Electrosurgery

by Verónica Ruiz

ELECTROSURGERY: AN ALTERNATIVE TECHNIQUE IN MINIMALLY INVASIVE SURGERY IN OUR CONSULTATION.

Electrosurgery is a minor dermatological surgery technique that we often use in our practice to provide cutting or destruction of superficial skin tissue using an electrosurgical device.

We have to differenciate electrosurgery from electrocautery, as they are often concepts that are misused interchangeably.

While electrosurgery applies electrical current to the patient, electrocautery uses thermal energy without passing electrical current to the patient. In the latter, the electrode heats up due to the resistance produced by the passage of electrical current, heat that is applied directly by contact to the tissue. Electrocautery systems are available in a small version (like a pen) with a disposable battery.

 

What is the electrosurgical knife or electric scalpel?

The electrosurgical knife or electric scalpel is an electrical device that generates controlled alternating current that applied to a tissue point through an electrode is capable of destroying soft tissue by applying an electric current of certain characteristics through a terminal.  In turn, it can be biterminal (2 electrodes) or monoterminal (1 single electrode). 

In our dermatology practice we use the monoterminal mode due to its adequate performance for a minor surgery.

this device consists of 4 main elements:

  1. A generator, capable of generating electrical current of two types, one for coagulation (electrocoagulation) and the other for cutting (electroscission).
  2. A terminal or an active electrode that is the part that transmits the current and contacts the patient or the instruments to destroy the tissue.  The electrode can be needle shaped (for fulguration / desiccation), Blade or loop shape (excision or cut) or blunt tip (for coagulation).
  3. System activation pedal.
  4. Earthing plate or neutral plate, which consists of a metal plate with a grounded wire and must be placed in an area with abundant muscle, without bony prominences, and close to the area to be intervened.

 

What skin injuries can be treated with electroscalpel?

We usually use the electro scalpel for the treatment and removal of benign skin injuries and some very superficial malignant injuries in certain patients.

These injuries are:

  • Benign injuries: filiform warts (or skin tags) seborrheic keratosis, flat warts, angiomas, or rub points, spider veins,(telangiectasias), condylomas, molluscum contagiosum, among others.
  • Malignant injuries: actinic keratosis, superficial carcinomas.

In my experience, I usually reserve the electrosurgical unit for use in the office and personally I do not use it as a cutting and / or coagulation technique when removing skin injuries in the operating room, instead of using the cold knife and absorbable suture for proper cutting and hemostasis.

The scabs (or eschar) produced in the tissue secondary to the use of the electrosurgical knife can make the histological interpretation difficult in Mohs surgery.

 

What complications can appear?

The main complications to consider when treating a patient with an electrical scalpel are the possibility of delayed bleeding and scarring with hypo or hyperpigmentation (whitish or dark scars). To avoid late bleeding (which does not occur immediately but minutes after the technique is performed), a small compression bandage can be placed on the treated area for several hours or a 1 day after the procedure.  To minimize the risk of hyperpigmentation, it is recommended that the patient uses high sun protection during the months after the technique is performed.

What cures have to be done after the procedure?

Generally, a wound is left open (not sutured) and covered with a sterile dressing; sometimes this dressing has to be somewhat thick and compressive to prevent possible bleeding. 

The patient is recommended that the day after the procedure, the dressing is removed and normal hygiene is performed on the treated area, applying daily some topical antiseptic (for example iodine or alcohol) to disinfect and help dry the wound and scab formation.

The scab will take 2-3 weeks to fall, leaving a more vulnerable area of skin, so it is very important to apply sun protection during the days and months after the technique is performed to avoid the development of little cosmetic spots (hyperpigmentation).

REFERENCES

  • Howe N, Cherpelis B. Obtaining rapid and effective hemostasis: Part II. Electrosurgery in patients with implantable cardiac devices. J Am Acad Dermatol 2013 Nov;69(5):677.e1-677.e9.
  • El-Gamal HM, Dufresne RG, Saddler K. Electrosurgery, pacemakers and ICDs: a survey of precautions and complications experienced by cutaneous surgeons. Dermatol Surg 2001 Apr;27(4):385-90.
  • Arash Taheri, Parisa Mansoori, Laura F Sandoval, Steven R Feldman, Daniel Pearce, Phillip M Williford. Electrosurgery: part I. Basics and principles. J Am Acad Dermatol 2014.