Ignorance of electrosurgery among obstetricians and gynaecologists

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Ignorance of electrosurgery among obstetricians and gynaecologists
  Ignorance of electrosurgery among obstetriciansand gynaecologists Zorana Mayooran, a Scott Pearce, b Jim Tsaltas, b Luk Rombauts, b T. Ian H. Brown, a Anthony S. Lawrence, b Kym Fraser, c David L. Healy b Objective  The purpose of this study was to assess the level of skill of laparoscopic surgeons in electrosurgery. Design  Subjects were asked to complete a practical diathermy station and a written test of electrosurgicalknowledge. Setting  Tests were held in teaching and non-teaching hospitals. Sample  Twenty specialists in obstetrics and gynaecology were randomly selected and tested on the MonashUniversity gynaecological laparoscopic pelvi-trainer. Twelve candidates were consultants with 9–28 yearsof practice in operative laparoscopy, and 8 were registrars with up to six years of practice in operativelaparoscopy. Seven consultants and one registrar were from rural Australia, and three consultants were fromNew Zealand. Methods  Candidates were marked with checklist criteria resulting in a pass/fail score, as well as a weightedscoring system. We retested 11 candidates one year later with the same stations. Main outcome measures  No improvement in electrosurgery skill in one year of obstetric and gynaecologicalpractice. Results  No candidate successfully completed the written electrosurgery station in the initial test. A slightimprovement in the pass rate to 18% was observed in the second test. The pass rate of the diathermy stationdropped from 50% to 36% in the second test. Conclusion  The study found ignorance of electrosurgery/diathermy among gynaecological surgeons. One yearlater, skills were no better. INTRODUCTION Electrosurgeryunitshavebecomeanecessityinoperatingtheatres.Straycurrentresultingfrominsulationfailure,directcoupling, capacitive coupling and other malfunction of electrosurgical units may compromise patient safety. At the1993 meeting of the American College of Surgeons, 54% of the506surgeonssurveyedreportedtheyknewofacolleaguewho had encountered electrosurgery complications. 1 Thesetypes of incidents are prevalent in laparoendoscopic proce-dures, where a surgeon’s field of view restricts the visibilityof an electrosurgical instrument to only its tip. Injuries tonon-targeted tissues are therefore unnoticed as they occuralong the shaft of the instrument and are unrecognised. Theyare often diagnosed post-operatively if the patient presentswith peritonitis, haemorrhage, organ or vessel perforation orinfection. 2 Electrosurgical incidents arising from stray currents canbe minimised with the use of appropriate technology suchas return electrode monitoring systems, active electrodemonitoring units and tissue response generators. 3–5 Thesemeasures will not, however, prevent all electrosurgicalburns. Additional contributors to electrosurgical incidentsare poor technique and inadequate knowledge of theprinciples of electrosurgery. Surgeons must therefore beprovided with adequate training in electrosurgery. 3 Surgeons must be aware of the type and age of theelectrosurgical unit used, its safety mechanisms, the oper-ative environment and the type of tissue cauterised as theyare legally responsible. Oxygen-enriched atmospheres inotolaryngology,forinstance,requireminimalpowersettingsand sparing use of supplemental oxygen in an effort toprevent flash fires. 6 In open surgery, non-hazardousoperating environments are essential. A patient treatedfor appendicitis was set on fire caused by the heat from theelectrosurgical instrument which ignited a skin cleaningsolution. The flames were doused with a couple of buckets BJOG: an International Journal of Obstetrics and Gynaecology December 2004, Vol. 111, pp. 1413–1418 D  RCOG 2004  BJOG: an International Journal of Obstetrics and Gynaecology  www.blackwellpublishing.com/bjog a  Department of Electrical and Computer SystemsEngineering, Monash University, Clayton, Victoria, Australia b  Department of Obstetrics and Gynaecology, MonashUniversity, Clayton, Victoria, Australia c  Institute for the Advancement of University Learning,Oxford University, UK  Correspondence : Professor D. L. Healy, Department of Obstetrics andGynaecology, Monash University, Monash Medical Centre, Level 5, 246Clayton Road, Clayton 3168 Victoria, Australia.DOI: 10.1111/j.1471-0528.2004.00334.x  of water. 7 This incident occurred not long after a similarcase where the electrosurgical instrument ignited a sterilis-ing solution during a caesarean section. 8 We designed a prospective study testing electrosurgicalskill and theoretical diathermy knowledge. METHODS Twenty specialists of the Royal Australian and NewZealand College of Obstetricians and Gynaecologists(RANZCOG) participated in this study. Candidates werechosen randomly after advertising in our specialist Collegeof Obstetricians and Gynaecologists newsletters and jour-nals. Eight were registrars (levels 1, 3, 4, 5 and 6) with upto six years of practice in operative laparoscopy. Thefrequency with which registrars performed operative lapa-roscopy at the time of testing ranged from zero to ‘morethan once per week’. Twelve candidates were FRANZCOGconsultants with 9–28 years of practice in operative lapa-roscopy, which they performed between ‘once in twoweeks’ to ‘more than once per week’. Six consultants werefrom rural areas. The age of candidates ranged from 27 to60 years. All candidates were right-handed.Eleven subjects were retested after one year. Two candi-dates from New Zealand and four from interstate were unableto travel to Melbourne to be retested. Two other Melbourne-based consultants and one registrar left for overseas andinterstate posts, respectively, following the initial test.The endoscopic visualisation system was a three-chipendoscopic camera, laparoscope, camera control unit andcamera light source. Both the visualisation system and onelaparoscopic training box used by the study were providedby N. Stenning & Co. (Sydney, Australia). Another laparo-scopic trainer used in the study, ZOE Gynecologic Simula-tor, was purchased from Gaumard Scientific (Miami,Florida, USA). Stainless steel laparoscopic instruments suchas 5 mm laparoscopic forceps and haemostatic clip applica-tors were supplied by N. Stenning & Co. Laparoscopicscissors, diathermy scissors, ligating loops and laparoscopicbags were supplied by Tyco Healthcare (Sydney, Australia).The diathermy station and the four electrosurgery ques-tions were designed in consultation with senior laparoscop-ic surgeons. The four electrosurgery questions were basedon the text in the ‘Principles of electrosurgery’ booklet byValleylab. 4 The diathermy station was then designed to testpractical electrosurgery skills other than those alreadytested in written form. The tasks were presented to consul-tant laparoscopic surgeons for testing and approval prior tobeing used on a larger sample.Prior to starting the electrosurgery test, candidates wereprovided with the ‘Principles of electrosurgery’ booklet.The test was comprised of the following: . 20 minutes reading time for the ‘Principles of electro-surgery’ booklet and a description of the two tasks, . practical diathermy station, . theoretical electrosurgery station: answering four elec-trosurgery questions based on the text in the booklet, 4 which remained with the candidate during the test andcould be re-read during the test.Assessment in the context of assessing surgical skillshas two main aims: (1) to indicate competence in specificlaparoscopic tasks; and (2) to provide adequate feedback for individuals to improve in these tasks to a competentstandard. A grade does not indicate to the individualexactly what he/she needs to do to improve to a compe-tent standard. A pass/fail assessment scheme with spe-cific written or verbal feedback on areas to be improvedprovides useful feedback that individuals can act upon.For comparison with the pass/fail assessment scheme,a weighted scoring method was used to derive a can-didate’s score for each task, as well as a final score inelectrosurgery.Both pass/fail and scoring methods of assessment useda checklist model for the two electrosurgery stations. Inthe pass/fail assessment model, a pass was awarded for atask only if all checklist items for that task were satisfied.In the scoring model, a grade for each task was derivedby adding the points for each checklist item satisfied forthat task. The practical diathermy station and a writtenstation on electrosurgery, along with their checklist items,were: Practical diathermy station (5 minutes) The candidate was asked to cut out a premarkedvolume of tissue on a piece of steak, using monopolarscissors.  Assessment checklist   the power setting was  < 55 WIn the context of this exercise, monopolar diathermysettings  > 55 W were found to be damaging to thetargeted tissue, causing excessive charring, and sparkingfor power settings above 70 W.  not too much tissue was graspedThe instrument is designed not to function if too muchtissue is grasped. The surgeon should be aware that thisis intentional.  task was completed on time  cut and/or coagulation were used  brief/intermittent activation was usedProlonged instrument activation will char and damagetissue. Excessive smoke will obscure the cameraview.Each checklist item listed above was worth 0.2 points. 1414 Z. MAYOORAN ET AL. D  RCOG 2004  BJOG: an International Journal of Obstetrics and Gynaecology  111 , pp. 1413–1418  Written electrosurgery station Question 1 (5 minutes) The candidate was asked to:  Describe monopolar electrosurgery.  Draw a monopolar circuit showing the direction of current.The surgeon must be aware of the current path and thepurpose of a patient pad when using monopolar diathermy,due to safety concerns. Monopolar diathermy is moredangerous than bipolar surgery.Assessment checklistThe two items listed above constitute the assessmentchecklist. The first item was worth 0.7 points and the seconditem 0.3 points. Question 2 (5 minutes) The candidate was asked to:  Describe bipolar electrosurgery.  Draw a bipolar circuit showing the direction of current.The surgeon must be aware of the current path and theabsence of a patient pad when using bipolar diathermy, dueto safety concerns.Assessment checklistThe two items listed above constitute the assessmentchecklist. The first item was worth 0.7 points and the seconditem 0.3 points. Question 3 (5 minutes) The candidate was asked to list all nine steps which canbe taken to avoid electrosurgical patient complications inminimally invasive surgery.These nine steps include the major electrosurgical safetyconcerns which all surgeons should know and include thefollowing, as outlined in the ‘Principles of electrosurgery’booklet 4 :1. Inspect insulation carefully2. Use lowest possible power setting3. Use a low voltage waveform (cut)4. Use brief intermittent activation5. Do not activate in open circuit6. Do not activate in close proximity or direct contact withanother instrument7. Use bipolar electrosurgery where appropriate8. Select an all metal cannula system as the safest choice9. Utilise available technology (tissue response generator,active electrode monitoring) to eliminate concerns aboutinsulation failure and capacitive couplingAssessment checklistThe nine items listed above constitute the assessmentchecklist. Each item was worth 0.11 points. Question 4 (5 minutes) The candidate was asked to describe what potentiallywas the most dangerous electrosurgical practice in laparo-scopic surgery and how it can be avoided.Assessment checklist  Identify one of the three most dangerous electrosurgicalpractices in laparoscopic surgery as outlined in the‘Principles of electrosurgery’ booklet 4 : direct coupling,insulation failure and capacitive coupling.  The majority of electrosurgical complications occur dueto the three safety considerations listed. Most of thesecomplications could be avoided with appropriate tech-nology and awareness.  Describe how the named dangerous electrosurgicalpractice can be avoided.In the pass/fail assessment model, a ‘pass’ was awardedfor each question if the answer was correct and complete. Acandidate passed the overall written electrosurgery stationif all four questions were passed.In the weighted scoring model, questions 1 and 2 weretesting basic knowledge of electrosurgery and were worth0.2 points each. Questions 3 and 4 tested more advancedelectrosurgery knowledge and were worth 0.3 points each.The total score for the written electrosurgery station wasthus ES total  ¼  (Q1 points)*0.2  þ  (Q2 points)*0.2  þ  (Q3points)*0.3  þ  (Q4 points)*0.3. The total score for eachcandidate was (diathermy station points)*0.5 þ (ES stationpoints)*0.5. A ‘pass’ in the weighted scoring system wasdefined as a score greater than or equal to 80%.The examiner was blinded to the candidates’ experienceand was of a non-medical background. A checklist basedassessment instrument further ensured that observations of  IGNORANCE OF ELECTROSURGERY AMONG OBSTETRICIANS AND GYNAECOLOGISTS 1415 D  RCOG 2004  BJOG: an International Journal of Obstetrics and Gynaecology  111 , pp. 1413–1418  candidates’ performance other than those specified did notintroduce bias.Eleven candidates were retested one year later. The testwas identical. RESULTS In the pass/fail assessment model, the pass rate of candidates on the practical monopolar diathermy stationwas 56%, with a median completion time of 125 seconds(25th centile of 91 seconds and 75th centile of 175seconds). Of those who passed, 60% were consultants and40% registrars. Eighty-nine percent of candidates satisfac-torily completed the task in 5 minutes. The fastest recordedtime was 43 seconds.A number of factors contributed to such a low pass rate.The first and most damaging was that 16% of candidateschose a power setting in the range of 80–120 W. Another16% of candidates grasped too much tissue. An additional11% did not use electrosurgery cut and/or coagulationfunctions but cut the tissue mechanically.One year later, the pass rate of the practical diathermystation dropped to 36%. Equal numbers of consultants andregistrars passed this station. On this retest, all candidatescompleted the task in the prescribed time. The median timeto completion was 101 seconds (25th and 75th centiles of 112 and 174 seconds, respectively).A written test of knowledge in electrosurgery revealedthat no candidate could successfully complete this task.Questions 3 and 4, which focussed mainly on issues of safety in electrosurgery, were the deciding factors in thisresult with respective pass rates of 20% and 16% (Fig. 1)on the initial test. Even though the individual pass rates forquestions 1, 2, 3 and 4 were 90%, 90%, 20% and 16%,respectively, a candidate had to pass all four questions inorder to pass the written station. The overall pass rate of 0%for the written electrosurgery station indicates that nocandidate could answer all four electrosurgery questions.Question 3 required the candidates to list nine safetychecks outlined in the electrosurgery booklet they wereprovided with. Only 65% could name some of these safety Fig. 1.  Pass rate for each of the four electrosurgery questions. Table 1.  Pass rates of candidates on the pass/fail and weighted scoringassessment models.Task Pass rate (%)on weightedscoring model(initial test)Pass rate (%)on pass/failmodel(initial test)Pass rate (%)on weightedscoring model(follow uptest)Pass rate (%)on pass/failmodel(follow uptest) Practicaldiathermystation 72 56 91 36 Written electrosurgery station Q1 90 90 100 100Q2 85 85 91 91Q3 25 20 45 36Q4 15 16 27 27Total 30 0 45 18 Electrosurgerytotal 45 0 45 91416 Z. MAYOORAN ET AL. D  RCOG 2004  BJOG: an International Journal of Obstetrics and Gynaecology  111 , pp. 1413–1418  checks; 15% gave an incorrect answer. Although 74% of subjectscouldnameoneofthethreemostdangerouselectro-surgical practices in question 4, only 16% knew how toavoid it.The pass rate for the written electrosurgery stationimproved marginally in the follow up test to 18%. Candi-dates who passed this task were all registrars, indicatingthat the success rate of registrars was greater than that of consultants. The pass rate for each of the individual fourquestions (Fig. 1) also improved. As described previously,even though the individual pass rates for questions 1, 2, 3and 4 were 100%, 91%, 36% and 27%, respectively, acandidate had to pass all four questions in order to pass thewritten station.In the weighted scoring assessment model, the pass rateof candidates on the initial and follow up tests followed thesame modest improvement as the pass rate of candidates inthe pass/fail model (Table 1). The pass rates arising fromthe scoring model, however, were greater than thoserecorded with the pass/fail model, resulting in the overallpass rates of 45% on both the initial and follow up testscompared with 0% and 9%, respectively, recorded with thepass/fail model (Table 1). The overall success rate of consultants on the initial (89%) and follow up tests(60%) was higher than that of registrars, 11% and 40%,respectively. Interestingly, the success rate of consultantsdeclined in one year of usual practice, while that of registrars improved. DISCUSSION Thisstudyhasunexpectedlyshownthatthereisignoranceofelectrosurgeryamongsurgicalspecialistsinobstetricsandgynaecology. Although the candidates were aware of thebasic differences between monopolar and bipolar electro-surgery, they demonstrated very poor knowledge of electro-surgical safety and hazard prevention. No improvementoccurred in one year as shown by retest of 11 candidates.Ninety-five percent of candidates in the initial and allcandidates in the follow up assessment reported usingmonopolar diathermy prior to the test, yet their pass rateswere 56% and 36% in the initial test and the retest,respectively. This outcome reveals inconsistency in theperformance of candidates indicating partial knowledge of the correct use of monopolar diathermy. The result is inagreement with the candidates’ theoretical knowledge of electrosurgery. This remained low even though it improvedslightly from a pass rate of 0% to 18% over a period of oneyear.The pass/fail assessment model was chosen as the mostappropriate assessment instrument in the context of assess-ing surgical skills. A weighted scoring assessment model ispresented for comparison. The greatest concern raised bythe use of a marking scheme is the different and erroneousways in which the final grade can be interpreted. Thefollowing marking scheme illustrates the inadequacies of a scoring system in the assessment of surgical skill in thiscontext. In our scoring system, each of the five componentsof the practical diathermy station was worth 0.2 marks.Candidate 6 received a score of 0.6 in the initial test withthree components correct. The two incorrect components of the station were grasping too much tissue, thus significantlyreducing the effect of the diathermy machine, and beingunable to cut out a piece of steak in less than 5 minutes. Inthe follow up test, the same candidate received a score of 0.8, suggesting improvement in performance, and compe-tence in this assessment task, since 80% was defined asa ‘pass’. This would, however, be a false indication of competence. Although this candidate completed four com-ponents correctly, s/he still used a power setting of only 5 Wto cut a piece of steak, resulting in insignificant diathermyeffect and having to resort to using diathermy scissors tomanually cut out the meat. This candidate’s knowledge of electrosurgery has clearly not improved, even though thescoring system would seem to suggest improvement. Ourpass/fail assessment model correctly identified bothattempts at the diathermy task as ‘fail’.The strengths of our study design incorporate both thetheoretical and practical knowledge of electrosurgery en-suring test consistency and comprehensiveness. The prac-tical diathermy station revealed aspects of electrosurgicaltechnique that could not be tested in a written format. Theseinclude grasping the right volume of tissue, choosingappropriate power settings and using brief intermittentactivation. The diathermy station also verified that candi-dates’ theoretical knowledge was applied in practice. Re-peating the same stations one year later proved to be avaluable tool in validating the initial results.The limitations of this study include the testing andretesting of rural surgeons and the restricted number of practical diathermy tasks. Co-ordination of a larger trialproved to be difficult within a period of one year due to theavailability of the subjects and surgical equipment. Onesuggestion on the improvement of the electrosurgery testwould be to include theoretical questions based on casestudies of most common endoscopic gynaecology proce-dures (i.e. ovarian cysts, endometriosis and ectopic preg-nancies). Another suggestion would be to include additionaldiathermy tasks comprised of the simulation of electrosur-gical incidents in future tests. This will further test thesurgeons’ abilities to recognise and manage electrosurgicalcomplications.In laparoscopic surgery where 85% of surgeons useelectrosurgical instruments, the incidence of electrosurgicalcomplications has risen from approximately 0.23% in 1970sto 0.5% in 1990s. 5 This trend has prompted the forma-tion of a Laparoscopic Litigation Group in the UnitedStates. 2 Electrosurgical injuries are sometimes difficult to diag-nose. Many are only diagnosed post-operatively. Perfora-tion of the bowel, small intestine and liver, and injuries to IGNORANCE OF ELECTROSURGERY AMONG OBSTETRICIANS AND GYNAECOLOGISTS 1417 D  RCOG 2004  BJOG: an International Journal of Obstetrics and Gynaecology  111 , pp. 1413–1418
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