Electrosurgery, Hemostasis Devices, and Energy Sources

Electrosurgery in the OR: How Energy-Based Devices Work

Electrosurgery uses high-frequency alternating electrical current to cut tissue and control bleeding. Understanding how these devices work—and how to handle them safely—is one of the most important responsibilities of the scrub role. Errors in electrosurgical technique are a documented source of patient burns, OR fires, and surgical complications.

Monopolar Electrosurgery

In monopolar electrosurgery, electrical current travels from the electrosurgical unit (ESU) generator through the active electrode (the pencil or instrument in the surgeon's hand), passes through the patient's body, and returns to the generator via the dispersive electrode (commonly called the grounding pad or return electrode) attached to the patient's skin.

The current is concentrated at the tip of the active electrode, generating enough heat to cut, coagulate, or fulgurate tissue. Because current must travel through the patient's entire body to complete the circuit, correct placement of the dispersive electrode is critical. The dispersive electrode must be placed on clean, dry, intact skin over a large muscle mass as close to the operative site as is practical, avoiding bony prominences, scar tissue, implanted metal devices, and hairy areas. Poor contact or incorrect placement can cause a burn at the dispersive electrode site.

The surgeon may use a monopolar pencil, a hand-switching or foot-switching device, in "cut" or "coagulation" mode. The scrub technologist hands the pencil in a safe, deliberate manner and ensures it is placed in its holster whenever not in use—never laid on the sterile drapes.

Bipolar Electrosurgery

In bipolar electrosurgery, current flows only between the two tines of a specialized forceps. There is no dispersive electrode because the circuit is completed entirely within the grasped tissue. Because current does not travel through the patient's body, bipolar electrosurgery is safer for patients with implanted cardiac devices and for use near delicate structures such as nerves.

Bipolar forceps are used primarily for precise coagulation of small vessels. The scrub technologist keeps the forceps tips clean of charred tissue using a damp sponge or specialized tip cleaner; buildup of eschar increases tissue resistance and reduces effectiveness.

Ultrasonic Energy Devices

Ultrasonic shears (such as the harmonic scalpel) use high-frequency mechanical vibration rather than electrical current to cut and coagulate tissue simultaneously. The blade vibrates at ultrasonic frequency, generating frictional heat in the tissue. Ultrasonic devices produce less smoke plume and lateral thermal spread than conventional electrosurgery and do not require a dispersive electrode. The scrub must allow the blade to cool briefly after activation before handing or placing the device, as the tip retains heat momentarily after use.

Fire Risk: The Fire Triad

OR fires are rare but life-threatening. The fire triad (fuel, oxidizer, ignition source) is the framework used to understand and prevent them. In the OR:

• Fuel: surgical drapes, alcohol-based prep solutions, gauze, the patient's hair, or intestinal gases
• Oxidizer: oxygen or nitrous oxide from the anesthesia delivery system, particularly in proximity to the face, neck, or chest (oxygen-enriched environment)
• Ignition source: the active electrode of the ESU, lasers, or any device that generates heat or spark

The scrub technologist contributes to fire prevention by always placing the active electrode in its holster when not in active use, never placing it on drapes, alerting the team when flammable prep solutions are being applied, and communicating with the anesthesia provider when work near the airway increases fire risk.

Scrub-Role Safety Responsibilities

The scrub technologist's responsibilities related to electrosurgery include:

1. Before the case: Inspect cords, pencils, and bipolar forceps for damage; confirm the dispersive electrode is available and within expiration date.

2. During the case: Hand the active electrode safely; return it to the holster after each use; keep bipolar tips clean; pass devices with clear verbal communication; monitor for smoke or unusual odors.

3. Settings and alarms: Do not adjust ESU settings independently; if a surgeon requests a change, confirm the request aloud and allow the circulator to adjust the generator.

4. Cord management: Route cords off the sterile field safely to prevent tension or accidental activation; never coil active cords tightly.

5. Specimen considerations: Avoid using the ESU on tissue submitted for pathology if possible, as heat can alter histologic findings.

6. Smoke plume: Electrosurgery generates surgical smoke, which contains harmful particulates and chemical byproducts. The scrub supports use of a smoke evacuation system when available and personal protective equipment (PPE) including appropriate masks.

Device Handling on the Sterile Field

All energy-based devices received onto the sterile field must be inspected for integrity of insulation and connections before use. Insulation defects on monopolar instruments can cause unintended burns at distant sites. The scrub passes sharp or active instruments using a hands-free or neutral-zone technique whenever feasible to reduce sharps injury risk.