Electrosurgery: principles and practice to reduce risk and maximize efficacy.

Science becomes art and art becomes function when fundamental principles are utilized to dictate surgical practice. Most important, the risk for inadvertent thermal injury during electrosurgery can be minimized by a sound comprehension of the predictable behaviors of electricity in living tissue.Guided by the Hippocratic charge of primum non nocere, the ultimate aim of energy-assisted surgery is the attainment of anatomic dissection and hemostasis with the least amount of collateral damage and subsequent scar tissue formation.Ideally, the surgeon’s final view of the operative field should accurately approximate the topography discoverable after postoperative healing. Despite the continued innovation of products borne to reduce thermal damage and then marketed as being comparatively safer, it is the hands and mind of the surgeon that serve to preserve tissue integrity by reducing the burden of delayed thermal necrosis and taking steps to prevent excessive devitalization of tissue. Regardless of the chosen modality, the inseparable and exponentially linked elements of time and the quantity of delivered energy must be integrated while purposefully moderating to attain the desired tissue effect. Ultimately, the reduction of unwanted thermal injury is inherently linked to good surgical judgment and technique, a sound comprehension of the applied energy modality, and the surgeon’s ability to recognize anatomic structures within the field of surgical dissection as well as those within the zone of significant thermal change.During the use of any energy-based device for hemostasis, out of sight must never mean out of mind. If the bowel, bladder, or ureter is in close proximity to a bleeder,they should be sufficiently mobilized before applying energy. Thermal energy should always be withheld until an orderly sequence of anatomic triage is carried out.Whenever a vital structure cannot be adequately mobilized, hemorrhage is preferentially controlled by using mechanical tamponade or suture ligature.