Inadvertent diathermy self-injury: a cautionary tale.
Surgical diathermy or electrocautery is the application of a high-frequency electric current to biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue . Since its first use in 1926 by Cushing in his neurosurgical practice, diathermy has become an integral part of surgical technique and electrosurgical instruments (the fire stick) are now used in upwards of 80% of surgical procedures . Although widely used, diathermy is not without risk; both to the patient and the surgeon. All of the equipment involved for diathermy should be checked for any damage to the insulation of the cables, electrodes and instruments as part of the pre-operative equipment checks. We describe a case where the surgeon suffered a full thickness burn due to a crack in the insulation on a pair of monopolar diathermy forceps.
Case report and diagnosis
Whilst coagulating small blood vessels, the surgeon felt a sharp and sudden shock causing the forceps to be dropped and the surgeon to recoil from the operating table. On examination, there was a hole burnt through his gloves and the surgeon had sustained a small full thickness burn to the dorsal aspect of the first web space (Fig. 1a). As is commonly practiced, the surgeon in question routinely held the diathermy forceps between thumb and index finger, with the apex of the instrument resting on the dorsal aspect of his first web space (Fig. 1b). On closer examination of the forceps, it became apparent that there was a crack in the insulation at the apex of the instrument (Fig. 2), correlating with the manner in which the forceps were held and the site of the burn.
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
It was postulated that the defect in the insulation had caused the diathermy current to short circuit via exposed metal at the instrument's apex into the surgeon, rather than passing through the tips of the instrument as intended. As per routine hospital policy, the incident was reported and the faulty instrument decommissioned. On further questioning, it became evident that similar faults have been found with other diathermy forceps with other surgeons sustaining similar injuries.
There are many cases reported in the literature of inadvertent diathermy injury to the patient . These fall into two categories, either direct burn as a result of conduction through metallic retractors or flash burns secondary to ignition of alcoholic skin preparations [4,5]. To date there are no actual reports of such injury to the surgeon.
The above incident is a reminder that despite scrupulous checks, instrument failures can occur that may harm the surgeon as well as the patient. This incident has resulted in a sense of heightened vigilance by the surgeon; he now routinely checks for instrument failures and has altered the way he holds the diathermy forceps, such that the apex of the instrument is held clear of his web space. Damage to diathermy forceps can also occur as a result of inappropriate use. In this case, it is possible that the damage was caused by incorrect placement of the diathermy forceps, straddling the instrument holster rather than placing them within.
This report also highlights the issue of gross underreporting of such incidents by surgeons. A brief inquiry around our department revealed that several other surgeons had sustained a similar injury, although this was unreported at the time. Failure to report damaged or faulty instruments should be regarded as a serious breach of clinical governance measures and not just accepted as de rigueur in today's NHS.
[1.] Hainer BL. Fundamentals of electrosurgery. J Am Board Family Practice 1991; 4: 419-26.
[2.] Tudor KI, Tudor M, Buca A, et al. Electrosurgery, the cornerstone of current achievements of brain tumor surgery--on the occasion of 80th anniversary. Acta Med Croatica 2008; 62: 33-40.
[3.] Hussain SA, Latif AB, Choudhary AA. Risk to surgeons: a survey of accidental injuries during operations. Br J Surg 1988; 75: 314-16. doi:10.1002/bjs.1800750407.
[4.] Demir E, O'Dey DM, Pallua N. Accidental burns during surgery. J Burn Care Res 2006; 27: 895-900. doi:10.1097/01.BCR.0000245650.67130.5C.
[5.] Fong EP, Tan WT, Chye LT. Diathermy and alcohol skin preparations--a potential disastrous mix. Burns 2000; 26: 673-5. doi:10.1016/S0305-4179(00)00020-6.
Department of Breast, Oncoplastic and Endocrine Surgery, Queen Alexandra Hospital, Portsmouth, UK
Corresponding address: George Wheble, Department of Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK.
Date accepted for publication 19 June 2011
This paper is available online at http://www.grandrounds-e-med.com. In the event of a change in the URL address, please use the DOI provided to locate the paper.
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|Author:||Wheble, G.A.C.; Pakzad, F.; Hurren, J.S.|
|Article Type:||Author abstract|
|Date:||Jan 1, 2011|
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