Should Podiatric Surgeons Cease Using Monopolar Electrocautery?

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Author(s): 
Stephen L. Barrett, DPM, Joseph M. Vella, and A. Lee Dellon, MD

As with other types of extremity surgery, podiatric surgery is very specialized and very diverse in the different types of procedures performed routinely by surgical specialists. Procedures can range from simple or complex osseous surgery to delicate peripheral nerve surgery — all of which require some type of hemostasis to be performed optimally.

   It is universally accepted that damage to tissues can result in a less optimal outcome for the patient. Such damage can occur via poor tissue handling, extensive dissection or collateral damage subsequent to a particular aspect of the overall surgical technique. For example, the injudicious use of electocautery can increase postoperative morbidity. Many times, the patient is subject to costly and painful additional reparative surgery because of nerve damage due to use of monopolar electrocautery.

   It is also widely accepted that the use of monopolar cautery is routine in podiatric surgery and that the use of bipolar cautery constitutes only a small percentage of the cases that utilize some form of electrosurgery for hemostasis.

   It is our conjecture that the widespread use of monopolar electrocautery is more a function of surgeon training rather than surgeons actually taking into consideration the goals of hemostasis and the physical properties of these different electrosurgical modalities. A review of the history and development and the physical characteristics of electrocautery may cause the surgeon using monopolar cautery to reconsider that modality and switch to the use of bipolar cautery.

   Functional results and research from other surgical specialties, such as neurosurgery and hand surgery, can be extrapolated into podiatric surgery to improve technique and outcomes.

A Guide To The History And Principles Of Electrosurgery

Heating tissue to achieve hemostasis is not a recently developed technique. In 1926, William T. Bovie, PhD, a physicist at Harvard, modernized the technique.1 Building on the advances of his predecessors, Bovie constructed an electrosurgical unit that “produced high-frequency current delivered by a ‘cutting loop’ to be used for cutting, coagulation and desiccation.”2

   At a staff meeting in which his new device was under discussion, Bovie was approached by Harvey Cushing, MD, a surgeon who was interested in using Bovie’s device to control blood loss in a brain operation.1 A 64-year-old patient of Cushing’s had an enlarging vascular myeloma of the head, a tumor that Cushing had unsuccessfully attempted to remove by more traditional means. The vascularity of the tumor was complicating the removal of the tumor but Bovie’s new electrosurgical device seemed promising.

   Accordingly, Cushing used Bovie’s device when he made another attempt at removing the myeloma. The operation was a success and Dr. Cushing thereafter used the Bovie device increasingly with excellent results.2

   In electrosurgery, electrical current passes through tissues to create a desired clinical effect.2 A generator produces the current and sends the current along to an active electrode. The active electrode then passes the current on to the tissue to create the desired effect, whether that is cutting, fulguration or desiccation. The current exits the tissue via the return electrode, which completes the electrical circuit by returning the current to the generator.2,3

What You Should Know About The Risks Of Monopolar Electrosurgery

In monopolar electrosurgery, the active electrode has a small tip that concentrates the electrical current before it enters the tissue. This high current density at the tip of the active electrode produces heat and energy, which facilitate the desired clinical effect such as cutting, fulguration or desiccation. In order to prevent this heat and energy from producing the same effect on the tissue where the current leaves the body, the return electrode is large and disperses the exiting current over a broad surface area.3,4

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