Electrosurgery is the application of a high-frequency electric current to

biological tissue as a means to cut, coagulate, desiccate, orfulgurate tissue.

[1][2]
[3][4][5][][!]
"#hese terms are used in specific $ays for this methodology%see
belo$&. 'ts benefits include the ability to ma(e precise cuts $ith limited blood
loss. )lectrosurgical de*ices are frequently used during surgical operations
helping to pre*ent blood loss in hospital operating rooms or in outpatient
procedures.
[+]
'n electrosurgical procedures, the tissue is heated by an electric current.
,lthough electrical de*ices may be used for the cauteri-ationof tissue in some
applications, electrosurgery is usually used to refer to a quite different method
than electrocautery. #he latter usesheat conduction from a probe heated to a
glo$ing temperature by a direct current "much in the manner of a soldering
iron&. #his may be accomplished by direct current from dry-cells in a penlight-
type de*ice. )lectrosurgery, by contrast, uses alternating current to directly
heat the tissue itself. .hen this results in destruction of small blood *essels
and halting of bleeding, it is technically a process
ofelectrocoagulation, although /electrocautery/ is sometimes loosely and
nontechnically used to describe it.
0ften electrosurgery is mista(enly referred to as diathermy. 1nli(e 0hmic
heating by electric current passing through the conducti*e tissue in
con*entional electrosurgery, diathermy means dielectric heating, produced by
rotation of molecular dipoles in high frequency alternating electric field. #his
effect is most $idely used in micro$a*e o*ens $hich operate at gigahert-
frequencies.
)lectrosurgery is commonly used in dermatological, gynecological, cardiac,
plastic, ocular, spine, )2#, ma3illofacial, orthopedic, urological, neuro- and
general surgical procedures as $ell as certain dental procedures.
)lectrosurgery is performed using an electrosurgical generator "also referred
to as po$er supply or $a*eform generator& and a handpiece including one or
se*eral electrodes, sometimes referred to as an 45 6nife. #he apparatus
$hen used for cutting or coagulation in surgery is still often referred to
informally by surgeons as a /7o*ie,/ after the in*entor.
Contents
[hide]
1 8istory
2 #issue heating by electric current
3 )lectrical stimulation of neural and muscle cells
4 9ommon electrode configurations for ground-return-pad de*ices
o 4.1 :edicated non-ground-return machines
5 )lectrosurgical modalities
o 5.1 .et field electrosurgery
)lectrosurgical $a*eforms
! ;re*ention of unintended harm
+ 2otes
< =ee also
1> )3ternal lin(s
History[edit]
:e*elopment of the first commercial electrosurgical de*ice is credited
to .illiam #. 7o*ie, $ho de*eloped the first electrosurgical de*ice $hile
employed at 8ar*ard 1ni*ersity.
[+][<]
#he first use of an electrosurgical generator
in an operating room occurred on 0ctober 1, 1<2 at ;eter 7ent 7righam
8ospital in 7oston, ?assachusetts. #he operation%remo*al of a mass from a
patient@s head%$as performed by 8ar*ey 9ushing.
[1>]
#he lo$
po$ered hyfrecator for office use $as introduced in 1<4>.
Tissue heating by electric current[edit]
.hen *oltage is applied across the material it produces electric field $hich
e3erts force on charged particles. , flo$ of free charge carriers
A electrons and ions - is called electric current. 'n metals and semiconductors
the charge carriers are primarily electrons, $hereas in liquids the charge is
carried predominantly by ions. )lectrical conduction in biological tissues is
primarily due to the conducti*ity of the interstitial fluids, and thus is
predominantly ionic. #ransition bet$een the electronic and ionic conduction is
go*erned byelectrochemical processes at the electrodeAelectrolyte interface.
Balue of electric current, I, is determined by the applied *oltage, V, and
material@s resistance, R, according to 0hmCs la$D
)lectric current of a constant polarity is referred to as direct current ":9&. ,
current of alternating polarity is referred to as alternating current ",9&.
'ts frequency is measured in cycles per second or hert- "8-&.
9urrent flo$ing through a resistor causes the generation of Eoule heating.
'n other $ords, the resistance of the tissue con*erts the electric energy of
the *oltage source into heat "thermal energy& $hich causes the tissue
temperature to rise. #he deposited electric po$er "energy per time& can be
calculated usingD
$here P represents the electric po$er, typically measured in $atts.
'n absence of heat conduction, the rate of temperature rise, dTFdt, in a
heated obGect is proportional to the deposited po$er P, and in*ersely
proportional to $hich is in turn proportional to the mass m of the obGect
and its specific heat capacity cD
Harger amount of heat is required to increase the temperature of a
hea*ier obGect. #hus $hen heat is generated in a small region of an
obGect, the temperature of that locali-ed region $ill rise much faster
than if the same amount of heat is e*enly dispersed o*er the entire
obGect.
9urrent density, j is a measure of the concentration of electric
current. , higher current density results in a higher concentration
of Eoule heating. ;o$er density generated by electric current in the
material, p is proportional to the square of the current density, and to
the materialCs resisti*ity, gD
'n absence of heat conduction, the rate of local temperature rise
is proportional to the po$er density, p, produced in that region of
tissue, and in*ersely proportional to its specific heat
capacity and density .
[11]
Electrical stimulation of neural and
muscle cells[edit]
2eural and muscle cells are electrically-e3citable, i.e. they
can be stimulated by electric current. 'n human patients such
stimulation may cause acute pain, muscle spasms, and
e*encardiac arrest. =ensiti*ity of the ner*e and muscle cells
to electric field is due to the *oltage-gated ion
channels present in their cell membranes. =timulation
threshold does not *ary much at lo$ frequencies "so
called rheobase-constant le*el&. 8o$e*er, the threshold starts
increasing $ith decreasing duration of a pulse "or a cycle&
$hen it drops belo$ a characteristic minimum "so
called chrona3ie&. #ypically, chrona3ie of neural cells is in the
range of >.1A1> ms, so the sensiti*ity to electrical stimulation
"in*erse of the stimulation threshold& decreases $ith
increasing frequency in the (8- range and abo*e. "2ote that
frequency of the alternating electric current is an in*erse of
the duration of a single cycle&. #o minimi-e the effects of
muscle and neural stimulation, electrosurgical equipment
typically operates in the radio frequency "45& range of
1>> (8- to 5 ?8-.
0peration at higher frequencies also helps minimi-ing the
amount of hydrogen and o3ygen generated by electrolysis of
$ater. #his is especially important consideration for
applications in liquid medium in closed compartments, $here
generation of gas bubbles may interfere $ith the procedure.
5or e3ample, bubbles produced during an operation inside an
eye may obscure a field of *ie$.
Common electrode configurations for
ground-return-pad devices[edit]
#here are se*eral commonly used electrode configurations or
circuit topologiesD
'n bipolar configuration the *oltage is applied to the patient
using a pair of similarly-si-ed electrodes. 5or e3ample,
special forceps, $ith one tine connected to one pole of the ,9
generator and the other tine connected to the other pole of
the generator. .hen a piece of tissue is held by the forceps, a
high frequency electric current flo$s from one to the other
forceps tine, heating the inter*ening tissue.
'n monopolar configuration the patient is attached to
the return electrode, a relati*ely large metal plate or a fle3ible
metali-ed plastic pad $hich is connected to the return
electrode of the ,9 source. #he surgeon uses a pointed
electrode to ma(e contact $ith the tissue. #he electric current
flo$s from the acti*e electrode, through the body to the return
electrode, and then bac( to the electrosurgical generator.
=ince electric current spreads from the pointed electrode as it
enters the body the current density is rapidly "quadratically&
decreasing $ith distance from the electrode. =ince the rate of
heating is proportional to the square of current density, the
heating occurs in a *ery locali-ed region, only near the probe
tip. 0n an e3tremity such as a finger, there is limited cross-
sectional area for the return current to spread across, $hich
might result in higher current density and some heating
throughout the *olume of the e3tremity.
#here is also a common intermediate configuration, $hen
both electrodes are located on the same probe, but the return
electrode is much larger than the acti*e one. =ince current
density is higher in front of the smaller electrode, the heating
and associated tissue effects ta(e place only "or primarily& in
front of the acti*e electrode, and e3act position of the return
electrode on tissue is not critical. =ometimes such
configuration is called sesquipolar, e*en though the origin of
this term in Hatin "sesqui& means a ratio of 1.5.
[12]
Dedicated non-ground-return machines[edit]
Main article: Hyfrecator
4elati*ely lo$-po$ered high frequency electrosurgery can be
performed on conscious outpatients $ith no return electrode
at all.
[13]
0perating at lo$ currents $ith no return electrode is
possible because, at the medium 45 frequencies "usually 1>>
A 5>> (8-& that the machines generate, the self-
capacitance of the patientCs body "$hich is bet$een the
patientCs body and the machineCs return potential or ground& is
large enough to allo$ the resulting displacement current to
act as a *irtual /return path./
0ne e3ample of such a machine is called a hyfrecator. #his
term began in 1<4> as a 7irtcher 9orporation brandname
8yfrecator for /High Frequency )radicator/, but no$ ser*es
generically to describe a general class of single-electrode,
non-isolated "earth-referenced& lo$-po$ered electrosurgical
machines intended mainly for office use. ,n accidental
additional return path through an earth-ground pro*ides a
danger of a burn at a site far a$ay from the probe electrode,
and for this reason single-electrode de*ices are used only on
conscious patients $ho $ould be a$are of such
complications, and only on carefully insulated tables.
'n such a setting, hyfrecators are not used to cut tissue, but to
destroy relati*ely small lesions, and also to stop bleeding in
surgical incisions made by blade instruments under local
anesthesia.
Electrosurgical modalities[edit]
'n cutting mode electrode touches the tissue, and sufficiently
high po$er density is applied to *apori-e its $ater content.
=ince $ater *apor is not conducti*e under normal
cirumstances, electric current cannot flo$ through the *apor
layer. )nergy deli*ery beyond the *apori-ation threshold can
continue if sufficiently high *oltage is applied "I JF-2>> B&
[11]
to
ioni-e *apor and con*ert it into a conducti*e plasma. Bapor
and fragments of the o*erheated tissue are eGected, forming a
crater.
[14]
)lectrode surfaces intended to be used for cutting
often feature a finer $ire or $ire loop, as opposed to a more
flat blade $ith a rounded surface.
9oagulation is performed using $a*eforms $ith lo$er
a*erage po$er, generating heat insufficient for e3plosi*e
*apori-ation, but producing a thermal coagulum instead.
)lectrosurgical desiccation occurs $hen the electrode
touches the tissue open to air, and the amount of generated
heat is lo$er than that required for cutting. #he tissue surface
and some of the tissue more deep to the probe dries out and
forms a coagulum "a dry patch of dead tissue&. #his technique
may be used for treating nodules under the s(in $here
minimal damage to the s(in surface is desired.
'n fulguration mode, the electrode is held a$ay from the
tissue, so that $hen the air gap bet$een the electrode and
the tissue is ioni-ed, an electric arc discharge de*elops. 'n
this approach the burning to the tissue is more superficial,
because the current is spread o*er the tissue area larger than
the tip of electrode.
[15]
1nder these conditions, superficial s(in
charring or carboni-ation is seen o*er a $ider area than $hen
operating in contact $ith the probe, and this technique is
therefore used for *ery superficial or protrusi*e lesions such
as s(in tags. 'oni-ation of an air gap requires *oltage in the
(B range.
7esides the thermal effects in tissue, electric field can
produce pores in the cellular membranes - a phenomenon
called electroporation. #his effect may affect cells beyond the
range of thermal damage.
Wet field electrosurgery[edit]
#here are $et and dry field electrosurgical de*ices. .et field
de*ices operate in a saline solution, or in an open $ound.
8eating is as a result of an alternating current that passes
bet$een t$o electrodes. 8eating is usually greatest $here the
current density is highest. #herefore it is usually the smallest
or sharpest electrode that generates the most heat.
Cut/Coag ?ost $et field electrosurgical systems operate in
t$o modesD /9ut/ causes a small area of tissue to be
*apori-ed, and /9oag/ causes the tissue to /dry/ "in the sense
of bleeding being stopped&. /:ried/ tissues are (illed "and $ill
later slough or be replaced by fibrotic tissue& but they are
temporarily physically intact after electrosurgical application.
#he depth of tissue death is typically a fe$ millimeters near
the contact of the electrode.
Cut 'f the *oltage le*el is high enough, the heat generated
can create a *apour poc(et. #he *apour poc(et typically
reaches temperatures of appro3imately 4>> degrees 9elsius,
$hich *apori-es and e3plodes a small section of soft tissue,
resulting in an incision.
Coag .hen the system is operating in /coag mode/ the
*oltage output is usually lo$er than in cut mode and less
po$er is deli*ered. #his therefore generates less heat and a
*apour poc(et is not generated. #issue remains grossly intact,
but cells are destroyed at the point of contact, and smaller
*essels are destroyed and sealed, stopping capillary and
small-arterial bleeding.
Electrosurgical waveforms[edit]
:ifferent $a*eforms can be used for different electrosurgical
procedures. 5or cutting, a continuous single frequency sine
$a*e is often employed. 4apid tissue heating leads to
e3plosi*e *apori-ation of interstitial fluid. 'f the *oltage is
sufficiently high "I 4>> B pea(-to-pea(&
[11]
the *apor sheath is
ioni-ed, forming conducti*e plasma. )lectric current continues
to flo$ from the metal electrode through the ioni-ed gas into
the tissue. 4apid o*erheating of tissue results in its
*apori-ation, fragmentation and eGection of fragments,
allo$ing for tissue cutting.
[11]
'n applications of a continuous
$a*e the heat diffusion typically leads to formation of a
significant thermal damage -one at the edges of the lesion.
0pen circuit *oltage in electrosurgical $a*eforms is typically
in the range of 3>>A1>,>>> B pea(-to-pea(.
8igher precision can be achie*ed $ith pulsed $a*eforms.
[11]
[14]
1sing bursts of se*eral tens of microseconds in duration
the tissue can be cut, $hile the si-e of the heat diffusion -one
does not e3ceed the cellular scale. 8eat accumulation during
repetiti*e application of bursts can also be a*oided if sufficient
delay is pro*ided bet$een the bursts, allo$ing the tissue to
cool do$n.
[14]
#he proportion of 02 time to 055 time can be
*aried to allo$ control of the heating rate. , related
parameter, duty cycle, is defined as the ratio of the 02 time to
the period "the time of a single 02-055 cycle&. 'n the
terminology of electrical engineering, this process of altering
an amplitude of a periodic $a*eform is called modulation.
5or coagulation, the a*erage po$er is typically reduced belo$
the threshold of cutting. #ypically, sine $a*e is turned on and
off in a rapid succession. #he o*erall effect is a slo$er heating
process, $hich causes tissue to coagulate. 'n simple
coagulationFcutting mode machines, the lo$er duty cycle
typical of coagulation mode is usually heard by the ear as
alower frequency and a rougher tone than the higher
frequency tone typical of cutting mode $ith the same
equipment.
?any modern electrosurgical generators pro*ide
sophisticated $a*eforms $ith po$er adGusted in real time,
based on changes of the tissue impedance.
Prevention of unintended harm[edit]
5or the high po$er surgical uses during anesthesia
the monopolar modality relies on a good electrical contact
bet$een a large area of the body "#ypically at least the entire
bac( of the patient& and the return electrode or pad ",lso
(no$n as dispersi*e pad or patient plate&. =e*ere burns "3rd
degree& can occur if the contact $ith the return electrode is
insufficient, or $hen a patient comes into contact $ith metal
obGects ser*ing as an unintended "capacitati*e& lea(age path
to )arthFKround.
#o pre*ent unintended burns, the s(in is cleaned and a
conducti*e gel is used to enhance the contact $ith the return
electrode. ;roper electrical grounding practices must be
follo$ed in the electrical $iring of the building. 't is also
recommended to use a modern )lectro=urgical 1nit that
includes a return electrode monitoring system that
continuously tests for reliable and safe patient contact. #hese
systems interrogate the impedance of a split or dual-pad
return electrode and $ill alarm out, disabling further generator
output in case of fault. ;rior generators relied on single pad
return electrodes and thus had no means of *erifying safe
patient connection. 4eturn electrodes should al$ays ha*e full
contact $ith the s(in and be placed on the same side of the
body and close to the body part $here the procedure is
occurring.
'f there is any metal in the body of the patient, the return
electrode is placed on the opposite side of the body from the
metal and be placed bet$een the metal and the operation
site. #his pre*ents current from passing selecti*ely through
metal on the $ay to the return electrode. 5or e3ample, for a
patient $ho has had a right sided hip replacement $ho is
scheduled for surgery, the return electrode is placed on the
left side of the body on the lateral side of the lo$er abdomen,
$hich places the return electrode bet$een the location of the
metal and the surgical site and on the opposite side from the
metal. 'f there is metal on both sides of the body, the return
electrode is placed bet$een the metal and the procedure site
$hen possible. 9ommon return electrode locations include
lateral portions of the outer thighs, abdomen, bac(, or
shoulder blades.
[+]
#he use of the bipolar option does not require the placement
of a return electrode because the current only passes
bet$een tines of the forceps or other bipolar output de*ice.
)lectrosurgery should only be performed by a physician $ho
has recei*ed specific training in this field and $ho is familiar
$ith the techniques used to pre*ent burns.
9oncerns ha*e also been raised regarding the to3icity
of surgical smo(e produced by electrosurgery. #his has been
sho$n to contain chemicals $hich may cause harm by
inhalation by the patients, surgeon or operating theatre staff.
[1]