol Laparosc. 1993;1:74 –77.
353–358.
24. Levy BS, Soderstrom RM, Dail DH. Bowel injuries during
8. Massarweh N, Cosgriff N, Slakey D. Electrosurgery: history, laparoscopy: gross anatomy and histology. J Reprod Med. 1985;
principles, and current and future uses. Am Coll Surg. 2006;202: 30:168 –172.
520 –530.
25. Reich H. Laparoscopic bowel injury. Surg Laparosc Endosc.
9. Wang K, Advincula AP. Current thoughts in electrosurgery. 1992;2:74 –78.
Int J Gynaecol Obstet. 2007;97:245–250.
26. Saltzstein EC, Schwartz SF, Levinson CJ. Perforation of the
10. Neufield GR. Principles and hazards of electrosurgery in- small intestine secondary to laparoscopic tubal cauterization.
cluding laparoscopy. Surg Gynecol Obstet. 1978;147:705–710. Ann Surg. 1973;178:34 –37.
11. Miller CE. Basic equipment and room setup. In: Shirk GJ, 27. Mayooran Z, Pearce S, Tsaltas J, et al. Ignorance of electro-
Editor, The Video Encyclopedia of Endoscopic Surgery for the surgery among obstetricians and gynaecologists. BJOG. 2004;
Gynecologist. St Louis: Medical Video Productions; 1994; 111:1413–1418.
11–19.
28. Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF,
12. Phipps JH. Understanding electrosurgery: safety and effi- Heniford BT. Comparison of ultrasonic energy, bipolar thermal
ciency. In: Lower A, Sutton Cand. Grudzinskas G, eds. Introduc- energy, and vascular clips for the hemostasis of small-, medium-,
tion to Gynecological Endoscopy. Oxford, UK: Iris Medical Me- and large-sized arteries. Surg Endosc. 2003;17:1228 –1230.
dia; 1996;39 –56.
29. Carbonell AM, Joels CS, Kercher KW, Matthews BD, Sing RF,
13. Tucker RD, Schimitt OH, Sievrt CE, et al. Demodulated low Heniford BT. A comparison of laparoscopic bipolar vessel seal-
frequency currents from electrosurgical procedures. Surg Gyne- ing devices in the hemostasis of small-, medium-, and large-sized
col Obstet. 1984;159:39 – 43. arteries. J Laparoendosc Adv Surg Tech A. 2003;13:377–380.

14. Martin DC, SoderstromRM, Hulka JF, et al. Electrosurgery 30. Pietrow PK, Weizer AZ, L’Esperance JO, Auge BK, Silverstein
safety. Am Assoc Gynecol Laparosc Tech Bull. 1995;1–7. A, Cummings T et al. Plasma kinetic bipolar vessel sealing: burst
pressures and thermal spread in an animal model. J Endourol.
15. Ryder RM, Hulka JF. Bladder and bowel injury after electro- 2005;19:107–110.
desiccation with Kleppinger bipolar forceps: a clinicopathologic
study. J Reprod Med. 1993;38:595–598. 31. Richter S, Kollmar O, Schilling MK, Pistorius GA, Menger
MD. Efficacy and quality of vessel sealing: comparison of a
16. Tucker RD, Volyes CR. Laparoscopic electrosurgical compli- reusable with a disposable device and effects of clamp surface
cations and their prevention. AORN. 1995;62:49 –78. geometry and structure. Surg Endosc. 2006;20:890 – 894.
17. Nduka CC, Super PA, Monson JR, Darzi AW. Cause and 32. Lamberton GR, Hsi RS, Jin DH, Lindler TU, Jellison FC,
prevention of electrosurgical injuries in laparoscopy. J Am Coll Baldwin DD. Prospective comparison of four laparoscopic ves-
Surg. 1994;179:161–170. sel ligation devices. J Endourol. 2008;22(10):2307–2312.
18. Hulka JF, Levy BS, Parker WH, Philips JM. Laparoscopic- 33. Hefni MA, Bhaumik J, El-Toukhy T, et al. Safety and efficacy
assisted vaginal hysterectomy: American Association of Gyneco- of using the LigaSure vessel sealing system for securing the
logic Laparoscopists 1995 membership survey. J Am Assoc Gy- pedicles in vaginal hysterectomy: randomised controlled trial.
necol Laparosc. 1997;4:167–171. BJOG. 2005;112(3):329 –333.

138 JSLS (2012)16:130 –139

34. Lee SJ, Park KH. Ultrasonic energy in endoscopic surgery. 39. Hindle AK, Brody F, Hopkins V, Rosales G, Gonzalez F,
Yonsei Medical Journal. 1999;40:545–549. Schwartz A. Thermal injury secondary to laparoscopic optic
cables. Surg Endosc. 2008;23:1720 –1723.
35. Shimi SM. Dissection techniques in laparoscopic surgery: a
review. J R Coll Surg Edinb. 1995;40:249 –259. 40. Ulmer B. Electrosurgery Continuing Education Module. Val-
leylab Institute of Clinical Education, 2000.
36. Goldstein SL, Harold KL, Lentzner A, et al. Comparison of
thermal spread after ureteral ligation with the laparosonic ultra- 41. AORN Recommended Practices for Electrosurgery, 2003.
sonic shears and the ligasure system. J Laparoendosc Adv Surg
42. Randle Voyles C, Tucker RD. Safe use of electrosurgical
Tech A. 2002;12:61– 63.
devices during minimally invasive surgery. In: Wetter PA, ed.
37. Heniford BT, Matthews BD, Sing RF, et al. Initial results with Prevention & Management of Laparoendoscopic Surgical Com-
an electrothermal bipolar vessel sealer. Surg Endosc. 2001;15: plications, 2nd Edition. Miami, Florida, USA: Society of Lapa-
799 – 801. roendoscopic Surgeons, Inc., 2005.
38. Sutton C. Power sources in endoscopic surgery. Curr Opin
Obstet Gynecol. 1995;7:248 –56.

JSLS (2012)16:130 –139 139