Impact of a hands-on component on learning in the Fundamental Use of Surgical Energy™ (FUSE) curriculum: a randomized-controlled trial in surgical trainees

Abstract

Background

While energy devices are ubiquitous in the operating room, they remain poorly understood and can result in significant complications. The purpose of this study was to estimate the extent to which adding a novel bench-top component improves learning of SAGES’ Fundamental Use of Surgical Energy™ (FUSE) electrosurgery curriculum among surgical trainees.

Methods

Surgical residents participated in a 1-h didactic electrosurgery (ES) course, based on the FUSE curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediate and at 3 months) assessments included knowledge of ES (multiple-choice examination), self-perceived competence for each of the 35 course objectives (questionnaire), and self-perceived comfort with performance of seven tasks related to safe use of ES. Data expressed as median[interquartile range], *p < 0.05.

Results

56 (29 control; 27 Sim) surgical trainees completed the curriculum and assessments. Baseline characteristics, including pre-curriculum exam and questionnaire scores, were similar. Total score on the exam improved from 46 %[40;54] to 84 %[77;91]* for the entire cohort, with higher immediate post-curriculum scores in the Sim group compared to controls (89 %[83;94] vs. 83 %[71;86]*). At 3 months, performance on the exam declined in both groups, but remained higher in the Sim group (77 %[69;90] vs 60 %[51;80]*). Participants in both groups reported feeling greater comfort and competence post-curriculum (immediate and at 3 months) compared to baseline. This improvement was greater in the Sim group with a higher proportion feeling “Very Comfortable” or “Fully Competent” (Sim: 3/7 tasks and 28/35 objectives; control: 0/7 tasks and 10/35 objectives).

Conclusions

A FUSE-based curriculum improved surgical trainees’ knowledge and comfort in the safe use of electrosurgical devices. The addition of a structured interactive bench-top simulation component further improved learning and retention at 3 months.

Appendices

Appendices

Appendix 1: Electrosurgery course objectives

By the end of the curriculum, trainees should be able to

• 1. Define proper electrosurgery terms

• 2. In a clinical situation, identify the application of ohm’s law, power equation, and energy

• 3. Explain the function (input and output) of a radiofrequency (RF) electrosurgical generator

• 4. Identify the characteristics and differences between monopolar and bipolar instruments

• 5. Identify the characteristics of the RF electromagnetic spectrum and why it is used for surgical applications

• 6. Explain how RF electrical energy causes effects in cells and tissue

• 7. Identify the different effects of ranges of temperature on cells and tissue

• 8. Explain the clinical effects of changing current densities

By the end of the curriculum, trainees should be able to identify

• 9. General patient protection measures for the electrosurgical generator

• 10. Various mechanisms whereby electrosurgical injuries may occur

Circumstances, mechanisms and prevention of

• 11. Dispersive electrode-related injury

• 12. Direct coupling-related injury

• 13. Insulation failure-related injury

• 14. Injury due to unintentional activation of the active electrode

• 15. Injury due to direct thermal extension from the active electrode

• 16. Alternate site-related injury

• 17. Capacitive coupling/induced current-related injury

• 18. Injury from residual heat from instrument tip

• 19. Energy-related single port access injury

• 20. Burn injury by the operative team

• 21. Hazards of byproducts and smoke produced during electrosurgery

• 22. Circumstances which promote OR fires and identify prevention strategies

• 23. Circumstances, mechanisms, and prevention of tracheotomy-related fires

• 24. How to respond to an OR fire

• 25. Problems that can occur when simultaneously using multiple energy devices

• 26. The characteristics of basic and advanced bipolar electrosurgical instruments

• 27. Clinical scenarios when basic bipolar instruments are indicated and identify appropriate power settings for use

• 28. Performance optimization methods for advanced bipolar instruments

• 29. Differences between bipolar and monopolar instruments as it relates to coupling, underwater use, current density, and lateral thermal spread

• 30. Tissue characteristics that reduce the effectiveness of advanced bipolar instruments

• 31. Considerations for electrosurgical device settings in infants and children

• 32. Considerations for choice and placement of dispersive electrodes for infants and children

• 33. Implanted devices that are affected by RF energy

• 34. Surgical devices that can cause electromagnetic interference (EMI)

• 35. Strategies to minimize interference from RF energy on a Cardiac Implanted Electronic Device (CIED)

Appendix 2: Simulation modules

Module 1: System setup

• Objectives: At the end of module 1, participants will be able to

  • Describe and setup components of an ESU explaining their purpose and relationship to one another

  • Explain and demonstrate the relationship between the design of the dispersive electrode and patient safety

  • Describe circumstances, mechanisms, and prevention of dispersive electrode-related injury

• Scenario: mannequin on the OR table with electrosurgical equipment

  • monopolar

  • bipolar

  • laparoscopic monopolar

• Task A:

  • Identify all the components of the circuit

  • Identify all the jacks and controls on the ESU

  • Identify how to modify the waveform and power settings on the ESU

  • Setup a circuit using the monopolar hand device

  • For a laparotomy

  • For a right hip replacement

  • For a right humerus ORIF

  • For a median sternotomy

  • For a craniotomy

  • Setup a circuit using the monopolar laparoscopic device with a foot pedal

  • Setup a circuit using the bipolar foot-activated device

• Task B:

  • Construct a circuit using monopolar ESU, 60 W light bulb, placing the split-pad dispersive elecrode on your arm and holding the light bulb in the same hand

  • Repeat with 20 W light bulb

  • Switch light bulb into other hand

  • Slowly unravel the dispersive electrode and observe the ESU’s response; describe how this would differ if a single-pad dispersive electrode was used

Module 2: Tissue effect

• Objectives: at the end of module 2, participants will be able to

  • Demonstrate the appropriate technical skills required to handle and operate the electrosurgical device

  • Explain the different tissue and cellular effects that can be created by RF electrosurgical instruments

  • Identify the different effects of ranges of temperature on cells and tissue

  • Explain and demonstrate how to create desired tissue effects by altering current density, by varying: power, waveform, electrode contact with tissue

• Scenario: steak will be placed on a bench-top and connected to a monopolar ESU using a single-pad dispersive electrode (Task A without the oscilloscope/analyzer; Task B with the oscilloscope/analyzer)

• Task A:

  • Using proper technique, make series of parallel 5 cm long, 1 cm deep incisions with monopolar hand electrode on the steak, 1 cm apart with the following settings:

  • Tissue vaporization with minimal desiccation at 20 W, 50 W and 70 W, using pure and blend modalities

  • Desiccation of tissue at 20 W, 50 W and 70 W, using pure and blend modalities

  • Fulgurate an area of 1 cm × 1 cm on the steak

  • Using the ESU at 30 W and on fulguration, activate the flat side of the device tip first using pure “cut” and subsequently using “coag”

  • Using the ESU at 30 W and on “cut,” apply the electrode tip on the steak for a total of 5 s. Do this first using the tip only, and then using the flat side of the device tip

  • Using a scalpel to make a 1 cm perpendicular incision across the electrosurgical incisions, describe the tissue effects of each incision

• Task B:

  • Using the monopolar device, connect the ES Analyzer and oscilloscope to the circuit and observe the waveforms created on the oscilloscope while using the monopolar device on the steak at 30 W in “cut”, “coag”, “blend 1”, “blend 2”, “blend 3” modes

Module 3: Mechanisms of electrosurgical injuries—I

• Objectives: at the end of module 3, participants will be able to

  • Identify circumstances and mechanisms of:

  • Capacitive coupling/induced current-related injury

  • Injury from metal-to-metal arcing

  • Direct burn injury to the operator

• Scenario: steak will be placed on a bench-top and connected to a monopolar ESU using a single-pad dispersive electrode

• Task A: Demonstrate metal-to-metal arcing on a stapler line using a monopolar ESU set at 40 W coag

• Task B: Induced current and capacitive-coupling

  • Wrap the cord of the monopolar hand electrode around the light bulb and activate using “cut” and “coag” at 50 W, with and without contact to the steak

  • Hold tissue forceps in one hand and hold monopolar hand electrode in other hand without touching the steak and activate using “cut” at 50 W, while instituting a small contact area between the tissue forceps and the steak. Do this while also making contact between monopolar electrode and steak. Repeat while wrapping the cord several times around your neck

• Task C: Direct burn injury to the operator

  • Place a water-filled glove on the steak and activate the monopolar hand electrode on the glove using desiccation at 40 W

Module 4: Mechanisms of electrosurgical injuries—II

• Objectives: at the end of module 3, participants will be able to

  • Identify circumstances and mechanisms of the following in relation to laparoscopy:

  • Capacitive coupling/induced current-related injury

  • Injury from insulation failure

• Scenario: steak will be placed on a bench-top and connected to a laparoscopic foot-pedal activated monopolar ESU circuit using a single-pad dispersive electrode

• Task A: Insulation failure

  • Attach laparoscopic graspers with insulation failure to the monopolar electrode and activate in proximity to steak at 50 W using coagulation waveform.

• Task B: Induced current and capacitive-coupling

  • Wrap piece of ham around laparoscopic monopolar electrode and activate using “cut” at 50 W while instituting a small contact area between the steak and ham

  • Hold laparoscopic needle-driver in one hand and hold monopolar hand electrode connected to laparoscopic hook in other hand without touching the steak and activate using “cut” at 50 W, while instituting a small contact area between the needle-driver and the steak. Do this while maximizing contact between needle-driver and hook laparoscopic instruments.

Each station of the bench-top simulation included a variety of electrosurgical equipment with monopolar, bipolar, and laparoscopic setups, as well as an oscilloscope to depict waveform.