BASIC SKILLS

Electrosurgery and energized

dissection

The flow of electrons through tissue between adjacent atoms

is defined as electrical current. This process is driven by the
difference in electrical potential, or voltage, between the atoms.
The electrical energy from the voltage source is converted into
heat energy as the tissue acts as a resistor within the circuit. The
power generated by this heat energy per unit of time is the
product of the current and voltage, expressed as:

David Messenger
Fiona Carter
Nader Francis

Ppower in Watts or Joules=second Icurrent in amperes

 Vvoltage in volts

Abstract
This article outlines the biophysics of electrosurgery and tissue energy
sources, including the basic concepts of both modalities. It explores the
biophysics of electrodiathermy, including current density, waveforms
and electrosurgical circuits. The principles of monopolar and bipolar
diathermy are described with reference to the safety issues pertinent to
implantable cardiac devices and other implants. Safe application of electrodiathermy in endoscopic and laparoscopic surgery are discussed,
exploring potential risks such as direct and capacitance coupling. The
principles behind tissue energizers, specifically advanced bipolar energy
sources and ultrasonic devices, are also covered.

Ohms law describes the relationship of current flowing within

the circuit as:
I V=Rresistance in Ohms
Therefore, power can also be expressed as:
P V 2 =R or I 2  R
Based on these equations, the power generated by an ESU is
proportional to the square of the current and voltage.

Keywords Argon plasma coagulation; biophysics; bipolar; coupling;

electrodiathermy; endoscopy; ERCP; laparoscopy; monopolar; risks; tissue energizers

Current density
The key to achieving the desired clinical effect at the active
electrode is based upon the principle of current density (current
applied per unit of area). The surface area of the active electrode
is small, thus producing a concentrated heating effect at the point
of contact on the patients tissues. Following the same rule, the
surface area of the patient return electrode in monopolar circuits
is much larger than that of the active electrode. This facilitates
dissipation of the current returning to the ESU, minimizing heat
production at the return electrode site. The rise in temperature is
also governed by the length of time the active electrode is in
contact with the tissues, as well as the resistance of the tissues.
This forms the basis of Joules law, which is essentially a derivation of Ohms law:

Introduction
Electrosurgery is based on the principle of energy transformation
from high-frequency alternating current (AC) into heat, thereby
permitting the cutting or coagulation of tissues at the point of
application. A clear distinction should be made with electrocautery, which refers to the use of direct current to generate heat
at the tip of an instrument.
The development of electrosurgery in the 1920s revolutionized the surgeons ability to achieve haemostasis. The physicist
William Bovie, in collaboration with the surgeon Harvey Cushing, was the first to pioneer the routine use of electrosurgery in
clinical practice.1 Electrosurgical units (ESUs) now form the
mainstay of the modern-day surgeons armamentarium. This
article aims to cover the basic principles, applications and potential hazards of electrosurgery, as well as provide an insight
into the newer energized dissection technologies.

Qheat energy in Joules I=cross  sectional area

 R  Ttime

Current waveforms
The alternating current produced by ESUs constantly change the
direction in which current flows. The rapid movement of electrons through the cytoplasm of cells causes the temperature to
rise. The speed at which this movement of electrons occurs per
unit of time is termed the frequency, measured in Hertz (Hz).
ESUs operate in the frequency range of 200 kHz to 3.3 MHz
(Figure 1). The use of such a high frequency range is crucial in
preventing the unwanted neuromuscular stimulation that would
otherwise occur at lower frequencies within the body, typically
<100 kHz.
The current waveform can be modulated to produce the
desired effect on the tissues. A pure cutting waveform is
continuous, sinusoidal and unmodulated (Figure 2). Ideally the
active electrode is held slightly away from the tissue to create a
tiny arc that achieves a cutting effect by vaporization of the tissue
over a short time period. The use of the cutting current in direct

Biophysics
An understanding of the physics underpinning electrosurgery is
fundamental to its safe and effective application by the surgeon.

David Messenger BMedSc MBChB MRCS is a Surgical Registrar at Yeovil

District Hospital, Yeovil, UK. Conflicts of interest: none declared.
Fiona Carter BSc PhD is Manager of the Southwest Surgical Training
Network, Yeovil, UK. Conflicts of interest: none declared.
Nader Francis FRCS PhD is a Consultant Colorectal Surgeon at Yeovil
District Hospital, Yeovil, UK. Conflicts of interest: none declared.

SURGERY 32:3

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The radiofrequency spectrum

No neuromuscular stimulation above 100KHz

60Hz

100KHz

Household
appliances
Neuromuscular
Stimulation
< 100KHz

Muscle
and nerve
stimulation
ceases

200KHz
3.3MHz
Electrosurgery

500KHz
1550KHz
AM Radio

60MHz
TV

Figure 1

contact with the tissue is referred to as desiccation. Direct contact

reduces the current density, causing cells to dry out and form a
coagulum rather than vaporize.
At the opposite end of the spectrum, pure coagulation waveforms are modulated (intermittent ESU output) reducing the
proportion of time that tissue is exposed to current to approximately 6% (Figure 2). This allows for more thermal spread
within the tissues, which reduces the cutting effect but enhances

the ability of the tissues to form a coagulum. It is important to

remember that coagulation modes require much higher voltages
than cut modes to deliver the same amount of power as the flow
of current is interrupted. Fulguration, or spray, refers to electrical
arcing in the coagulation mode with the aim of coagulating or
charring tissue over a wide area. Extreme care must be taken
when fulgurating tissue, as this mode requires the highest
voltage setting in order to overcome the resistance generated by

Current waveforms from pure cut to pure coagulation

LOW VOLTAG E

PURE CUT
100% ON

HIG H VOLTAG E

BLEND
50% ON
50% OFF

COAGULATION
6% ON
94% OFF

Figure 2

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 ideally choose a position in the same quadrant as the

operative site to ensure that the current travels the shortest
distance through the patients tissues
 the appropriate size of return electrode should be used;
paediatric plates are available for patients under 22 kg.
Since the early 1980s, electrosurgery generators have been
equipped with contact quality monitors (CQMs) that in combination with split plates, help to prevent the development of burns
as the CQM shuts down power delivery if the contact surface area
becomes too small.

the air between the electrode and tissue. At such high voltages
the integrity of the insulation surrounding the active electrode
and other instruments may be compromised.
Blended currents consist of a combination of both cutting and
coagulation waveforms. Blend settings can be varied to modify
the degree of current interruption to achieve varying degrees of
cutting and haemostasis.

Electrosurgical circuits
Monopolar
In monopolar delivery systems, current flows from the ESU
through the active electrode into the target tissue, through the
patient, the return electrode and then returns to the ESU
(Figure 3a). The importance of appropriate return electrode
positioning cannot be overstated. The most commonly reported
patient injury associated with electrosurgery are burns at the
return electrode site.2 The return electrode must be of low
resistance and of a sufficient surface area in order to effectively
dissipate heat. Poor contact can reduce the functioning surface
area of the return electrode, leading to an increase in current
density exiting the patient that could potentially cause a burn. It
is important that the following points are considered when
choosing the position of the return electrode:
 choose a well-vascularized muscle mass to maximize the
conduction of current
 avoid areas of vascular insufficiency and other areas of
high resistance, such as scar tissue, oedematous tissues or
bony prominences
 ensure that metal prostheses and electrocardiogram (ECG)
electrodes (potentially an alternative pathway for current
to discharge), are out of the direct path of the circuit. For
the same reason, all metal piercings should be removed

Bipolar
In bipolar electrosurgery the active and return electrodes are
located at the tip of the instrument. A classic example is the
forceps where current passes from the active tine, through the
tissue between the tines, to the return tine and back to the ESU
(Figure 3b). The patients body does not form part of the circuit.
Bipolar units use lower voltages to achieve haemostasis, as only
a small amount of tissue can be held between the tips of the
instrument. It can be used safely on narrow tissue pedicles, unlike monopolar electrosurgery where high current densities
develop down the pedicle and can cause thermal injury to a
remote structure.

General safety guidelines for use of electrosurgery

There are a range of responsibilities across the wider theatre team
in relation to the safe use of electrosurgery, and it is vital that each
team member is aware of their role.3 It is important that all relevant
team members receive appropriate training on each electrosurgical device as safety mechanisms and mode of operation varies for
each manufacturer. The overriding principle should be to use the
lowest effective power settings required and to follow a methodical
troubleshooting approach when such settings do not achieve the
desired effect.
Implantable cardiac devices
Wherever possible electrosurgery should be avoided in patients
with cardiac pacemakers and implantable cardiac defibrillators
(ICDs), though modern devices are less susceptible to erroneous
interference than older versions. Wherever feasible, bipolar
electrosurgical devices should be used in preference to monopolar devices.4 It is recommended that specific advice from a
cardiology team, which may require interrogation of the device,
is performed prior to surgery. In some instances the device is
reset to a maintain only mode to prevent inappropriate shock
delivery or discharge if there is electrical interference. Appropriate precautions should be taken during surgery, including ECG
monitoring and the availability of a defibrillator with an external
pacing function. Any monopolar diathermy use should be limited
to short bursts and the return electrode placed as far away from
the device as possible. For patients with ICDs requiring emergency surgery, consideration should be given to the positioning
of a magnet over the ICD that will inhibit shock delivery.

Monopolar circuit (a), Traditional bipolar circuit (b)

a)

b)

Cochlear implants
Bipolar modalities should be used when possible in patients with
cochlear implants. If monopolar electrosurgery cannot be avoided, the return electrode must be positioned as close as possible
to the active electrode during use.

Figure 3

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Skin preparation
When spirit-based fluids have been used for cleansing the patients skin, it is essential that the preparation is given adequate
time to dry to avoid the risk of ignition and serious burns. Care
must also be taken to avoid pooling of such fluids in the umbilicus, under the drapes or around the return electrode.2

superficial vascular lesions (e.g. angiodysplasia), the palliative

ablation of tumours and haemostasis following resection of large
polyps. In the operative setting, APC is commonly used for hepatic resection and retinal surgery.

Electrosurgery and laparoscopy

When electrosurgery is used in the context of laparoscopic surgery, the potential for injury is increased by the confined environment where vision is limited to the immediate operating field.
A significant portion of the operating instruments and trocars are
off camera where injuries from inadvertent energy transfer may
go unrecognized. A meticulous technique should be practised for
laparoscopic electrosurgical dissection. The tissue should be
tented away from surrounding structures and the ESU only
activated when the surgeon has good vision of the operative
field. As the tissue is divided by the active electrode, this instrument must be carefully controlled to avoid overshooting that
may cause potential thermal damage to surrounding organs. The
tip of the active electrode remains hot for several seconds after
activation, so care is needed to avoid inadvertent damage both
inside the abdominal cavity and outside, once the instrument has
been removed.
In addition to impairing the field of view, electrosurgical
smoke created during laparoscopic surgery has been shown to
contain a number of toxic chemicals.8 The use of smoke or
vapour extraction filters is essential to protect the patient and
operative team.
Electrothermal injuries have a reported incidence of between
1 and 5 injuries per 1000 cases.9,10

Therapeutic applications in endoscopy

Technological advances in the development of video endoscopes
over the past 30 years have revolutionized the field of therapeutic
gastrointestinal endoscopy. Electrosurgery is commonly used to
perform polypectomies and sphincterotomies of the ampulla, as
well as to control bleeding in certain instances.
Polypectomy
Monopolar snare polypectomy is standard practice in most
endoscopy units. Features and location of the polyp within the
gastrointestinal tract are critical to the appropriate application of
current. In pedunculated polyps where the cross-sectional area of
the stalk is relatively small, a higher current density is generated
during transection. A blended mode is recommended for transection to achieve haemostasis but limit thermal spread. Attention to the possibility of thermal damage is of particular
importance when performing polypectomies in the right colon, as
the colonic wall is thinner and more susceptible to perforation.
The thickness of the snare wire influences the tissue effect, with a
thick wire favouring coagulation and thinner wire favouring
cutting. Furthermore, the speed of snare closure may impact on
the adequacy of the current applied. Snare closure that is too
rapid may result in insufficient coagulation and subsequent
bleeding. Most endoscopists have moved away from using hot
biopsy forceps to perform polypectomies owing to the potential
for deep thermal injury and perforation. If hot biopsy is performed, then the forceps should be tented away from the bowel
wall to limit current concentration to a small area of the mucosa
and prevent passage into the submucosa and deeper.

Risks of electrodiathermy in laparoscopic surgery

The most frequently encountered electrothermal injuries arise as
a result of direct coupling, insulation failure and capacitance
coupling.
Direct coupling
Direct coupling occurs when the ESU is accidentally activated
while the active electrode is near another metal instrument.
Current flows through the secondary instrument following the
pathway of least resistance and can potentially damage adjacent
structures outside the visual field.

Sphincterotomy
Sphincterotomes in endoscopic retrograde cholangiopancreatography (ERCP) consist of either a monofilament or braided cutting wire. Factors associated with increased effectiveness of cut
initiation and propagation include a shorter duration of time in
contact with the tissue, higher force applied with the wire to the
tissue and higher power settings.5 The type of current used for
sphincterotomy has not been shown to influence the incidence of
post-sphincterotomy pancreatitis,6 although there is some evidence to suggest that pure cut current settings may increase the
risk of bleeding.7

Insulation failure
This is defined as a break in the insulation that coats the active
electrode. Persistent use of high voltage settings can cause defects in the insulating material. Excessive use of re-usable instruments, which are subject to repetitive passage through
trocars and frequent mechanical sterilization, has also been
implicated in insulation failure. The distal third of a laparoscopic
instrument is the most common site of insulation failure. Current
can discharge from a defect in the insulation that is outside the
field of vision and may go undetected by even the most careful of
surgeons.

Argon plasma coagulation (APC)

APC is a form of non-contact, monopolar electrosurgery, which
unlike conventional fulguration uses a stream of inert argon gas
passing over the tip of the instrument to confine the current to an
ionized stream (argon requires ionization to conduct current)
and allow precision application to the tissues. Current exiting the
instrument follows the path of least resistance, so that tissue that
is already coagulated, and of an increased resistance, is avoided.
This means that a large surface area can be treated rapidly. APC
is predominantly used in the endoscopic setting for coagulating

SURGERY 32:3

Capacitance coupling
A capacitor develops whenever two conductors are separated by
a non-conductor. An electrostatic field is created between the two
conductors across which current can be transferred. In the

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operative field and will require safe extraction in the same

fashion as electrosurgical smoke.

context of laparoscopic surgery, an inadvertent capacitor may

be created by the composition and placement of the surgical instruments. For example, current may be transferred from the
active electrode (conductor) through its intact insulation and into
adjacent conductive materials, typically a metal trocar. The use
of a plastic trocar does not entirely eliminate capacitance as
conductive tissues, such as bowel, can also complete the definition of a capacitor. Hybrid trocar systems, where metal trocars
are held in place by plastic anchors, should be avoided as the
plastic anchor prevents current from dissipating through the
abdominal wall and may exit through adjacent tissue on its way
to the return electrode.

Summary
A sound understanding of the principles of electrosurgery and
tissue energizers is essential for their safe use in the operating
theatre environment. The risks associated with ESUs are multifactorial and these should be stratified according to individual
patient conditions. A team-based approach that involves all staff
in the operating theatre should be employed to minimize the
risks of ESUs, but ultimately it is the responsibility of the surgeon
to ensure their safe use.
A

Tissue energizers
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preventing patient burns at the return electrode site during highcurrent electrosurgical procedures. Health Devices 2005; 34: 273e9.
3 Association for Perioperative Practice. Standards and guidelines: the
electrosurgery team, 2002. http://www.afpp.org.uk/careers/
Standards-Guidance (accessed 26 October 2013).
4 Guidelines for the perioperative management of patients with
implantable pacemakers or implantable cardioverter defibrillators,
where the use of surgical diathermy/electrocautery is anticipated.
Medicines and Healthcare products Regulatory Agency, 2006. http://
www.mhra.gov.uk/home/groups/dts-bi/documents/websiteresources/
con2023451.pdf (accessed 26 October 2013).
5 Ratani RS, Mills TN, Ainley CC, Swain CP. Electrophysical factors
influencing endoscopic sphincterotomy. Gastrointest Endosc 1999;
49: 43e52.
6 Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical
current for endoscopic biliary sphincterotomy: a meta-analysis of
adverse outcomes. Gastrointest Endosc 2007; 66: 283e90.
7 Norton ID, Petersen BT, Bosco J, et al. A randomized trial of endoscopic
biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms. Clin Gastroenterol Hepatol 2005; 3: 1029e33.
8 Hensman C, Baty D, Willis RG, Cuschieri A. Chemical composition of
smoke produced by high-frequency electrosurgery in a closed
gaseous environment. Surg Endosc 1998; 12: 1017e9.
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of electrosurgical injuries in laparoscopy. J Am Coll Surg 1994;
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10 Hulka JF, Levy BS, Parker WH, Philips JM. Laparoscopic-assisted
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1997; 4: 167e71.

In an effort to minimize the risks associated with conventional

ESUs in laparoscopic surgery, recent focus has shifted towards
the development of advanced bipolar and ultrasonic devices.
Advanced bipolar
The basis of bipolar vessel sealing technology relies on integrated adaptive controls measuring the impedance and temperature of the tissues. The bipolar current is combined with
optimal mechanical compression by the jaws of the instrument
to fuse and seal vessel walls. A high frequency, low voltage
current is delivered to the target tissue, which denatures the
elastin and collagen in the vessel wall. The mechanical pressure then allows the denatured proteins to form a coagulum.
It is claimed that vessels up to 7 mm can be sealed by
advanced bipolar devices, although this figure should be
viewed with caution as the presence of atherosclerosis, calcification and the collagen to elastin ratio all affect the burst
pressure of a vessel.
Ultrasonic devices
Ultrasonic devices convert electrical energy from the generator
into ultra-high frequency mechanical energy in the instrument
(55.5 kHz per second with the Harmonic scalpel, EthiconEndosurgery). The heat generated by this process causes protein denaturation and formation of a coagulum that seals vessels.
Ultrasonic devices tend not to be able to seal blood vessels in
excess of 5 mm in diameter. They divide tissue by two cutting
mechanisms. The first is cavitational cutting and fragmentation.
The instrument blade vibrates producing heat pressure changes,
leading to low temperature cellular vaporization and rupture that
allows for precision cutting. The second mechanism is the power
generated by the high-frequency vibrations of the blade stretching tissue beyond its elastic limit. Ultrasonic dissection does not
generate temperature in excess of 80  C, minimizing the distance
of thermal spread within the tissues. Another type of ultrasonic
device is the Lotus (SRA Developments Ltd) that employs
torsional ultrasound in order to minimize the potential distal
drilling effect that may be created by the longitudinal compression forces generated by conventional ultrasonic devices. It
should be noted that ultrasonic devices can create a significant
amount of vapour or spray during use, which may obscure the

SURGERY 32:3

Acknowledgements
The authors wish to thank Andrea De Marchis at Ethicon for the
provision of the images used in Figures 1, 2, 3a, 3b.

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