Should Podiatric Surgeons Cease Using Monopolar Electrocautery?
There is “very little chance for unintended dispersal of current” and therefore little chance of the associated complications.2 This also results in “a more refined area of coagulation with less char formation. Damage to the surrounding tissue is minimized” and so is “unwanted muscle and nerve stimulation.”1,3
Due to the many advantages of bipolar electrosurgery, many surgeons prefer it and many more recommend it. Brill stated that the advantages of bipolar electrosurgery have “quickly catapulted the use of bipolar electrosurgery as the principal method for non-mechanical laparoscopic tubal sterilization” and added further that “most gynecologic surgeons are inherently more comfortable and apt to use bipolar rather than monopolar electrosurgery.”8
Malis commented on the decreased damage to the tissue induced by bipolar electrosurgery and how “the geometry of the current flow permits the use of the bipolar system in the most delicate areas where unipolar currents would be completely unacceptable.”9
In podiatric surgery and especially lower extremity peripheral nerve surgery, there is no advantage to the use of monopolar cautery over bipolar cautery as hemostasis does not diminish with the use of bipolar cautery. We have seen several cases of iatrogenic drop foot in neurolysis of the common peroneal nerve (common fibularis), in which the surgeon used monopolar cautery, which caused thermal injury to the nerve. In specialized lower extremity peripheral nerve surgery workshops, we emphasize that use of monopolar cautery is dangerous and can have disastrous consequences for the patient.
Bipolar cautery is not only recommended in patients with pacemakers or other implanted devices — such as cochlear implants — by the Association of periOperative Registered Nurses (AORN), but also in patients needing arthroscopic shoulder surgery.1,10,11 This shows the versatility and safety of this incredible technology.
There are minimal disadvantages to bipolar electrosurgery, such as “increased time needed for coagulation … and adherence to tissue with incidental tearing of adjacent blood vessels.”1 However, in lower extremity surgery, this is rarely a real consideration and the benefits and safety for the patient so far outweigh this potentially small laparoscopic complication.
Technology is always improving, however, and new bipolar devices are no exception. Surgeons implementing bipolar cautery in podiatric surgery find that there is no real compromise in hemostasis. Decreasing the tissue damage induced by monopolar electrosurgery and the associated postoperative morbidity while concurrently increasing patient safety should be the goal of all surgeons.
Dr. Barrett is an Adjunct Professor with the Arizona Podiatric Medical Program at the Midwestern University College of Health Sciences in Glendale, Ariz. He is a Fellow of the American College of Foot and Ankle Surgeons.
Joseph Vella is a fourth-year podiatry student with the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences in Glendale, Ariz.
Dr. Dellon is a Professor of Plastic Surgery and Neurosurgery at Johns Hopkins University in Baltimore.