Should Podiatric Surgeons Cease Using Monopolar Electrocautery?

Stephen L. Barrett, DPM, Joseph M. Vella, and A. Lee Dellon, MD

   This electrosurgical delivery system has inherent risks and dangers. Burns are one of the most common complications of monopolar electrosurgery.1 Burns are the result of a concentrated current exiting the body, which can happen if the dispersive electrode is not in full contact with the body, if it has dried out or if it becomes disconnected.1,3,5 As Advincula and Wang pointed out, “Excessive hair, adipose, scar tissue and even the presence of fluid lotions can diminish the quality of contact between the return electrode and the patient’s skin.”3 In these situations, current will seek other routes, such as electrocardiogram leads, towel clips, intravenous stands or stirrups, neurosurgical head frames and even the operating table.1,2,5 Although return electrode monitoring systems can usually detect if the dispersive electrode has lost full contact with the patient’s skin, they will not prevent all burns.6

   Fires are another problem associated with electrosurgical devices. These devices are the most common cause of operating room fires and explosions with 100 cases reported each year. “Electrosurgical units can ignite nearby sources of fuel that include paper or cloth drapes, flammable liquids or gaseous anesthetics when in proximity with an oxygen-rich environment,” according to Advincula and Wang.3

   Electromagnetic interference is another inherent danger of monopolar electrosurgery. The electrical current in a monopolar device can interfere not only with electrocardiogram monitors but also with pacemakers, conductive prosthetic joints and cochlear implants.1,2 In the case of the pacemaker, this interference can result in asystole, syncope, bradycardia, ventricular fibrillation, reprogramming or even destruction of the pacemaker. As for cochlear implants, they can be damaged by the electrical interference or cause “unintended cochlear stimulation and injury through the electrode array.”1

   Finally, the current can cause unwanted muscle and nerve stimulation.1 It is not hard to see why monopolar cautery is considered to be so much more dangerous than bipolar cautery.6

A Pertinent Overview Of The Emergence Of Bipolar Electrosurgery

In February 1973, Jacques Emile-Rioux, MD, a gynecologist from Laval University in Quebec, Canada, attended a staff meeting to discuss an intestinal burn during a laparoscopic sterilization.7 Troubled by this puzzling complication, he struggled to find a solution. Then he found one: “All of a sudden, it hit me. Why not bring the current into one prong of the forceps and retrieve it from the other, thus providing the shortest path for the returning current — that is, whatever is between them.”7

   He quickly made his idea a reality. From sturdy, malleable coat hanger wires, Emile-Rioux made the prongs by flattening one end of each on an anvil and twisting the other ends with pliers, making finger holds. For insulation, he used a thin piece of wood introduced in a hollow, rigid tubing from a broom.7 Emile-Rioux then showed his creation to someone in the department of electrical engineering, who had a prototype ready for him a week later.

   Emile-Rioux brought his bipolar prototype to his next abdominal hysterectomy. He coagulated one tube with a conventional monopolar instrument and coagulated the other tube with his new device.7 The pathologist evaluated the depth of coagulation as “quite sufficient.” As he noted, the only difference was that on the bipolar side, only the tube was coagulated whereas on the unipolar side, coagulation had spread into the mesosalpinx. Thus bipolar electrosurgery was born.

   This ingenious contraption became the solution to many of the problems (including burns, fires and electromagnetic interference) created by the monopolar electrosurgical unit. Since the active electrode is on one side of the forceps, the return electrode is on the other side of the forceps. Furthermore, the only tissue involved is the tissue that the forceps grasp (in between the two electrodes).

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