Dear Rangarajan

your technique, a "watchful waiting" method is an accepted one provided that the burning time is just a "moment" but for missed long burning time this method may result in missing a hidden perforated bowl.

Regards

Several recent sources seem to recommend to oversew even small serosal abrasions based on a often quoted 1999 journal article from Johns Hopkins Hospital. Full text at:

http://sitemaker.umich.edu/rei/files/bowelperf.pdf

There are two things here that help

1. Always keep all the metal of a metal tipped instrument in view and don't let the camer focus on just the operating zone if there is a part of the instruemnt out of view. Then you will avoid burning tissue inadvertently

2 Learn how to use spray current - and then learn that the depth of serosal injury from a very short burst of spray is minimal and ofr most poart of the bowel (with the exception of the caecum which is very thn) the depth of burn injury is very unikley to ever cause a perforation. Unless a serosal spray burn is on the caecum then there is no need to oversew the area.

Dear Dr. Attwood,

Thanks for your reply. Even though I'm aware of keeping the entire metal part of the instrument under direct vision, sometimes it still happens! I often wonder why the metal part is that long in the first place!

Dear dr. Rangarajan,

It is frustrating for the surgeon when this complication occurs and the decision what to do is sometimes difficult to meet. In our country the surgeon should recognize it during the procedure and act in a proper way, but nobody really and exactly knows what this proper way would be. I think that the action of the surgeon depends on the size and depth of the injury. If there is only a small whitish mark on a bowel one should just observe it, however, if the lesion is bigger I do believe, that the one should oversew the lesion, put patients on antibiotics and keep them in hospital for observation. If patients are released home soon after the procedure we usually instruct them to come back immediately if they feel that something is wrong (fever, abdominal pain, nausea, vomiting...). During the surgery we use unipolar current only occasionally. We prefer the Ultracision harmonic scalpel because it is much safer to use but still one can damage bowel with this instrument....

Regards,

Igor

Thanks for that great insight Dr. Igor. In my practice, most of these injuries occured during TAPP, where we use monopolar scissors for dissection

This is one of the problem during laparoscopic surgery,

By adopting practice of doing nothing may end up with postopertaive perforation whether its clinical or subclinical.

Small point of attachment of diathermy to the bowel 1-2mm for A second or two may be of no clinical significance.However larger spot would need covering by suturing the bowel over that area(single or two stitches) or omentum patch to be on the safe side.

We used to cover the burn on the bowel by either techniques and got no single case of postoperative bowel perforation.

Thanks for that response Dr. Hussain.

Of course, we cannot ignore all injuries. If injury is severe, suturing is ideal like you suggested

Any thermal injury in the above situation is difficulult to assess the depth and lateral spread,as mentioned by Dr MR it is always safer to over sew them immidiately,otherwise we may miss the actual site.

Electrocautery may injure the bowel if the surgeon is not careful. Thermal injury due to unipolar cautery is particularly ominous because the extent of injury is greater than what can be grossly observed. The incidence of this type of injury can be reduced using bipolar cautery devices. If the underlying muscular and mucosal layers remain intact, these small areas of “denuded” serosa need not be repaired, since most experts believe that suture placement increases the likelihood of future adhesions. The serosal and muscular layers should be repaired if the mucosa is exposed, however. Otherwise the bowel wall will weaken at the site, making it vulnerable to perforation. The seromuscular layers can be approximated easily using interrupted 4-0 silk on a small tapered needle. Be careful to avoid placing the stitch through the mucosa, which would violate the bowel lumen.

When the defect of the seromuscular layer is large (when a more extensive area is denuded during dissection of densely adherent bowel away from a tumor or endometriotic lesion), repair becomes more involved. This may require resection of the injured area with primary anastomosis.

The solution to the accidental burns problem by electrocautery might be this: Medical device company 'Encision' reported FDA approval for its AEM Endoshield Burn Protection System (EndoShield). 

Read more: http://medcitynews.com/2014/06/encision-wins-us-fdas-premarket-approval-aem-endoshield-burn-protection-system/#ixzz36ZESsuGr

This is one serious adverse event of  laparoscopic surgery. It related to situation of patients,such as adhension,obsese,preoperative i ntestinal preparation,etc.I think that the solution might be: firstly, ultracision harmonic scapel should be recommanded in such surgery,especially for hysterectomy; secondly,sufficent surgical experience is impoetant in achieving optimal otcome after surgery.

It all depends on serosa integrity. If the injury interrupts the serosa I prefer to repair the continuity with one or two stiches.

It is very unpleasant complication during laparoscopy. If it is only small serosal injury lower than 1cm in a normal small bowel it does not need to do anything. But if there is a larger injury, deeper or in case of oedematous small bowel it require repairing with couple of stiches.

The best way to prevent this injury is not to use electrocautery. I have stopped using it since 1998 and adopted the ultrasound knife. There are several in the market. The harmonic scalpel is the most common one. we have thousands of cases with no injuries at all. The use of the electrocautery is a real hazard. 

Have to use electrocautery with great care during laparosocpic surgery - in addition to direct cautery injury, there is also potential for thermal injury  - the instrument tip & surrounding tissue gets very hot during use, and the distance from bowel can be overestimated due to magnification. 

Unrecognised bowel injury can lead to delayed perforation & peritonitis, with documented cases of fatal outcomes. If patient is deteriorating, needs expedient action with repeat laparoscopy or laparotomy.

Recognised injuries should be oversewn if small, may need segmental resection if large area injured.

When in doubt, put on a stitch. Don't think that it's allright untill you see a nomal collouring of the bowel. Also don't trust the ultrasound knife as not being able to make a perforation. The thermal injury of this device might even be greater then the injury from electrosurgery. You read this in this article.

 Ultrasonic Scalpel Causes Greater Depth of Soft Tissue Necrosis Compared to Monopolar Electrocautery at Standard Power Level Settings in a Pig Model

Kia Homayounfar; Johanna Meis; Klaus Jung; Bernd Klosterhalfen; Thilo Sprenger; Lena-Christin Conradi; Claus Langer; Heinz Becker

Posted: 04/30/2012; BMC Surg. 2012;12(3) © 2012 BioMed Central, Ltd.

Please do not use the term electrocautery because none of us is using a glowing poke to perform surgery. In electrocautery only heat is passing through the patient. In electrosurgery, electric currents are used to get to the result which might lead to an injury at a distant site.

Guido:

You should review your knowledge be before you express your opinion. This is a serious comment. I expressed it to the readers of this blog with the intention to assist you in having better results.

The electrosurgical instruments function with electrical current. Electricity is a dangerous source of energy, that causes local, and distant complications. The use of alternate energy sources (mechanical, laser, and others) have been developed with the aim of avoiding the use of electricity.

The speed of electrical diffusion  within the contact area through which it enters, is deeper and faster than the one experienced with ultrasound energy, and the degree of heat generation is related to the resistance of the current in the tissues.

Of all of the alternative options available at the operating suits the safest, most economic and easy to use is ultrasonic energy. It has been available for clinical use for the past 18 years with multiple studies supporting it.

If you are interested in recent Cochrane reviews you should review the following: Ultrasonic and Nonultrasonic Instrumentation: A Systematic Review and Meta-analysis. Matthews, Brent MD; Nalysnyk, Luba MD, MPH; Estok, Rhonda RN, BSN; Fahrbach, Kyle PhD; Banel, Deirdre BA; Linz, Heather BA; Landman, Jaime MD Archives of Surgery. 143(6):592-600,E1-E2, June 2008. Fifty-one primary studies that examined 4902 patients were included in this systematic review, of which 24 were randomized trials and 27 were nonrandomized studies. Comparative meta-analyses for blood loss, surgery time, and hospital length of stay were performed using a random-effects model and stratified by surgery type. Heterogeneity was tested using Q statistics. Statistical significance was defined as P < .05. Conclusion: Meta-analysis of outcomes comparing ultrasonic with conventional nonultrasonic surgical instrumentation demonstrates significant improvement of several perioperative outcomes in procedure-specific settings when ultrasonic instrumentation is used.

If you want to belong to a serious diverse world where  the terms used to refer to their instruments are employed in a way different to the one you are used to in your own town, please refrain from using irony or sarcasm when you express your feelings, within the diverse scientific blogs.

There are other places where this may be more attractable to use. Ways that may not be taken as a bad comment. When we participate in this blog with our well intentioned  comments, instead of trying to find uncomfortable responses, we try to contribute with  a humble collaboration to help other surgeons that are really interested in achieving better results in their cases and find ways to ask their peers though this serious blogs. Please think about it. 

Every electrosurgical device can/could damage the intestinal wall especially if not adeguately handled and during laparoscopy. In addition the damage depends also by duration (unknown) and estension and strenght of casual application device against the bowel. Theoretically and also as demonstrated by several reports, new surgical devices (ultrasound or radiofrequency knives) are less dangerous, safer and easier to be emploied.

Probably the human (surgeon) factor has a key role in level  and sevetity of damaging.

In my opinion, every time that I see any serosal injury I put on a stitch for preventing risk of delayed post-operative bowel perforation (that is a rare but 

Addendum...

... that is a rare late related complication, but insidious. Thank you for this interesting question.

Very interesting topic , but nobody spoke about the setting of the cautery. a injury caused by a hook at 100 is not the same with one caused at 20. We are trained to use it at 20 and if you anydoubt do not hesitate to put a stich. I do not agree the ideea that by putting a stich you will increase the risk of adhesions. In case of postoperative complications this stich could be extremely helpful to identify the injury.

This complication is rare in expert susrgeons. The resulda of cautery injury is not so catostrofic. I'n my opinion to prevent this you have to put surgigical filed at the betom of the 

Dear dr Rangarajan,

That is a very interesting question, since it can't be answered in an evidence based matter. As already pointed out, the last article coping with this subject dates some 15 years ago.

I follow our department policy of reinforcing with simple interrupted 3/0 or 4/0 PDS sutures every identified electrosurgery bowel injury. It's not difficult to do and from our experience of laparoscopic redo and reoperations, adhesions aren't encountered at the sites of suturing in general. It's logical to reinforce a site of thermal injury as there is a risk of late perforation due to bowel wall necrosis.

Even though newer devices seem to control the diffusion of energy in a more predictable manner, i think that everyone agrees that there is no such thing as a complication-proof surgical instrument. We should also take into account the economic cost of systematically using these devices for every operation.

Indeed, I couldn't agree more with dr Nedelcu about the importance of using the lowest current energy for every device to minimize electric current diffusion and tissue thermal injury.

In the end i don't know if suturing a thermal bowel serosal injury prevents a late bowel perforation as i remember of a patient reoperated for peritonitis secondary to a late small bowel perforation on a serosal electrosurgery injury that had been reinforced with suture. But since placing a suture on the small bowel is not that difficult, i find it logical to continue suturing a bowel serosal thermal wound until scientific evidence proves otherwise.

This should not be a common occurrence - all laparoscopic surgeons should take great care to avoid diathermy injury to bowel. Unrecognised &/or untreated injuries can lead to delayed perforation, peritonitis, sepsis and even death. It is potentially very serious.

If it's identificated during the surgery, a simple stich can make everybody sleep well. Depending on the power of the electrocautery one can even do nothing. During open sugery somethime we use the electrocautery to do hemostasis by soft contact, this makes me believe that low power injury 20 or 30 watts may even be observed. But as I said in the beggining, a simple stiich can make everybody sleep well.

Complications in surgery is enevitable. It is like day after night. But we have to minimize them and salvage them as early as possible if it is not possible to prevent them at all. They say prevention is better than cure!

My take on this topic is a bit different. If it is only serosal injury nothing has to be done. Unfortunately  it is very difficult to determine whether it is only serosal injury during laparoscopy for obvious reason. The most important thing here is if it is a full thickness injury than it can create great morbidity and mortality. The mortality of 3.6% has been reported for small bowel perforation during laparoscopy. This is mainly because of miss injury presenting late to the hospital after discharge.

Varoius factors are responsible for electrocautery injury during laparoscopic surgery. Like the Energy mode ( Monopolar or bipolar), Current wave form (Cutting or coagulation - coagulation causing more damage at same level of power) and Surgical Technique ( Expertise of the surgeon, dexterity, tissue proximaity and dwell time or contact time). More over instrument failure like insulation failure, coupling and direct coupling can lead to this type of  injury.

So how  to prevent them- Have basic knowledge of electrosurgical biophysics, choose the appropriate current wave and mode, improve dexterity and hand eye co-ordination, bowel preparation in advanced laparoscopic procedures, team training and education and heightened alertness and zero tolerance for repair.

If the injury is more than serosal, two layers repair of the gut is mandatory.

I would bury the injury with seromuscular suture and sleep well

Amen!!

Dear Dr.Rangarajan M and colleagues.

I have found this interesting question only now. Sorry for the delayed answer.

There are some useful springs of information to prevent diathermic bowel injury.

https://www.fesdidactic.org/

In particular, "Fundamental use of surgical energy" module.

In my practice, I had no such cases in laparoscopic procedures, but in open operations, especially in extensive adhesiolysis, I prefer to bury burn points with the sero-muscular stitches. You never know how deep is the injury. It is better to prevent, then to treat late perforation and peritonitis.

Dear Dr.Rangarajan M and colleagues.

I have found this interesting question only now. Sorry for the delayed answer.

I believe it is important to use the least possible monopolar electric power. Laparoscopic surgery is a technique in which the image is maximized. if the operating field is particularly affected by adhesions with omentum, and hollow organs such as the right flexure of the colon and the anterior wall of the duodenum, as occurs in acute cholecystitis, lysis may be more complex but not impossible. if possible, use bipolar forceps or advanced technologies such as ultrasound.