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MEDICAL EDUCATION
Electrosurgery
Part I. Basics and principles
Arash Taheri, MD,a Parisa Mansoori, MD,b Laura F. Sandoval, DO,a Steven R. Feldman, MD, PhD,a,b,c
Daniel Pearce, MD,a and Phillip M. Williford, MDa
Winston-Salem, North Carolina
CME INSTRUCTIONS
The following is a journal-based CME activity presented by the American Academy of
Dermatology and is made up of four phases:
1. Reading of the CME Information (delineated below)
2. Reading of the Source Article
3. Achievement of a 70% or higher on the online Case-based Post Test
4. Completion of the Journal CME Evaluation
Learning Objectives
After completing this learning activity, participants should be able to list the various
electrosurgical modalities and describe their indications and contraindications;
delineate the tissue effects of various electrical waveforms; recognize the factors
influencing depth of tissue injury; and identify the sources of possible complications
and describe strategies for the prevention of these complications.
Target Audience:
Dermatologists and others involved in the delivery of dermatologic care.
Accreditation
The American Academy of Dermatology is accredited by the Accreditation Council for
Continuing Medical Education to provide continuing medical education for physicians.
AMA PRA Credit Designation
The American Academy of Dermatology designates this journal-based CME activity
for a maximum of 1 AMA PRA Category 1 Credits. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
AAD Recognized Credit
This journal-based CME activity is recognized by the American Academy of
Dermatology for 1 AAD Credit and may be used toward the American Academy of
Dermatologys Continuing Medical Education Award.
Disclaimer:
The American Academy of Dermatology is not responsible for statements made by
the author(s). Statements or opinions expressed in this activity reflect the views of the
author(s) and do not reflect the official policy of the American Academy of
Dermatology. The information provided in this CME activity is for continuing
education purposes only and is not meant to substitute for the independent medical
judgment of a healthcare provider relative to the diagnostic, management and
treatment options of a specific patients medical condition.
Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers
of this journal-based CME activity have reported no relevant financial relationships
with commercial interest(s).
Authors
Dr Feldman is a consultant and speaker, has received grants, or has stock options in
Abbott Labs, Amgen, Anacor Pharmaceuticals, Inc, Astellas, Caremark, Causa
Research, Celgene, Centocor Ortho Biotech Inc, Coria Laboratories, Dermatology
Foundation, Doak, Galderma, Gerson Lehrman Group, Hanall Pharmaceutical Co
Ltd, Informa Healthcare, Kikaku, Leo Pharma Inc, Medical Quality Enhancement
Corporation, Medicis Pharmaceutical Corporation, Medscape, Merck & Co, Inc, Merz
Pharmaceuticals, Novan, Novartis Pharmaceuticals Corporation, Peplin Inc, Pfizer
Inc, Pharmaderm, Photomedex, Readers Digest, Sanofi-Aventis, SkinMedica, Inc,
Stiefel/GSK, Suncare Research, Taro, US Department of Justice, and Xlibris. Drs
Taheri, Mansoori, Sandoval, Williford, and Pearce have no conflicts of interest to
declare.
Planners
The planners involved with this journal-based CME activity have reported no relevant
financial relationships with commercial interest(s). The editorial and education staff
involved with this journal-based CME activity have reported no relevant financial
relationships with commercial interest(s).
Resolution of Conflicts of Interest
In accordance with the ACCME Standards for Commercial Support of CME, the
American Academy of Dermatology has implemented mechanisms, prior to the
planning and implementation of this Journal-based CME activity, to identify and
mitigate conflicts of interest for all individuals in a position to control the content of
this Journal-based CME activity.
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The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency
alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the
mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage
is responsible for at least the majorityif not allof the tissue effects in electrosurgery. Adjacent to the active
electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that
determines the final tissue effects of a current is the depth and the rate at which heat is produced.
Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation.
An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue
and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling
point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which
leads to tissue fragmentation and cutting. ( J Am Acad Dermatol 2014;70:591.e1-14.)
Key words: coagulation; current; electricity; electrocoagulation; electrodesiccation; electrofulguration;
electrosurgery; high frequency; radiofrequency.
INTRODUCTION
Key points
d
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Taheri et al 591.e3
Electrical current or
mode of choice
Alternative currents
Electrocautery
Direct current
Electrosurgery
High-frequency alternating
current
Electrocoagulation (contact
coagulation)
Electrodesiccation
Same as electrocoagulation
Same as electrocoagulation
Electrofulguration (spray or
noncontact coagulation)
Interrupted current
(fulguration mode)
Interrupted current
(coagulation mode)
Bipolar electrosurgery
Monopolar electrosurgery
Bipolar mode
Monopolar modes (for
cutting, coagulation,
desiccation, and
fulguration)
Biterminal electrosurgery
All modes (for cutting,
coagulation, desiccation,
and fulguration)
Monoterminal electrosurgery All modes except for pure
cutting (monoterminal
mode is not suitable for
pure cutting)
Alternating current
Definition
*The cutting mode in some electrosurgical units cannot provide a very low power output that is necessary for a superficial coagulation using
a fine-tip electrode.
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FUNDAMENTALS OF ELECTRICITY
Key points
d
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C
Fig 5. Current leakage in electrosurgery circuit. Current
leakage from active electrode cable to the patients body
may result in a burn. It can occur as a result of putting the
active cable near the patients body (A) or near any
conductive element that is in direct contact or close
contact to the patients body or surgical staff (B; object
F). Examples of object F can be a surgical table or a
metallic clamp that is used for securing the cable to the
surgical drapes over the patients body. On the other hand,
if the active and dispersive electrode cables are put near
each other, current will leak from the active to
dispersive electrode cable before reaching the active
electrode (C). As a result of this power loss, the power
dissipated in tissue will be less than the output power of
the generator.
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BASIC MECHANISM OF
ELECTROSURGERY
Key points
d
An active electrode can concentrate the current at a small area and provide a sufficiently
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Taheri et al 591.e7
CURRENT WAVEFORMS
Key points
d
ELECTROSURGICAL MODALITIES
Electrocoagulation
Key points
d Coagulation can be performed in contact
mode or in spray (fulguration) mode. However, the term electrocoagulation is usually
used to refer to electrocoagulation in contact
mode
d At the end of contact electrocoagulation, the
more superficial coagulated tissues may dry
out (desiccation). The current may decrease
or stop flowing at this time, a popping sound
may be heard, and sparking may occur
through the dried, nonconductive layer,
leading to explosion and fragmentation of
the dried layer
d Practically, a fine-tip electrode can be best
used for superficial electrocoagulation and a
large-tip electrode with a large contact area
only for deep coagulation
d In contact mode, depth of coagulation is
proportional to the size of electrode tip,
Size of area
Large
Medium depth
destruction with
some collateral
damage
Small to
large
Method of application
of current
Electrical current or
mode of choice
Alternative currents
Setting
Possible indications*
Continuous current
(cutting mode)
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Table II. Settings of electrosurgical units for destruction/coagulation based on the indication and type of procedure46-57
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Taheri et al 591.e9
*Although electrosurgery can be used for the mentioned indications, it is not necessarily the treatment of choice.
y
Depending on the power and the speed of movement of the electrode on the target, electrofulguration potentially can induce either a very superficial or a relatively deep destruction.
z
Because of the risk of viral transmission through the smoke, electrofulguration is not a preferred method for the treatment of viral warts.
x
Fragile tumors can be treated using curettage and electrodesiccation as an alternative to excision. However, depending on variables, such as tumor type, location, and size, for many cases of basal
cell carcinoma and keratoacanthoma and most cases of squamous cell carcinoma excision rather than curettage and electrodesiccation is preferred.
Continuous current
(cutting mode)
Small to
large
Loop excision
A thin wire in
loop shape
Medium
Large-tip electrode
to large
and contact method
Deep destruction
(usually used as
an alternative to
excision)
Continuous current
(cutting mode)
power, and duration of activation time. However, a relatively low power may be able to
provide a deeper maximum coagulation
depth than a higher power because of delayed occurrence of desiccation with lower
power
Fulguration mode can provide a superficial
coagulation if a relatively low power is used.
It can cause deeper tissue damage if a relatively higher power is used or if the activated
electrode is kept over a confined area for a
longer period of time
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C
Fig 9. Electrocoagulation and electrodesiccation. The
process starts with coagulation (A). At the end of coagulation, the more superficial coagulated tissue dries out
(desiccation) and become less electrically conductive,
potentially preventing the current from continuing to
flow (B). However, sparking may then occur through the
nonconductive desiccated layer, leading to disruption of
this layer, passage of more current, more heat production,
and deeper thermal damage (C).
Electrosection
Key points
d For a pure cutting (relatively clean incision
with little hemostasis) a thin electrode and a
continuous cutting current (cut mode) is
used. The cutting of the tissue should be
brisk, using the lowest possible power
setting
d A thick electrode cannot provide a pure
clean cut
d Blend cutting can be performed using an
interrupted current (blend or coagulation
mode)
Electrosection provides a means of cutting tissue
in place of a scalpel. The major advantage of this
method of cutting is that hemostasis is achieved
immediately upon incision by coagulation on either
side of the incision wall. Larger blood vessels may
still require additional spot coagulation at the
completion of the cutting to achieve hemostasis.
A thin needle or wire can concentrate current on
a small area in the same way that a fine-tip
coagulation electrode does, and allows the same
cutting effect to be achieved with a lower power
setting. This leads to less heat production and less
collateral tissue coagulation compared with a
thicker electrode.37,58 Therefore, a thin needle or
wire is used to make a relatively clean incision with
minimal coagulation and hemostasis on either side
of the incision wall (Fig 10). A thick needle
electrode can cut through the tissue if a very high
power current is used. In this case, current density
and temperature decreases from electrode more
slowly compared with a thin electrode.25 The result
is a deeper coagulation margin during cutting that
leads to more effective hemostasis and also more
tissue damage. This mode is called blend cut,
meaning a blend of cutting and coagulation
(Fig 10).
When the cutting electrode comes in contact with
the tissue, an initial tissue heating and explosive
vaporization of the medium around the electrode
leads to isolation of the metallic electrode from the
tissue. Ionization of the vapor around the electrode
allows maintaining the current through the vapor
cavity by spark. Therefore, the cutting may continue
without a direct contact between the active electrode
and tissue.25,35 The higher the peak voltage of the
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CONCLUSIONS
The superficial coagulation of small areas (eg,
small, flat, benign epidermal tumors) can be performed with a fine-tip electrode. Cutting, blend,
coagulation, or fulguration mode currents can be
used; however, fulguration or coagulation mode
currents are more likely to cause tissue fragmentation and deeper destruction by producing spark
through the desiccated tissues. Therefore, fulguration current should be avoided for a very superficial
coagulation in contact mode (contact coagulation).
On the other hand, the cutting mode in some
electrosurgical units cannot provide a very low
power output that is necessary for a superficial
coagulation using a fine-tip electrode. In this case,
coagulation mode, which may have a lower minimum output power, may be used. A large-tip
electrode is used for deep coagulation of a large
area. A high power is usually necessary; therefore,
the cutting mode may be needed. Making a relatively
clean incision with little hemostasis (pure cutting)
requires a thin electrode and a cutting current
(cut mode). Blend cutting can be performed using
an interrupted current (ie, blend or coagulation
mode).
Cutting mode current is suitable for all electrosurgical methods except for fulguration, which requires
a higher peak voltage. This is the reason some
electrosurgical units only provide cut and fulguration
modes.
A knowledgeable selection of the electrosurgical
circuit, electrode configuration, power, waveform,
voltage, and activation time is necessary for
achieving the best possible surgical results.
Surgeons should be familiar with the principles of
electrosurgery and its electrophysical properties.
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