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Background: The ability to ambulate is an important indicator for wellness and quality of life. A major health event, such as a surgery, can derail this ability, and return to preoperative walking ability is a marker for recovery. Self-reported walking measurements by patients are subject to bias, thus wearable technology such as activity monitors have risen in popularity. We evaluated postoperative ambulation using an accelerometer in outpatient general surgery procedures with the hypothesis that those patients with less postoperative ambulation were at risk for adverse outcomes. Methods: A retrospective review of patients undergoing outpatient abdominal surgeries from November 2016 to July 2019 at a Veteran Affairs Medical Center. Patients wore an accelerometer preoperatively and postoperatively to measure their ambulation (steps/day). Outcome measures were 30-day readmissions and Emergency Department (ED) utilization. Postoperative ambulation was defined as daily percentages of their preoperative baseline. Patients without preoperative baseline data, > 3 missing days or any missing days prior to reaching baseline were excluded. Results: One-hundred-six patients underwent outpatient abdominal surgery. Twenty-two patients were excluded. Patients stratified into adult (18–64 years, 44 patients, 52%) and geriatric (≥ 65 years, 40 patients, 48%) cohorts. Geriatric patients were less likely to meet their preoperative baseline by postoperative day 7, 35% vs 61%, p = 0.016. Adult patients who failed to meet their preoperative baseline in first postoperative week had higher ED utilization; 4 (24%) vs 1 (4%), p = 0.04. Geriatric patients who failed to meet their baseline trended toward increased ED utilization; 5 (19%) vs. 1 (7%), p = 0.31. Conclusion: Patients aged < 65 who fail to return to their preoperative daily step count within one week of outpatient abdominal surgery are 6× more likely to be seen in the ED. Postoperative ambulation may be able to predict ED utilization and recovery after outpatient surgery. [ABSTRACT FROM AUTHOR]

Background: Stray energy transfer from monopolar instruments during laparoscopic surgery is a recognized cause of potentially catastrophic complications. There are limited data on stray energy injuries in robotic surgery. We sought to characterize stray energy injury in the form of superficial burns to the skin surrounding laparoscopic and robotic trocar sites. Our hypothesis was that stray energy burns will occur at all laparoscopic and robotic port sites. Methods: We conducted a prospective, randomized controlled trial of patients undergoing elective unilateral inguinal hernia repair at a VAMC over a 4-year period. Surgery was performed via transabdominal preperitoneal approach either laparoscopic-assisted (TAPP) or robotic-assisted (rTAPP). A monopolar scissor was used to deliver energy at 30W coagulation for all cases. At completion of the procedure, skin biopsies were taken from all the port sites. A picro-Sirius red stain was utilized to identify thermal injury by a blinded pathologist. Results: Over half (54%, 59/108) of all samples demonstrated thermal injury to the skin. In the laparoscopic group, 49% (25/51) samples showed thermal injury vs. 60% (34/57) in the robotic group (p = 0.548). The camera port was the most frequently involved with 68% (13/19) rTAPP samples showing injury vs. 47% (8/17) in the TAPP group (p = 0.503). There was no difference in the rate of injury at the working port site (rTAPP 53%, 10/19 vs. TAPP 47%, 8/17; p = 0.991) or the assistant port site (rTAPP 58%, 11/19 vs. TAPP 53%, 9/17; p = 0.873). Conclusions: Stray energy causes thermal injury to the skin at port sites in the majority robotic laparoscopic TAPP inguinal hernia repairs. There is no difference in stray energy transfer between the laparoscopic and robotic platform. This is the first study to confirm in-vivo transfer of stray energy during robotic surgical procedures. More study is needed to determine the clinical significance of these thermal injuries. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has brought many challenges including barriers to delivering high-quality surgical care and follow-up while minimizing the risk of infection. Telehealth has been increasingly utilized for post-operative visits, yet little data exists to guide surgeons in its use. We sought to determine safety and efficacy of telehealth follow-up in patients undergoing cholecystectomy during the global pandemic at a VA Medical Center (VAMC). Methods: This was a retrospective review of patients undergoing cholecystectomy at a level 1A VAMC over a 2-year period from August 2019 to August 2021. Baseline demographics, post-operative complications, readmissions, emergency department (ED) visits and need for additional procedures were reviewed. Patients who experienced a complication prior to discharge, underwent a concomitant procedure, had non-absorbable skin closure, had new diagnosis of malignancy or were discharged home with drain(s) were ineligible for telehealth follow-up and excluded. Results: Over the study period, 179 patients underwent cholecystectomy; 30 (17%) were excluded as above. 20 (13%) missed their follow-up, 52 (35%) were seen via telehealth and 77 (52%) followed-up in person. There was no difference between the two groups regarding baseline demographics or intra-operative variables. There was no significant difference in post-operative complications [4 (8%) vs 6 (8%), p > 0.99], ED utilization [5 (10%) vs 7 (9%), p = 0.78], 30-day readmission [3 (6%) vs 6 (8%), p = 0.74] or need for additional procedures [2 (4%) vs 4 (5%), p = 0.41] between telehealth and in-person follow-up. Conclusion: Telehealth follow-up after cholecystectomy is safe and effective in Veterans. There were no differences in outcomes between patients that followed up in-person vs those that were seen via phone or video. Routine telehealth follow-up after uncomplicated cholecystectomy should be considered for all patients. [ABSTRACT FROM AUTHOR]

Introduction: Stray energy from surgical energy instruments can cause unintended thermal injuries. There are no published data regarding electrosurgical generators and their influence on stray energy transfer during robotic surgery. There are two approved generators for the DaVinci Xi robotic platform: a constant-voltage regulating generator (cVRG) and a constant-power regulating generator (cPRG). The purpose of this study was to quantify and compare stray energy transfer in the robotic Xi platform using a cVRG versus a cPRG. Methods: An ex vivo bovine model was used to simulate a standard multiport robotic surgery. The DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) robotic platform was attached to a trainer box using robotic ports. A 5 s, open-air activation of the monopolar scissors was done with commonly used electrosurgical settings using a cPRG (ForceTriad, Covidien-Medtronic, Boulder, CO) or cVRG (ERBE VIO 300 dV 2.0, ERBE USA, Marietta, GA). Stray energy transfer was quantified as the change in tissue temperature (°C) nearest the tip of the assistance grasper (which was not in direct contact with the active monopolar scissors). Results: Stray energy transfer occurred with both generators. Utilizing common, comparable settings for standard coagulation, significantly less stray energy was transferred with the cVRG versus cPRG (4.4 ± 1.6 °C vs. 41.1 ± 13.0 °C, p < 0.001). Similarly, less stray energy was transferred using cut modes with the cVRG compared to the cPRG (5.61 ± 1.79 °C vs. 33.9 ± 18.4 °C, p < 0.001). Conclusion: Stray energy transfer increases tissue temperatures more than 45C in the DaVinci Xi robotic platform. Low voltage modalities, such as cut or blend; as well as a cVRG generator, significantly reduces stray energy. Robotic surgeons can minimize the risk of stray energy injuries by using these low risk modes and/or generator. [ABSTRACT FROM AUTHOR]

Introduction: Enteral access is required for a variety of reasons from neuromuscular disorders to dysphagia. Gastrostomy tubes (GTs) can be placed endoscopically, surgically, or radiographically and complications include infection, bleeding, leakage and unintentional removal. Routine post-procedural follow-up is limited by inconsistent guidelines and management by different specialty teams. We established a dedicated GT clinic to provide continuity of care and prophylactic GT exchange. We hypothesized that patients followed in the GT clinic would have reduced Emergency Department (ED) utilization. Methods: A retrospective review of patients who underwent GT placement from January 2010 to January 2020 was conducted. Baseline demographics, indications for GT placement, number and reason for ED visits and utilization of a multidisciplinary GT clinic were studied. Results: A total of 97 patients were included. The most common indication for placement was dysphagia (88, 91%) and the most common primary diagnosis was head and neck malignancy (51, 51%). The GT clinic is a multidisciplinary clinic staffed by surgeons and residents, dieticians, and wound care specialists and cared for 16 patients in this study. Three patients (19%) in the GT clinic group required ED visits compared to 44 (54%) in the standard of care (SOC) group (p < 0.05). There was an average of 0.9 ED visits per patient (range 0–7) in the GT clinic group vs 1.6 ED visits per patient (range 0–20) in the SOC group (p = 0.34). Feeding tubes were prophylactically exchanged an average of 7 times per patient in the GT clinic group vs 3 times per patient in the SOC group (p < 0.05). Conclusion: A multidisciplinary clinic dedicated to GT care limits ED visits for associated complications by more than 50%. Follow-up in a dedicated clinic with prophylactic tube exchange decreases ED visits and should be considered at facilities that care for patients with GTs. [ABSTRACT FROM AUTHOR]

Background: The Fundamental Use of Surgical Energy (FUSE) program was developed by The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to promote the safe use of surgical energy. A curriculum that could be used in hospital educational programs was needed to expand access. The goal of this project was to develop a short, inexpensive, online module that emphasizes key FUSE learning objectives. The accompanying survey assessed perceived relevancy. Methods: The SAGES FUSE Committee developed the Hospital Compliance Module. The target audience included all OR personnel. The Module was piloted at Beth Israel Deaconess Medical Center. The data were analyzed using Chi-square with Yates' correction two-tailed test. Results: Three-hundred-eighty individuals completed the survey: 198 (52%) surgeons, 139 (37%) nurses, 28 (7%) surgical technicians, and 15 (4%) house staff. For "...the Module taught me valuable information" 155 (41%) responded extremely and 350 (92%) responded at least somewhat. For "As a result of [the Module] how likely are you to change how you set up or use energy devices...?" 103 (27%) responded extremely and 305 (80%) responded at least somewhat. For "How likely are you to recommend this compliance module...?" 143 (38%) responded extremely and 333 (88%) responded at least somewhat. Conclusion: The FUSE Hospital Compliance Module is effective and efficient. It should be considered for widespread distribution by hospitals to enhance staff education. [ABSTRACT FROM AUTHOR]

Background: Recovery of preoperative ambulation levels 1 month after surgery represents an important patient-centered outcome. The objective of this study is to identify clinical factors associated with the inability to regain baseline preoperative ambulation levels 28 days postoperatively. Methods: This is a prospective cohort study enrolling patients scheduled for elective inpatient abdominal operations. Daily ambulation (steps/day) was measured with a wristband accelerometer. Preoperative steps were recorded for at least 3 full calendar days before surgery. Postoperatively, daily steps were recorded for at least 28 days. The primary outcome was delayed recovery of ambulation, defined as inability to achieve 50% of preoperative baseline steps at 28 days postoperatively. Results: A total of 108 patients were included. Delayed recovery (< 50% of baseline preoperative steps/day) occurred in 32 (30%) patients. Clinical factors associated with delayed recovery after multivariable logistic regression included longer operative time (OR 1.37, 95% CI 1.05–1.79), open operative approach (OR 4.87, 95% CI 1.64–14.48) and percent recovery on POD3 (OR 0.73, 95% CI 0.56–0.96). In addition, patients with delayed ambulation recovery had increased rates of postoperative complications (16% vs 1%, p < 0.01) and readmission (28% vs 5%, p < 0.01). Conclusion: After elective inpatient abdominal operations, nearly one in three patients do not recover 50% of their baseline preoperative steps 28 days postoperatively. Factors that can be used to identify these patients include longer operations, open operations and low ambulation levels on postoperative day #3. These data can be used to target rehabilitation efforts aimed at patients at greatest risk for poor ambulatory recovery. [ABSTRACT FROM AUTHOR]

Introduction: More than 3 million patients have a cardiac implanted electronic device (CIED) such as a pacemaker or implanted cardioverter-defibrillator in the USA. These devices are susceptible to electromagnetic interference (EMI) leading to malfunction and injury. Radiofrequency energy, the most common modality for obtaining hemostasis during endoscopy, is the most common source of EMI. Few studies have evaluated the effect of endoscopic radiofrequency energy on CIEDs. We aim to characterize CIED dysfunction related to endoscopic procedures. We hypothesize that EMI from endoscopic energy can result in patient injury.Methods: We queried the Manufacturer and User Facility Device Experience (MAUDE) database for CIED dysfunction related to electrosurgical devices over a 10-year period (2009-2019). CIED dysfunction events were identified using seven problem codes (malfunction, electromagnetic interference, ambient noise, pacing problem, over-sensing, inappropriate shock, defibrillation). These were cross-referenced for the terms "cautery, electrocautery, endoscopy, esophagus, colonoscopy, colon, esophagoscopy, and esophagogastroduodenoscopy." Reports were individually reviewed to confirm and characterize CIED malfunction due to an endoscopic procedure.Results: A search for CIED dysfunction resulted in 43,759 reports. Three hundred and eleven reports (0.7%) were associated with electrocautery, and of these, 45 reports (14.5%) included endoscopy. Ten reports involving endoscopy (22%) specified upper (3, 7%) or lower (7, 16%) endoscopy while the remainder were non-specific. Twenty-six of reports involving endoscopy (58%) suffered injury because of CIED dysfunction: Of these, 17 (65%) received inappropriate shocks, 5 (19%) had pacing inhibition with bradycardia or asystole, 3 (12%) had CIED damage requiring explant and replacement, and 1 (4%) patient suffered ventricular tachycardia requiring hospital admission.Conclusion: The use of energy during endoscopy can cause dysfunction of CIEDs. This most commonly results in inappropriate defibrillation, symptomatic bradycardia, and asystole. Patients with CIEDs undergoing endoscopy should undergo pre- and post-procedure device interrogation and re-programming to avoid patient injury. [ABSTRACT FROM AUTHOR]

Introduction: Stray energy transfer from surgical monopolar radiofrequency energy instruments can cause unintended thermal injuries during laparoscopic surgery. Single-incision laparoscopic surgery transfers more stray energy than traditional laparoscopic surgery. There is paucity of published data concerning stray energy during single-incision robotic surgery. The purpose of this study was to quantify stray energy transfer during traditional, multiport robotic surgery (TRS) compared to single-incision robotic surgery (SIRS).Methods: An in vivo porcine model was used to simulate a multiport or single-incision robotic cholecystectomy (DaVinci Si, Intuitive Surgical, Sunnyvale, CA). A 5 s, open air activation of the monopolar scissors was done on 30 W and 60 W coag mode (ForceTriad, Covidien-Medtronic, Boulder, CO) and Swift Coag effect 3, max power 180 W (VIO 300D, ERBE USA, Marietta, GA). Temperature of the tissue (°C) adjacent to the tip of the assistant grasper or the camera was measured with a thermal camera (E95, FLIR Systems, Wilsonville, OR) to quantify stray energy transfer.Results: Stray energy transfer was greater in the SIRS setup compared to TRS setup at the assistant grasper (11.6 ± 3.3 °C vs. 8.4 ± 1.6 °C, p = 0.013). Reducing power from 60 to 30 W significantly reduced stray energy transfer in SIRS (15.3 ± 3.4 °C vs. 11.6 ± 3.3 °C, p = 0.023), but not significantly for TRS (9.4 ± 2.5 °C vs. 8.4 ± 1.6 °C, p = 0.278). The use of a constant voltage regulating generator also minimized stray energy transfer for both SIRS (0.7 ± 0.4 °C, p < 0.001) and TRS (0.7 ± 0.4 °C, p < 0.001).Conclusions: More stray energy transfer occurs during single-incision robotic surgery than multiport robotic surgery. Utilizing a constant voltage regulating generator minimized stray energy transfer for both setups. These data can be used to guide robotic surgeons in their use of safe, surgical energy. [ABSTRACT FROM AUTHOR]

Introduction: Stray energy transfer from monopolar radiofrequency energy during laparoscopy can be potentially catastrophic. Robotic surgery is increasing in popularity; however, the risk of stray energy transfer during robotic surgery is unknown. The purpose of this study was to (1) quantify stray energy transfer using robotic instrumentation, (2) determine strategies to minimize the transfer of energy, and (3) compare robotic stray energy transfer to laparoscopy.Methods: In a laparoscopic trainer, a monopolar instrument (L-hook) was activated with DaVinci Si (Intuitive, Sunnyvale, CA) robotic instruments. A camera and assistant grasper were inserted to mimic a minimally invasive cholecystectomy. During activation of the L-hook, the non-electric tips of the camera and grasper were placed adjacent to simulated tissue (saline-soaked sponge). The primary outcome was change in temperature from baseline (°C) measured nearest the tip of the non-electric instrument.Results: Simulated tissue nearest the robotic grasper increased an average of 18.3 ± 5.8 °C; p < 0.001 from baseline. Tissue nearest the robotic camera tip increased (9.0 ± 2.1 °C; p < 0.001). Decreasing the power from 30 to 15 W (18.3 ± 5.8 vs. 2.6 ± 2.7 °C, p < 0.001) or using low-voltage cut mode (18.3 ± 5.8 vs. 3.1 ± 2.1 °C, p < 0.001) reduced stray energy transfer to the robotic grasper. Desiccating tissue, in contrast to open air activation, also significantly reduced stray energy transfer for the grasper (18.3 ± 5.8 vs. 0.15 ± 0.21 °C, p < 0.001) and camera (9.0 ± 2.1 vs. 0.24 ± 0.34 °C, p < 0.001).Conclusions: Stray energy transfer occurs during robotic surgery. The assistant grasper carries the highest risk for thermal injury. Similar to laparoscopy, stray energy transfer can be reduced by lowering the power setting, utilizing a low-voltage cut mode instead of coagulation mode and avoiding open air activation. These practical findings can aid surgeons performing robotic surgery to reduce injuries from stray energy. [ABSTRACT FROM AUTHOR]

Introduction: The SAGES Fundamental Use of Surgical Energy (FUSE) program accompanied by a bench-top simulation has shown to improve knowledge of the safe use of energy devices. However, there are significant barriers and costs associated with delivering an effective structured simulation curriculum to a widespread international audience. The purpose of this study was to evaluate if bench-top simulation FUSE curriculum through telementoring is as effective as a live-in house proctor for electrosurgical training. Methods: A two-armed multi-institutional randomized controlled trial was designed, including a 1-h didactic electrosurgery course (FUSE curriculum), followed by a structured 1-h bench-top simulation training session. For the simulation, participants were randomized to either a live proctor who delivered the course on-site (LIVE group), or a proctor from a remote location using videoconferencing platform (TELEM group). Pre- and post-curriculum (immediate and 6 months) knowledge and self-perceived comfort and competence were assessed. Data are expressed as median [interquartile range], *p < 0.05. Results: Sixty-five (35 LIVE; 30 TELEM) surgical trainees from three institutions participated. Baseline characteristics were similar. Total score on the exam improved from 47% [40–54] to 78% [71–84]* amongst all participants, with similar immediate post-curriculum scores in the LIVE group compared to the TELEM group (77% [69–83] vs 80% [75–85]). At 6 months, performance on the exam declined significantly for both groups, but remained similar between the two (LIVE: 59% [51–71] vs TELEM: 71% [57–77]). Participants in both groups reported feeling greater comfort and competence post-curriculum (immediate and at 6 months) compared to baseline, with no difference between the two groups. Conclusion: A bench-top simulation FUSE course delivered via a telementoring platform seems to improve surgical trainees' knowledge and comfort in the safe use of electrosurgical devices as effectively as when it is delivered by a live proctor, despite long-term decay for both methods. [ABSTRACT FROM AUTHOR]

Introduction: Surgical fires are a rare event that still occur at a significant rate and can result in severe injury and death. Surgical fires are fueled by vapor from alcohol-based skin preparations in the presence of increased oxygen concentration and a spark from an energy device. Carbon dioxide (CO2) is used to extinguish electrical fires, and we sought to evaluate its effect on fire creation in the operating room. We hypothesize that CO2 delivered by the energy device will decrease the frequency of surgical fires fueled by alcohol-based skin preparations.Methods: An ex vivo model with 15 × 15 cm section of clipped, porcine skin was used. A commercially available electrosurgical pencil with a smoke evacuation tip was connected to a laparoscopic CO2 insufflation system. The electrosurgical pencil was activated for 2 s at 30 watts coagulation mode immediately after application of alcohol-based surgical skin preparations: 70% isopropyl alcohol with 2% chlorhexidine gluconate (CHG-IPA) or 74% isopropyl alcohol with 0.7% iodine povacrylex (Iodine-IPA). CO2 was infused via the smoke evacuation pencil at flow rates from 0 to 8 L/min. The presence of a flame was determined visually and confirmed with a thermal camera (FLIR Systems, Boston, MA).Results: Carbon dioxide eliminated fire formation at a flow rate of 1 L/min with CHG-IPA skin prep (0% vs. 60% with no CO2, p < 0.0001). Carbon dioxide reduced fire formation at 1 L/min (25% vs. 47% with no CO2, p = 0.1) with Iodine-IPA skin prep and fires were eliminated at 2 L/min of flow with Iodine-IPA skin prep (p < 0.0001).Conclusion: Carbon dioxide can eliminate surgical fires caused by energy devices in the presence of alcohol-based skin preps. Future studies should determine the optimal technique and flow rate of carbon dioxide in these settings. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopy is the standard tool for the evaluation and treatment of gastrointestinal disorders. While the risk of complication is low, the use of energy devices can increase complications by 100-fold. The mechanism of increased injury and presence of stray energy is unknown. The purpose of the study was to determine if stray energy transfer occurs during endoscopy and if so, to define strategies to minimize the risk of energy complications.Methods and Procedures: A gastroscope was introduced into the stomach of an anesthetized pig. A monopolar generator delivered energy for 5 s to a snare without contacting tissue or the endoscope itself. The endoscope tip orientation, energy device type, power level, energy mode, and generator type were varied to mimic in vivo use. The primary outcome (stray current) was quantified as the change in tissue temperature (°C) from baseline at the tissue closest to the tip of the endoscope. Data were reported as mean ± standard deviation.Results: Using the 60 W coag mode while changing the orientation of the endoscope tip, tissue temperature increased by 12.1 ± 3.5 °C nearest the camera lens (p < 0.001 vs. all others), 2.1 ± 0.8 °C nearest the light lens, and 1.7 ± 0.4 °C nearest the working channel. Measuring temperature at the camera lens, reducing power to 30 W (9.5 ± 0.8 °C) and 15 W (8.0 ± 0.8 °C) decreased stray energy transfer (p = 0.04 and p = 0.002, respectively) as did utilizing the low-voltage cut mode (6.6 ± 0.5 °C, p < 0.001). An impedance-monitoring generator significantly decreased the energy transfer compared to a standard generator (1.5 ± 3.5 °C vs. 9.5 ± 0.8 °C, p < 0.001).Conclusion: Stray energy is transferred within the endoscope during the activation of common energy devices. This could result in post-polypectomy syndrome, bleeding, or perforation outside of the endoscopist's view. Decreasing the power, utilizing low-voltage modes and/or an impedance-monitoring generator can decrease the risk of complication. [ABSTRACT FROM AUTHOR]

Background: Single-incision laparoscopic surgery (SILS) places multiple instruments in close, parallel proximity, an orientation that may have implications in the production of stray current from the monopolar "Bovie" instrument. The purpose of this study was to compare the energy transferred during SILS compared to traditional four-port laparoscopic surgery (TRD).Method: In a laparoscopic simulator, instruments were inserted via SILS or TRD setup. The monopolar generator delivered energy to a laparoscopic L-hook instrument for 5-s activations on 30-Watts coag mode. The primary outcome (stray current) was quantified by measuring the heat of liver tissue held adjacent to the non-electrically active 10-mm telescope tip and Maryland grasper in both the SILS and TRD setups. To control for the potential confounder of stray energy coupling via wires outside the surgical field, the camera cord and active electrode wires were oriented parallel or completely separated.Results: SILS and TRD setups create similar amounts of stray current as measured by increased tissue temperature at the non-electrically active telescope tip (41 ± 12 vs. 39 ± 10 °C; p = 0.71). Stray current was greater in SILS compared to TRD at the tip of the non-electrically active Maryland forceps (38 ± 9 vs. 20 ± 10 °C; p < 0.01). Separation of the active electrode and camera cords did not change the amount of stray energy in the SILS orientation for either telescope (39 ± 10 °C bundled vs. 36 ± 10 °C separated; p = 0.40) or grasper (38 ± 9 °C bundled vs. 34 ± 11 °C separated; p = 0.19) but did in the TRD orientation (41 ± 12 bundled vs. 24 ± 10 separated; p < 0.01). When SILS was compared to TRD with the cords separated, SILS increased stray energy at both the telescope tip and grasper tip (36 ± 10 vs. 24 ± 10 °C; p < 0.01 and 34 ± 11 vs. 17 ± 8 °C; p < 0.01).Conclusion: SILS increases stray energy transfer nearly twice as much as TRD with the use of the monopolar instrument. Strategies to mitigate the amount of stray energy in the TRD setup such as separation of the active electrode and camera cords are not effective in the SILS setup. These practical findings should enhance surgeons using the SILS approach of increased stray energy that could result in injury. [ABSTRACT FROM AUTHOR]

Background: The monopolar instrument emits stray radiofrequency energy from its cord when activated. This is a source of unintended thermal injury to patients. Stray energy emitted from the dispersive electrode cord has not been studied. The purpose of this study was to determine whether, and to what extent, the dispersive electrode cord contributes to unintentional energy transfer and describe practical steps to minimize risk.Methods: In a laparoscopic simulator, a monopolar generator delivered radiofrequency energy to an L-hook. Thermal imaging quantified the change in tissue temperature nearest to the tip of a non-electrical instrument following activation. The orientation of the dispersive electrode cord was varied relative to other instruments.Results: When the dispersive electrode cord is parallel to the camera cord, tissue temperature increased at the telescope tip by 46 ± 6 °C from baseline (p < 0.001). Similar heat was generated when the camera cord was oriented parallel to the active electrode cord (46 ± 6 vs. 48 ± 7 °C, respectively, p = 0.48). Adding a second dispersive electrode decreased the temperature change (46 ± 6 vs. 25 ± 9 °C, p < 0.001). Temperature increase was greater with coagulation versus cut mode (33 ± 7 vs. 22 ± 6 °C, p < 0.001).Conclusion: Stray energy emitted from the dispersive electrode cord heats tissue >40 °C via antenna coupling; the same magnitude as the active electrode cord. Practical steps to minimize stray energy transfer include avoiding orienting the dispersive electrode cord in parallel with other cords, adding a second dispersive electrode, and using low-voltage cut mode. [ABSTRACT FROM AUTHOR]

Introduction: The Fundamental Use of Surgical Energy (FUSE) program includes a Web-based didactic curriculum and a high-stakes multiple-choice question examination with the goal to provide certification of knowledge on the safe use of surgical energy-based devices. The purpose of this study was (1) to set a passing score through a psychometrically sound process and (2) to determine what pretest factors predicted passing the FUSE examination.Methods: Beta-testing of multiple-choice questions on 62 topics of importance to the safe use of surgical energy-based devices was performed. Eligible test takers were physicians with a minimum of 1 year of surgical training who were recruited by FUSE task force members. A pretest survey collected baseline information.Results: A total of 227 individuals completed the FUSE beta-test, and 208 completed the pretest survey. The passing/cut score for the first test form of the FUSE multiple-choice examination was determined using the modified Angoff methodology and for the second test form was determined using a linear equating methodology. The overall passing rate across the two examination forms was 81.5%. Self-reported time studying the FUSE Web-based curriculum for a minimum of >2 h was associated with a passing examination score (p < 0.001). Performance was not different based on increased years of surgical practice (p = 0.363), self-reported expertise on one or more types of energy-based devices (p = 0.683), participation in the FUSE postgraduate course (p = 0.426), or having reviewed the FUSE manual (p = 0.428). Logistic regression found that studying the FUSE didactics for >2 h predicted a passing score (OR 3.61; 95% CI 1.44-9.05; p = 0.006) independent of the other baseline characteristics recorded.Conclusion(s): The development of the FUSE examination, including the passing score, followed a psychometrically sound process. Self-reported time studying the FUSE curriculum predicted a passing score independent of other pretest characteristics such as years in practice and self-reported expertise. [ABSTRACT FROM AUTHOR]

Background: Energy devices can result in devastating complications to patients. Yet, they remain poorly understood by trainees and surgeons. A single-institution pilot study suggested that structured simulation improves knowledge of the safe use of electrosurgery (ES) among trainees (Madani et al. in Surg Endosc 28(10):2772-2782, 2014). The purpose of this study was to estimate the extent to which the addition of this structured bench-top simulation improves ES knowledge across multiple surgical training programs.Methods: Trainees from 11 residency programs in Canada, the USA and UK participated in a 1-h didactic ES course, based on SAGES' Fundamental Use of Surgical Energy™ (FUSE) curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediately and 3 months after) knowledge of the safe use of ES was assessed using separate examinations. Data are expressed as mean (SD) and N (%), *p < 0.05.Results: A total of 289 (145 control; 144 Sim) trainees participated, with 186 (96 control; 90 Sim) completing the 3-month assessment. Baseline characteristics were similar between the two groups. Total score on the examination improved from 46% (10) to 84% (10)* for the entire cohort, with higher post-curriculum scores in the Sim group compared with controls [86% (9) vs. 83% (10)*]. All scores declined after 3 months, but remained higher in the Sim group [72% (18) vs. 64% (15)*]. Independent predictors of 3-month score included pre-curriculum score and participation in a goal-directed simulation.Conclusions: This multi-institutional study confirms that a 2-h curriculum based on the FUSE program improves surgical trainees' knowledge in the safe use of ES devices across training programs with various geographic locations and resident volumes. The addition of a structured interactive bench-top simulation component further improved learning. [ABSTRACT FROM AUTHOR]

Background: Insulation defects are observed in 3-39 % of laparoscopic instruments. Electrosurgical injuries due to insulation defects or capacitive coupling remain an issue in laparoscopic surgery with a prevalence of 0.6-5 per thousand cases. Shielded instruments with active electrode monitoring (AEM) have been postulated to prevent these injuries. The benefit of these instruments has not been quantified. Most bowel injuries are unrecognized intra-operatively. Injury is revealed only after the patient exhibits peritonitis symptoms and surgical intervention to repair the bowel is required. These injuries may result in devastating and costly complications or mortality. The extent of bowel injury possible with commonly used generator settings and associated energy output has never been histologically defined. Our objectives in this experimental study were: quantify and compare the energy released through insulation defects or capacitive coupling with standard unshielded monopolar versus shielded instruments with (AEM), determine energy required to cause a visible burn, and relate the histological burn depth to a given amount of energy.Methods: Ex vivo porcine jejunum was used for tissue testing. An oscilloscope measured energy output from three common electrosurgical generators at recommended power settings with standard or AEM instruments with insulation defects and in capacitive coupling scenarios. Presence of a visible burn was noted, and depth of tissue damage for a given amount of energy was measured histologically.Results: All samples that received ≥3.8 J of energy had visible burns. As little as 10 J caused full wall thickness burns. 3.8 J was exceeded at the 30- and 50-W power settings in every experimental scenario using standard monopolar instruments; AEM instruments never approached this much energy.Conclusions: Serious burn injury results from small amounts of energy leaked from standard instruments. AEM instruments appeared protective and did not leak sufficient energy to cause burn injuries to the bowel. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to compare histologic evidence of thermal injury at the epigastric and umbilical incisions after elective laparoscopic cholecystectomy performed using the monopolar 'Bovie' instrument set on the higher voltage coag mode versus the lower voltage blend mode. We hypothesized that the higher voltage coag mode would create more unintended thermal tissue injury at the epigastric trocar's incision. Methods: A prospective blinded randomized controlled trial of patients undergoing elective laparoscopic cholecystectomy was performed. Patients were randomized to have their operation performed with the monopolar instrument set at 30 W on either the coag mode or the blend mode. Immediately at the end of the operation, a biopsy sample of skin was obtained from the lower edge of the epigastric incision (through which the monopolar instrument was inserted) and the umbilical incision (through which the camera/telescope was inserted). The outcomes measured were histologic evidence of thermal injury at the epigastric and umbilical incisions (determined by a blinded pathologist). Results: Forty patients were randomized (20 per group). Baseline demographics in the two groups were similar for age, gender, body mass index, preoperative diagnosis, operative time, and blood loss. Unintentional thermal injury was found at 20 % of epigastric incisions and 35 % of umbilical incisions in the total group. The incidence of thermal injury was higher after operations using the coag mode compared to the blend mode at both the epigastric (35 vs. 5 %; p = 0.044) and umbilical (55 vs. 15 %; p = 0.019) trocar incisions. Conclusions: Radiofrequency energy from the monopolar Bovie instrument causes unintentional thermal injury to skin adjacent to the epigastric and umbilical trocar incisions. The incidence of thermal injury was reduced by using the lower voltage blend mode compared to the coag mode at both the epigastric and umbilical trocar incisions. Registration number: NCT016648060 (). [ABSTRACT FROM AUTHOR]

Background: Electromagnetic coupling can occur between the monopolar 'Bovie' instrument and other laparoscopic instruments without direct contact by a phenomenon termed antenna coupling. The purpose of this study was to determine if, and to what extent, radiofrequency energy couples to other common laparoscopic instruments and to describe practical steps that can minimize the magnitude of antenna coupling. Methods: In a laparoscopic simulator, monopolar radiofrequency energy was delivered to an L-hook. The tips of standard, nonelectrical laparoscopic instruments (either an unlit 10 mm telescope or a 5 mm grasper) were placed adjacent to bovine liver tissue and were never in contact with the active electrode. Thermal imaging quantified the change in tissue temperature nearest the tip of the telescope or grasper at the end of a 5 s activation of the active electrode. Results: A 5 s activation (30 watts, coagulation mode, 4 cm separation between instruments) increased tissue temperature compared with baseline adjacent to the grasper tip (2.2 ± 2.2 °C; p = 0.013) and telescope tip (38.2 ± 8.0 °C; p < 0.001). The laparoscopic telescope tip increased tissue temperature more than the laparoscopic grasper tip ( p < 0.001). Lowering the generator power from 30 to 15 Watts decreased the heat generated at the telescope tip (38.2 ± 8.0 vs. 13.5 ± 7.5 °C; p < 0.001). Complete separation of the camera/light cords and the active electrode cord decreased the heat generated near the telescope tip compared with parallel bundling of the cords (38.2 ± 8.0 vs. 15.7 ± 11.6 °C; p < 0.001). Conclusions: Commonly used laparoscopic instruments couple monopolar radiofrequency energy without direct contact with the active electrode, a phenomenon that results in heat transfer from a nonelectrically active instrument tip to adjacent tissue. Practical steps to minimize heat transfer resulting from antenna coupling include reducing the monopolar generator power setting and avoiding of parallel bundling of the telescope and active electrode cords. [ABSTRACT FROM AUTHOR]

Background: This study aimed to quantify the clinical parameters of mono- and bipolar instruments that inhibit pacemaker function. The specific aims were to quantify pacer inhibition resulting from the monopolar instrument by altering the generator power setting, the generator mode, the distance between the active electrode and the pacemaker, and the location of the dispersive electrode. Methods: A transvenous ventricular lead pacemaker overdrive paced the native heart rate of an anesthetized pig. The primary outcome variable was pacer inhibition quantified as the number of beats dropped by the pacemaker during 5 s of monopolar active electrode activation. Results: Lowering the generator power setting from 60 to 30 W decreased the number of dropped paced events (2.3 ± 1.2 vs 1.6 ± 0.8 beats; p = 0.045). At 30 W of power, use of the cut mode decreased the number of dropped paced beats compared with the coagulation mode (0.6 ± 0.5 vs 1.6 ± 0.8; p = 0.015). At 30 W coagulation, firing the active electrode at different distances from the pacemaker generator (3.75, 7.5, 15, and 30 cm) did not change the number of dropped paced beats ( p = 0.314, analysis of variance [ANOVA]). The dispersive electrode was placed in four locations (right/left gluteus, right/left shoulder). More paced beats were dropped when the current vector traveled through the pacemaker/leads than when it did not (1.5 ± 1.0 vs 0.2 ± 0.4; p < 0.001). Conclusions: Clinical parameters that reduce the inhibition of a pacemaker by monopolar instruments include lowering the generator power setting, using cut (vs coagulation) mode, and locating the dispersive electrode so the current vector does not traverse the pacemaker generator or leads. [ABSTRACT FROM AUTHOR]

Background: Energy devices are essential laparoscopic tools. Residual heat is defined as the increased instrument temperature after energy activation is completed. This study aimed to determine the length of time a surgeon needs to wait before touching other tissue using four common laparoscopic energy sources. Methods: Thermal imaging quantified instrument and tissue temperature ex vivo using monopolar coagulation, argon beam coagulation, ultrasonic dissection, and bipolar tissue fusion devices. To simulate realistic operative usage, each instrument was activated for 5 s four consecutive times with 5 s pauses between fires. Thermal conductivity to bovine liver tissue was measured 2.5, 5, 10, and 20 s after final activation. Results: The maximum increase in instrument tip temperature was 172 ± 63°C for the ultrasonic dissection, 81 ± 18°C for the monopolar coagulation, 46 ± 19°C for the bipolar tissue fusion, and 1 ± 1°C for the argon beam coagulation ( P < 0.05 for all comparisons). Touching the instrument tip to tissue at four intervals after the final activation (2.5, 5, 10, and 20 s) found that ultrasonic energy raised the tissue temperature higher (maximum change, 58°C) than the other three energy devices at all four time points ( P < 0.05). Conclusions: Ultrasonic energy instruments have greater residual heat than monopolar electrosurgery, bipolar tissue fusion, and argon beam. The ultrasonic energy instrument tips heated tissue more than 20°C from baseline even 20 s after activation; whereas all the other energy sources raised the tissue temperature less than 20°C by 5 s. These practical findings may alter a surgeon's usage of these common energy devices. [ABSTRACT FROM AUTHOR]

Electrosurgery is used in virtually every laparoscopic operation. In the early days of laparoscopic surgery, capacitive coupling, associated with hybrid trocars, 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 insulation failure in reusable and disposable instruments, and (3) to determine the location of insulation failures. At four major urban hospitals, reusable laparoscopic 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 crossed the instrument’s insulation to create a closed loop circuit. Statistical analysis was performed using Fisher’s exact or χ2 analysis (*denotes significance set at p < 0.05). Two hundred twenty-six laparoscopic instruments were tested (165 reusable). Insulation failure occurred more often in reusable (19%; 31/165) than in disposable 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 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). 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 insulation failure. The distal third of laparoscopic instruments is the most common site of insulation failure. [ABSTRACT FROM AUTHOR]