title: Quantifying inadvertent thermal bowel injury from the monopolar instrument.
abstract: Insulation defects are observed in 3-39 % of laparoscopic instruments. Electrosurgical injuries due to insulation defects or capacitive coupling remain an issue in laparoscopic surgery with a prevalence of 0.6-5 per thousand cases. Shielded instruments with active electrode monitoring (AEM) have been postulated to prevent these injuries. The benefit of these instruments has not been quantified. Most bowel injuries are unrecognized intra-operatively. Injury is revealed only after the patient exhibits peritonitis symptoms and surgical intervention to repair the bowel is required. These injuries may result in devastating and costly complications or mortality. The extent of bowel injury possible with commonly used generator settings and associated energy output has never been histologically defined. Our objectives in this experimental study were: quantify and compare the energy released through insulation defects or capacitive coupling with standard unshielded monopolar versus shielded instruments with (AEM), determine energy required to cause a visible burn, and relate the histological burn depth to a given amount of energy.
  
  
  
  Ex vivo porcine jejunum was used for tissue testing. An oscilloscope measured energy output from three common electrosurgical generators at recommended power settings with standard or AEM instruments with insulation defects and in capacitive coupling scenarios. Presence of a visible burn was noted, and depth of tissue damage for a given amount of energy was measured histologically.
  
  
  
  All samples that received ≥3.8 J of energy had visible burns. As little as 10 J caused full wall thickness burns. 3.8 J was exceeded at the 30- and 50-W power settings in every experimental scenario using standard monopolar instruments; AEM instruments never approached this much energy.
  
  
  
  Serious burn injury results from small amounts of energy leaked from standard instruments. AEM instruments appeared protective and did not leak sufficient energy to cause burn injuries to the bowel.
authors.affiliation: Department of Clinical and Translational Sciences, University of Colorado Anschutz Medical School, 3936 Bogey Ct., Aurora, CO, 80503, USA. Kimberly.Martin@UCDENVER.EDU.
authors.forename: Kimberly E
authors.initials: KE
authors.lastname: Martin
authors.affiliation: Department of Biostatistics, University of Colorado Anschutz Medical School, Aurora, CO, USA.
authors.forename: Camille M
authors.initials: CM
authors.lastname: Moore
authors.affiliation: Department of Pathology, University of Iowa, Iowa City, IA, USA.|Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Tucker
authors.affiliation: Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Pascal
authors.initials: P
authors.lastname: Fuchshuber
authors.affiliation: Department of Surgery, University of Colorado Anschutz Medical School, Aurora, CO, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Robinson
mesh_terms: D000818:Animals; D002056:Burns / Q000209:etiology* / Q000473:pathology; D004566:Electrodes; D004598:Electrosurgery / Q000009:adverse effects* / Q000295:instrumentation; D004868:Equipment Failure; D007422:Intestines / Q000293:injuries; D007583:Jejunum / Q000293:injuries* / Q000473:pathology; D010535:Laparoscopy / Q000009:adverse effects*; D008953:Models, Anatomic; D013525:Surgical Instruments / Q000009:adverse effects*; D013552:Swine
keywords: Bowel injury; Capacitive coupling; Insulation defect; Monopolar