TECHNOLOGY FOCUS

Electrosurgery 201: Basic Electrical Principles

Charles W. Van Way III, MD, and Christian Sutter Hinrichs, MD

Department of Surgery, University of Missouri—Kansas City, Kansas City, Missouri, and Department of
Medical Education, Saint Luke’s Hospital of Kansas City, Kansas City, Missouri

INTRODUCTION
The safe use of electrosurgery in the operating room requires a
basic understanding of the principles of electricity and how they
apply to electrosurgery. In this, the second article in a series, we
will examine these principles. In future issues we will address
topics such as radio-frequency tumor ablation, laparoscopic
electrosurgery, and the argon beam coagulator. In this article we
focus on what the surgeon should know about electricity and its
application to electrosurgery.

BASIC ELECTRICITY
Electrical current is defined as the flow of electrons through a
circuit in response to an applied electromotive force. Electrons
orbit the nuclei of atoms. In the atoms of some substances,
known as conductors, the atoms are loosely held, and can flow
from one atom to the next. This flow of electrons through a
conductor constitutes current.
Current flows from positive to negative. Now, electrons are
negatively charged. That means that electrons flow from the
negative pole of a battery to its positive pole. This doesn’t make
a great deal of sense, but it all goes back to the 18th century.
They could have set up the conventions so that electrons would
have turned out to be positive, and then current flow would
follow electron flow. They didn’t. Blame it all on Ben Franklin,
who had at least something to do with it. So we have to live with
the convention that current flows positive to negative, when
what is really going on is that electrons are flowing from nega-
tive to positive.
Fortunately, electrosurgery is not direct current, but alternat-
ing current. Radio-frequency alternating current, in fact. The
positive-to-negative convention has little effect on understand-
ing electrosurgery (Fig. 1).
Current—alternating or direct—is measured in amperes or,
for smaller current flows, milliamperes. The electromotive
force, which pushes electrons from atom to atom, is also called
voltage, and is measured in volts. The effort required to push
Correspondence: Inquiries to Charles W. Van Way III, MD, Department of Medical Edu-
cation, St. Luke’s Hospital, 4401 Wornall Road, Kansas City, MO 64111; fax: (816)
932-5179; e-mail: cvanway@saint-lukes.org
FIGURE 1. Direct vs alternating current. (Courtesy of Valleylab Inc, Pfizer
Hospital Products Group, 5920 Longbow Drive, Boulder, CO 80301.)
current through a conductor, or a human body, is known as
resistance and is measured in ohms. These elements— current,
voltage, and resistance—combine to create a circuit.
A circuit is a continuous pathway for the flow of electrons.
There must be a continuous circuit for electrons to flow. The
components are a voltage source, resistive element, and current
path. This electrical system is analogous to the human cardio-
vascular system. Current can be seen as blood flow, the voltage
source as the heart, the resistive element as the small vessels and
capillaries, and the current path as the blood vessels.
The flow of current through a conductor is governed by
Ohm’s Law, which ties together current (I), voltage (V), and
resistance (R):
V
I⫽
R
It states that current is equal to voltage divided by resistance. In
other words, current increases as voltage increases and current
decreases as resistance increases.
Current passing through a circuit can do work. If one turns
on a light, current through the light bulb makes light (and
heat). The amount of work done by the current is called power.
Power is defined as the rate at which work is done in the circuit
and is represented by

CURRENT SURGERY • © 2000 by the Association of Program Directors in Surgery 0149-7944/00/$20.00 261
Published by Elsevier Science Inc. PII S0149-7944(00)00234-8

FIGURE 2. The electrosurgical circuit contains the generator, the elec-
trosurgical instrument, the patient, and the return electrode. (Courtesy of
Valleylab Inc, Pfizer Hospital Products Group, 5920 Longbow Drive,
Boulder, CO 80301.)
P ⫽ VI, where P ⫽ power.
Power is equal to voltage across the circuit multiplied by the
current (in amperes).
The electrosurgical generator, electrodes, and patient make
up the circuit (Fig. 2). The electrosurgical generator serves as a
source of voltage. The active electrode conducts electrons to the
patient. The patient acts as a resistive element. Electrons then
return via the patient return electrode. The power setting on the
electrosurgical generator allows us to control the power it sup-
plies.
As noted above, electrosurgery uses high-frequency alternat-
ing current. In an electrosurgical generator, the current alter-
nates polarity or direction 500,000 (or so) times a minute. This
is in contrast to direct current, which does not alternate polar-
ity. Batteries are the most familiar source of direct current.
Ordinary house current is low-frequency alternating current,
changing direction 60 times/second.
Alternating current is defined by its magnitude, measured in
amperes or milliamperes, and by its frequency, measured in
hertz (Hz). One hertz is one cycle/second. The hertz is named
after a famous scientist, and the term cycle was replaced with
hertz 20 or 30 years ago. This replacement makes all of this even
more hard to understand than it would be otherwise, but at least
Dr. Hertz is immortalized.
In the United States, the frequency of standard wall outlets is
60 Hz. The cutting and coagulation effects that are used in
electrosurgery appear when the frequency gets into the lower
radio-frequency range, 300,000 to 1 million Hz. Most genera-
tors use around 500,000 Hz (500 kHz; Fig. 3).
The term resistance properly refers only to direct current cir-
cuits. The alternating current equivalent is impedance. Imped-
ance is pretty similar to resistance, and is also expressed in ohms.
But impedance includes the effects of capacitance and induc-
tance, and is frequency dependent. Inductance is not very im-
portant in biologic systems, but capacitance is. Viewed as an
262
FIGURE 3. The radio-frequency spectrum extends from the type of alter-
nating current used in homes to the high frequencies used in radio and
television broadcasting. Electrosurgery is at the low end of the radio
broadcast band of frequencies. (Courtesy of Valleylab Inc, Pfizer Hospital
Products Group, 5920 Longbow Drive, Boulder, CO 80301.)
electrical circuit, the human body is a resistance and capacitance
connected in parallel (ie, side by side).
EFFECT OF ELECTROSURGERY ON TISSUE
The effect of electrosurgery on tissue is due to the heating action
of current on tissue. Cutting, fulguration, or desiccation are
secondary to the conversion of electrical current to heat. As
discussed in the last section, cutting current is “pure” radio
frequency, whereas coagulation current, which produces fulgu-
ration and desiccation, is interrupted some 30,000 times/sec-
ond (Fig. 4). Because the bursts of coagulation current are short,
the tissue can cool down a bit between bursts, and heat builds
up over a wider area. This controls bleeding by coagulating
tissue over a 1- to 3-mm area. But cutting current, which has no
“cool down” interval between bursts, rapidly heats the tissue at
the electrode to the boiling point, vaporizing the tissue under
the electrode, and thus dividing it. Now, if one turns up the
power high enough, coagulation current will cut perfectly well.
But an examination of the cut edge shows that such cutting is
associated with more charring and tissue damage than when
using the cutting current.
Most surgeons set the cutting power too low. This is because
operating room personnel tend to use “30-30” in their initial
settings, and surgeons feel they cannot safely raise the power
much above that. This is, of course, nonsense. Generators usu-
ally go up to between 100 and 120 watts (W). Given the legal
environment described above, no manufacturer can afford to
market a machine capable of unsafe levels.
Subjectively, electrosurgical cutting feels like dragging the
electrode through tissue, a very different feeling from cutting
with a knife. This feeling can be modified by increasing the
power level of the cutting current. When you use cutting cur-
rent it is important to use enough power. Although coagulation
current can be effective in the range of 30 to 50 W, cutting
current requires 50 to 80 W to be effective. We recommend 40
CURRENT SURGERY • Volume 57/Number 3 • May/June 2000
 FIGURE 4. On the left is pure cutting and on
the right is coagulation. The various levels of
blended cutting are intermediate wave forms.
(Courtesy of Valleylab Inc, Pfizer Hospital Prod-
ucts Group, 5920 Longbow Drive, Boulder,
CO 80301.)

to 50 W for coagulation, and at least 60 W for blended cutting. where patients were touching grounded operating room tables
The amount of “blend” has some influence. The less blend, the or other equipment. The legal profession did not ignore these,
less drag. less common though they might have been. The more enter-
Because coagulation current is more effective at lower power, prising lawyers sued not only the hospital, but also the manu-
many surgeons habitually use coagulation current for cutting. facturers of the equipment. Ah, the American legal system is the
Although this can be useful in some circumstances, such as wonder of the world.
going across muscle, it is generally poor technique. Cutting The electrosurgical manufacturers have, over the past 20
current, even with a blend level of 2 or 3, produces much less years, gone to great lengths to prevent return site burns and
collateral damage and charring of the tissue than does coagula- burns caused by unintentional grounding of patients. Today, all
tion current. electrosurgical equipment is isolated (Fig. 5). That means that
Actually, electrosurgery is usually quite safe. Unintended in- the circuit composed of the generator, the patient, and the
juries produced by the surgeon are relatively uncommon. Of return electrode is isolated from any other electrical circuit. In
course, no technology can help the surgeon if he or she cuts the particular, the circuit is isolated from ground. So putting the
wrong structure, or unintentionally applies current to a struc- patient in contact with a grounded piece of equipment cannot
ture adjacent to the intended target. But most of us use electro- cause a burn. Furthermore, the old ground pad has become a
surgery every day and have little trouble with it. Lasers, by highly sophisticated return electrode. The return electrode can
comparison, are considerably more dangerous to use. But elec-
trosurgery has its definite hazards.
The most common site of electrosurgical injury is at the
return electrode. Conversion of current to heat occurs at the
active site, where the current is concentrated into a small area.
The return electrode is supposed to be low resistance large
enough to disperse the current, and to produce no heat. But if
the patient return electrode has dried out or come loose, then
there may be only a small area of contact with the patient’s skin.
The current exiting the body at that point may have a high
enough current density to heat the skin, which may result in an
unintended burn. The same problem can be produced by an
electrode that has a poor quality (high resistance) contact with
the skin.
Electrosurgical burns at the return site (“ground pad burns”)
were a serious problem for many years. In fact, more lawsuits FIGURE 5. All electrosurgical systems used today are isolated from the
were filed against hospitals for this cause than for any other power line, and from ground, so that the generator and the patient form a
closed system. Notice also that the return electrode is monitored by an
operating room injury. There are lawyers who have lived well interrogation circuit. (Courtesy of Valleylab Inc, Pfizer Hospital Products
and retired rich on ground pad burns. Burns were also seen Group, 5920 Longbow Drive, Boulder, CO 80301.)

CURRENT SURGERY • Volume 57/Number 3 • May/June 2000 263

be constantly checked by the electrosurgical generator to ensure
that it is still connected to the patient properly, and that it is
safe. This is done by splitting the electrode into 2 parts and
using a separate “interrogation circuit” to measure the resis-
tance between them. As long as that resistance remains low, the
return electrode is perfectly safe. If the resistance rises, the
“ground fault” light goes on, and the generator switches off
(Fig. 6).
Use of electrosurgery in laparoscopy was considered quite
dangerous in the early days. Back in the 1970s and 1980s, when
the gynecologists were pioneering laparoscopy, there were a
number of intestinal injuries produced unintentionally during
such procedures. Partly for that reason, the early use of laparos-
copy by general surgeons was associated with lasers. But as we FIGURE 6. The interrogation circuit used to monitor the return electrode.
have gained more experience, and as the equipment has become It is both low voltage and low current, and is safe even if the return
better designed and safer, most surgeons have replaced lasers electrode is defective. The generator uses this circuit to ensure that the
return electrode can safely carry the much larger current used in electro-
with electrosurgery. However, . . . the use of electrosurgery in surgery. (Courtesy of Valleylab Inc, Pfizer Hospital Products Group, 5920
laparoscopy, and the dangers peculiar to doing so, will be the Longbow Drive, Boulder, CO 80301.)
subject of a later article in this series.

CONCLUSION some aspects of how they apply to clinical situations. To be safe

surgeons, we must understand the technology we employ.
An understanding of the principles of electricity is the founda- Building on these concepts, we will further explore radio-fre-
tion for the safe use of electrosurgery. We have examined the quency ablation, laparoscopic surgery, and other new technol-
terminology and concepts that govern electricity, and shown ogies in coming articles.

264 CURRENT SURGERY • Volume 57/Number 3 • May/June 2000