Understanding the Relationship between
Surgical Gloves and Electrosurgery

ELECTROSURGERY BASICS Electrosurgery is the application of electrical (Radio Frequency [RF]) current to biological tissue. An electrosurgical generator supplies the source of electric current, which transfers energy (electrons) to tissue. The term “Bovie,” a manufacturer’s trademark named after one of the early pioneers, Dr. William T. Bovie, is often used synonymously with the term “Electrosurgery.” The terms “electrosurgery” and “electrocautery” are also often used synonymously; however, this is incorrect, and it is important that the two are not confused. In electrosurgery, the electrical current is applied directly to the tissue and the patient is part of the circuit. Electrocautery is the indirect application of electrical current by heating a conductive element, which burns tissue. Another distinguishable difference is that electrosurgical units are considered AC (alternating current) energy sources and electrocautery units are DC (direct current) sources. An electrosurgery source is quickly identifiable in the OR by the patient return electrode/ dispersive pad applied to the patient. HOW COMMON IS ELECTROSURGERY? The use of electrosurgery during an operative procedure is almost as common as wearing gloves. There are various energy sources and methods employed with the use of electrosurgery. RF current is typically used by the surgeon to cut tissue or to obtain hemostasis (stop bleeding). Electrosurgery is a safe and efficient instrument for both invasive and minimally invasive surgical (MIS) procedures. HOW AN ELECTROSURGICAL UNIT OPERATES The circuitry of an electrosurgery unit is composed of the generator and active electrode (handheld instrument), the patient, and the patient return electrode/ dispersive pad, which is sometimes referred to as the passive or ground electrode (patient pad or plate). Electrons, or the electrical charge, travel from the generator through the active electrode, through the patient, and return to the generator via the patient return electrode/dispersive pad, completing the electrical circuit. At the point where the current passes through the active electrode, the electrical energy is converted into thermal energy, resulting in high-energy heat. The heat causes disintegration of tissue cells, which may be seen as desiccation (destruction) or hemostasis of the tissue. Of course, the effect upon the tissue depends on a multiplicity of factors, such as the amperage of the electrical current, the size of the active electrode tip, and the time the electrical generator is activated. A final, but very important, point to stress here is to consider an absolute law of electricity, which is: electrical current always follows the path of least resistance. During electrosurgery, if the environment so dictates, the hand of the operating surgeon or assistant may offer the optimal path. WHAT PROBLEMS EXIST WITH ELECTROSURGERY? Advances in electrosurgical technology have made it a safe and necessary practice in almost all types of surgical intervention. However, there are idiosyncrasies linked to the modality which warrant astute awareness by all members of the healthcare team involved when electrosurgery is employed. Among the potential concerns for the operative team are interference with video and anesthesia monitoring equipment, patient return electrode/ dispersive pad site burns, and alternate site burns to the patient that may occur if the electrosurgical current is sufficiently concentrated to a site other than the patient return electrode/ dispersive pad. Also, sparks from an electrosurgery unit could provide an ignition source for an intraoperative fire. Another problem related to the use of electrosurgery is electrical shock or burn to the operating surgeon or assistant through the surgical glove.1 When this occurs, the clinician often attributes the hazard to a preexisting hole in the glove (i.e., a break in insulation). The clinician simply changes gloves and continues on. While this may be the case, and changing gloves is likely the solution, there are other variables to be considered. It is possible that the hazard did not occur from a preexisting hole in the glove barrier but, in effect, a hole could result from the electrical hazard. The glove barrier may not have had a hole in it at all before the episode occurred. It has been suggested by researchers that the potential for a member of the operative team to receive a shock or burn through the surgical glove—natural rubber or synthetic—may occur three different ways aside from a preexisting hole: DC Conduction RF Capacitive Coupling High-voltage Dielectric Breakdown2 DC Conduction This suggests that the impedance of the glove barrier to the electrical current is low enough to let the current pass through. The impedance or resistance properties of a surgical glove may be reduced as a result of extended wear and exposure to blood and fluids, or from perspiration inside the glove. A “ballooning” phenomenon can typically be seen at the tips of the glove, which suggests that the glove has lost some of its barrier protective property. Another term often used to explain the barrier breakdown effect is “hydration,” simply defined as the absorption of water into the latex film. A glove that has become hydrated measures a lower electrical resistance than a non-hydrated glove.3 A surgical glove that hydrates slowly may offer added protection against the problems associated with electrosurgical shock. Routine re-gloving and double-gloving can prevent these problems as well. RF Capacitive Coupling During electrosurgery the operating surgeon’s perspiring conductive skin and the metal hemostat applied, for example, to a blood vessel, are considered capacitors (two conductors) separated by an insulator, the glove barrier. When alternating current is applied to the hemostat from the active electrode, it induces electrical charge on the other conductor. The thinner the glove film, the more efficiently current can be induced to surge from one conductor (the hemostat) to the other conductor (the surgeon’s hand). This does not imply that electrical shock is imminent in every procedure; certainly, conditions (as described in this manual) dictate. But what is suggested in the literature is that all gloves, intact or otherwise, are capable of transferring large amounts of RF current.1 Here again, selectively choosing an optimal barrier (e.g., an ultra-thick glove) may prove to be a more effective insulator for the operating surgeon when employing electrosurgery. High-voltage Dielectric Breakdown This phenomenon results when the glove barrier cannot withstand the effects of the high-energy force from an electrosurgery generator. If the voltage is sufficiently high, it can produce a hole in the glove and a resultant burn. Again, there are contributing variables, such as the amount of time the current is applied or the surgical technique used. Example: It is a very common practice for the surgeon or first assistant to clamp a bleeding vessel and “zap” the bleeder with the active electrode while holding onto the hemostatic instrument. The voltage or force from the generator is exerted onto the entire clamp. The real potential for an electrical hazard is to the person holding the clamp. If the clamp is being held by just the tip of one finger, this allows only a small area for the current to concentrate, increasing the current density to the finger holding the clamp. If all conditions are right, the result is an electrifying “zap.” Basically, it is the same principle as touching a doorknob with your finger and getting “zapped” after walking across a carpeted room and generating static electricity. A safe method is to keep a firm hold on the hemostat while obtaining hemostasis with the electrosurgery instrument.4 This ensures a larger area, decreasing the chance for the concentration of current at the site.

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