Surg Endosc (2010) 24:462–465
DOI 10.1007/s00464-009-0601-5
Insulation failure in laparoscopic instruments
Paul N. Montero Æ Thomas N. Robinson Æ
John S. Weaver Æ Greg V. Stiegmann
Received: 20 February 2009 / Accepted: 16 June 2009 / Published online: 2 July 2009
Ó Springer Science+Business Media, LLC 2009
Abstract
Background Electrosurgery is used in virtually every
laparoscopic operation. In the early days of laparoscopic
surgery, capacitive coupling, associated with hybrid tro-
cars, was thought to be the major cause of laparoscopic
electrosurgery injuries. Modern laparoscopy has reduced
capacitive coupling, and now insulation failure is thought
to be the main cause of electrosurgical complications. The
aim of this study was (1) to determine the incidence of
insulation failures, (2) to compare the incidence of insu-
lation failure in reusable and disposable instruments, and
(3) to determine the location of insulation failures.
Methods At four major urban hospitals, reusable laparo-
scopic instruments were checked for insulation failure
using a high-voltage porosity detector. Disposable L-hooks
were collected following laparoscopic cholecystectomy
and similarly evaluated for insulation failure. Instruments
were determined to have insulation failure if 2.5 kV cros-
sed the instrument’s insulation to create a closed loop
circuit. Statistical analysis was performed using Fisher’s
exact or v2 analysis (*denotes significance set at p \ 0.05).
Results Two hundred twenty-six laparoscopic instruments
were tested (165 reusable). Insulation failure occurred more
often in reusable (19%; 31/165) than in disposable instru-
ments (3%; 2/61; *p \ 0.01). When reusable sets were
evaluated, 71% (12/17) were found to have at least one
instrument with insulation failure. Insulation failure inci-
dence in reusable instruments was similar between hospitals
P. N. Montero
T. N. Robinson (&)
J. S. Weaver

G. V. Stiegmann
Department of Surgery, University of Colorado Denver School
of Medicine, 12631 East 17th Ave., MS C313, P.O. Box 6511,
Aurora, CO 80045, USA
e-mail: thomas.robinson@uchsc.edu
123
that routinely checked for insulation failure (19%; 25/130)
and hospitals that do not routinely check for insulation
failures (33%; 7/21; p = 0.16). Insulation failure was most
common in the distal third of the instruments (54%; 25/46)
compared to the middle or proximal third of the instruments
(*p \ 0.05).
Conclusion One in five reusable laparoscopic instruments
has insulation failure; a finding that is not altered by
whether the hospital routinely checks for insulation defects.
Disposable instruments have a lower incidence of insula-
tion failure. The distal third of laparoscopic instruments is
the most common site of insulation failure.
Keywords Radiofrequency
Monopolar electrosurgery

Laparoscopic
Insulation failure
Monopolar radiofrequency electrosurgery is used in virtu-
ally every laparoscopic operation. Injury from inadvertent
energy transfer has a reported incidence of 1-5 recognized
injuries per 1,000 cases [1, 2]. Many such injuries create
catastrophic complications [3] and result in medicolegal
actions [4].
Four types of laparoscopic electrosurgery injury patterns
exist: insulation failure, capacitive coupling, direct cou-
pling, and direct application [5, 6]. In the early days of
laparoscopic surgery, use of hybrid (a combination of
plastic and metal) trocars lent to the occurrence of capac-
itive coupling, which was thought to be the major cause of
laparoscopic electrosurgery injuries [7, 8]. Modern elec-
trosurgery generators [9] and guidelines to avoid the use of
hybrid trocars [10] have reduced capacitive coupling;
insulation failure is now thought to be a main cause of
laparoscopic electrosurgery injuries.
Surg Endosc (2010) 24:462–465
The purpose of this study was to examine laparoscopic
insulation defects. The specific aims of this study were (1)
to determine the incidence of insulation failures, (2) to
compare the incidence of insulation failure in reusable and
disposable instruments, and (3) to determine the location of
insulation failures.
Methods
Regulatory exemption due to designation as nonhuman
research was obtained from the Colorado Multi-Institu-
tional Review Board (COMIRB #08-1377). Laparoscopic
instrument insulation was tested using the Micromed PD-
8 K (Blackstone, MA) porosity detector. Using a 2.5-kV
interrogation current, an insulation failure was defined as
present when current crossed the insulation and created a
closed loop circuit, signaling an alarm and creating a visible
arc.
Reusable instruments (n = 165) from four major urban
hospitals were tested. Two of the four hospitals routinely
tested their laparoscopic instruments for insulation failure.
All reusable instruments underwent mechanized steriliza-
tion after each use. Disposable L-hook active electrodes
(n = 61) were tested after a single-use following laparo-
scopic cholecystectomy. Disposable L-hooks were obtained
from Covidien (Boulder, CO), Conmed (Centennial, CO),
and Megadyne (Draper, UT). All laparoscopic instruments
evaluated had a 30-cm length of insulation. Location of an
insulation defect was defined from 0 cm (adjacent to
working tip) to 30 cm (adjacent to handle). All operations
were performed with disposable (all plastic) trocars
(Table 1).
Statistical analysis was performed using Fisher’s exact or
v2 analysis for dichotomous variables and Student’s t test
for continuous variables. Significance was set at p \ 0.05.
Results
In August 2008, 226 instruments (165 reusable and 61
disposable) were tested; we found that 33 (15%) instru-
ments had insulation failure(s). Insulation failure occurred
more often in reusable (19%; 31/165) than in disposable
Table 1 Insulation failures in laparoscopic instruments
Insulation defect
Absent Present
Reusable instruments 81% (134/165) 19% (31/165)
Disposable instruments 97% (59/61) 3% (2/61)
Reusable instrument sets 29% (5/17) 71% (12/17)
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instruments (3%; 2/61; *p \ 0.01). When reusable sets
were evaluated, 71% (12/17) were found to have at least
one instrument with insulation failure. Insulation failure
incidence in reusable instruments was similar between
hospitals that routinely checked for insulation failure (19%;
25/130) and hospitals that did not routinely check for
insulation failure (33%; 7/21; p = 0.16).
In the reusable instruments, 46 insulation defects were
identified in 32 instruments. More than one insulation
failure was found in eight (25%) reusable instruments.
Three reusable instruments had two insulation defects, four
reusable instruments had three such leaks, and one reusable
instrument had four sites of failure.
The location of the insulation failure was most common
in the distal third of the instruments (54%; 25/46) com-
pared with the middle or proximal third of the instruments
(*p \ 0.05) (Fig. 1).
Discussion
One in five reusable laparoscopic instruments has insula-
tion failure, a finding that is not altered if the hospital
routinely checks for insulation defects. One in four reus-
able laparoscopic instruments had more than one defect in
their insulation. Disposable instruments have a lower
incidence of insulation failure compared with reusable
instruments. The distal third of laparoscopic instruments is
the most common site of insulation failure.
Monopolar radiofrequency electrosurgery is a univer-
sally used tool for laparoscopic procedures. This technology
was initially thought to be contraindicated in laparoscopic
applications because of fears of high complication rates
[11]. Contributing factors to laparoscopic electrosurgery
injuries include a limited field of vision and four known
mechanisms for inadvertent energy transfer: insulation
failure, capacitive coupling, direct coupling, and direct
application [5, 6].
Insulation failure of a laparoscopic instrument is defined
as a break or defect in the insulation that coats the instru-
ment. Insulation failure is caused by excessive use of reus-
able instruments, particularly with repetitive passage
through trocars and frequent mechanized sterilization pro-
cessing [12]. High voltages carried with certain electrosur-
gical power modes (e.g., coagulation mode) can also
contribute to defects by weakening insulation over time [13].
Insulation material applied to laparoscopic instruments is
typically heat shrink material made from a variety of com-
pounds including polyvinylidene fluoride, polyethylene, and
polyvinyl chloride. Because both reusable and disposable
instruments in this study were manufactured by several
different companies, the instruments studied had more than
one type of insulation material. Most laparoscopic
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464
Fig. 1 Location of insulation defect and clinical significance. Distri-
bution of the insulation defects along the shaft of a 30-cm laparoscopic
instrument is depicted. A laparoscopic instrument is drawn below the
graph with the length of the shaft of the instrument exactly overlying
the 30 cm of the graph’s x axis. To highlight the most clinically
equipment has insulation material that is at least 0.008 in.
thick. In this study, many insulation defects were visible
prior to instrument testing. A large number of defects,
however, were not apparent until our porosity detector was
passed over the shaft. Such defects in instrument insulation
can deliver most or all of the current to unintended tissues
[9]. This study does not address if the surgeon can detect
insulation defects at the start of the surgical procedure.
However, careful inspection of instruments with a porosity
detector clearly detects insulation defects present in both
reusable and disposable instruments.
The first important finding of this study was the high
incidence of insulation failure in reusable laparoscopic
instruments. Interestingly, despite testing for such defects
in some hospitals, we found similar rates of insulation
failure for hospitals that check for insulation failure and for
those that do not. These findings should alert the laparo-
scopic surgeon that every laparoscopic instrument set
likely has one or more reusable instruments with an insu-
lation defect. From a system perspective, hospitals should
consider instituting methodical insulation failure detection
programs to survey their laparoscopic equipment.
The second important finding of this study was that 18%
of insulation defects are located in the section of the
instrument most likely to create a catastrophic electrosur-
gical injury. Originally described as ‘‘Zone 2’’ by Voyles
and Tucker [6], the location along the instrument, which is
outside the view of the monitor but distal to the protective
cannula, carries the highest risk for creating an injury that
even the most attentive surgeon is unable to detect. This
clinically relevant section of the instrument increases as the
instrument is further inserted into the trocar and decreases
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Surg Endosc (2010) 24:462–465
relevant insulation defects, a monitor (i.e., the surgeon’s view) and a
cannula are drawn. Six insulation defects (18%) occurred outside the
view of the monitor and beyond the protection of the cannula, a
location known to create catastrophic unrecognized injuries [6]
as the instrument is withdrawn from the trocar. In Fig. 1, a
monitor and cannula are superimposed on a graphic dis-
tribution of insulation defects, highlighting the incidence of
the most clinically relevant insulation defects.
The main limitations of this study are fourfold. First, the
clinical significance of these insulation defects is difficult
to extrapolate without in vivo histological testing of vul-
nerable tissue (i.e., bowel) exposed to the insulation defects
at clinically relevant electrosurgery generator power set-
tings. Indeed, to our knowledge, no clinically identified
complications resulted from use of the defective instru-
ments we discussed. However, our data collection sug-
gested that the insulation defects appeared relevant since
sparks frequently arced between the interrogation current
probe and the exposed active electrode. Second, the rele-
vance of an insulation defect was counted equally in all
instruments. This accounting is suboptimal since insulation
defects in instruments commonly used as active electrodes
(i.e., L-hooks and spatulas) carry a much greater clinical
significance in comparison with assistant and dissecting
instruments that are not commonly used as the active
electrode. Third, laparoscopic instruments were tested with
only one voltage setting. Completion of the closed loop
circuit of the porosity detector is dependent on the thick-
ness of the defect and the voltage used for testing. We
chose 2.5 kV as this mimics coagulation mode at 30 W, a
commonly used setting. Other interrogation current settings
would signal alarms at different depths of insulation defect.
Finally, the defects were not quantified in any manner.
Although visible arcs of up to 5 mm were seen during
testing, we did not measure or record any data regarding
size of the arc. We did not quantify the current across the
Surg Endosc (2010) 24:462–465
insulation defect in relation to size or whether the active
electrode tip was also conducting energy at the time. Pre-
sumably, when the circuit is closed (on the bench or in
vivo), energy is transmitted across the path of least resis-
tance, which creates a number of confounding variables
when determining clinical significance in the dynamic
setting of a laparoscopic operation.
In summary, insulation failure is common in reusable
laparoscopic instruments. The incidence of insulation fail-
ure in laparoscopic instruments is not altered by the pres-
ence of current hospital-based detection programs. The
laparoscopic surgeon must recognize the high incidence
of insulation failures present in his/her instruments and
adopt practices to minimize the potential for catastrophic
complications.
Acknowledgments The authors gratefully acknowledge the tech-
nical and equipment support provided by Kimberly Krugman, Ned
Cosgriff, Jason Haubelt, Pete Rather, and Kevin Skruch. Honoraria
are received from Covidien for teaching and consultation (TNR and
GVS) and from Conmed Electrosurgery for teaching (TNR).
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