Cases & Commentaries

Lap Burn

Commentary By Kay Ball, RN, MSA

The Case

A woman was scheduled for an elective diagnostic
laparoscopy for dysfunctional uterine bleeding. After accessing the
abdomen with the trocar without complication, the surgeon inserted
the laparoscope but found that she needed to reposition the trocar.
She removed the laparoscope and placed it on the tray in front of
her. After adjusting the trocar, she picked up the laparoscope and
noticed the drapes were melted where the distal tip of the scope
had been placed. The drapes had been covering the patient, and
examination revealed a second-degree burn of the thigh. The burn
healed without any scarring.

The Commentary

The patient suffered only a minor burn and had no
long-term sequelae; fortunately, the burning drapes were recognized
quickly. However, this case highlights both a specific risk of
laparoscopic surgery and an associated, more general risk of
serious patient harm or extensive damage from fires in the
operating room.

The popularity of minimally invasive procedures
continues to grow, with over 2.3 million laparoscopies being
performed each year in the United States.(1) The many complications of laparoscopic surgery include
internal bleeding, infection, and pain from gas distention. Patient
burns, though less common, are clearly a morbid complication,
accounting for about 5% of laparoscopic injuries.(2) Although most laparoscopic burn injuries result from
stray electrosurgical current released inside the abdomen, the less
common complication of external burns is, as this case
demonstrates, a potential hazard.

Surgical suites offer a host of conditions that
create risks of fires and patient burn injuries. Most patients are
given supplemental oxygen as part of anesthesia. Fuel is present in
the form of surgical drapes, sponges, plastic instruments, prepping
solutions, and other flammable materials. Heat is provided by
electrosurgical devices, lasers, and even light sources for
laparoscopic illumination. The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) has recognized the risk of
surgical fires and burns and estimates that with approximately 60
million surgical procedures being performed annually, roughly 100
surgical suite fires will occur, causing approximately 20 serious
injuries and 1 to 2 deaths.(3)

Fires or burns related to laparoscopy, such as
the one in this case, usually are caused by either instrument
malfunction or individual clinician errors. Laparoscopic surgery
requires a complex illumination system to provide adequate
visualization of an enclosed body cavity. There are two major
components to the system: the light source and the light cable. A
variety of light sources provide different quality of light and
different temperatures. Although these variables depend upon the
lamp used, all of them have safety mechanisms in place to minimize
the heat generated by the light source.(4) Within the light source is a heat filter to help
remove the excess heat produced by the infrared light waves and by
the heat buildup resulting from the obstruction within the pathway
of the light. Also, light source fans are used to dissipate the
excess heat energy while light cable connectors also help disperse
the heat.

The light cable is another key component of the
illumination system. Laparoscopic light cables are available as
fiberoptic or gel-filled. The fiberoptic cables consist of bundles
of fragile tiny glass fibers that optically transmit the light
through internal reflections. The gel-filled cables consist of a
clear liquid optical gel that is capable of transmitting 30% more
light than optic fibers.(5)
These cables can be more hazardous than fibers, since they transmit
more heat.

Given the complexity of the illumination system,
instrument or component malfunction can lead to excessive heat
generation and result in fires or patient burns. For example, high
temperatures may be produced if any of the heat minimizing devices
fail within the light source, if different connectors or components
are used, or if the light source or light cable is defective.
Moreover, heat dissipation may not be effective if different brands
of connectors are used. Careful inspection of all instruments and
equipment before use is critical and proper maintenance can ensure
the equipment is in good working order.

Even when all the heat-dissipating mechanisms are
in place and are functioning correctly, the temperature at the
distal end of the light cable can reach levels well above the
ignition temperature of most surgical drapes. Thus, as in this
case, it is clinician mishandling of the laparoscope that often
leads to fires and patient burns during laparoscopy. Recognizing
this inherent risk in the procedure, experts have offered
suggestions specific to the handling of the laparoscope to minimize
this risk. For example:

  • The light source should not be
    turned on before the cable is connected to the endoscope because
    the end of the cable becomes hot and could ignite dry
    combustibles.(6)
  • If
    the cable is disconnected from the endoscope during surgery, then
    the cable end should be held away from the drapes or placed on a
    moist towel to prevent burns and fires.(7)
  • Keep illuminated
    endoscopic light cords away from drapes, patient's skin,
    personnel's skin, or any flammable material.(8)

All surgeons who
perform minimally invasive laparoscopic procedures should be aware
of these guidelines, and physicians-in-training should be educated
on the importance of handling the laparoscope safely. As well,
institutions can implement system changes to minimize the risk of
patient burns and fires associated with laparoscopy.
Recommendations include labeling all light sources with the
following: "Warning: High-intensity fiberoptic light sources and
cables can ignite drapes and other materials. Complete all
fiberoptic cable connections before activating the light
source."(9)
Electrosurgical instrumentation that is not being used can be
placed in holsters to protect from fires or burns if accidentally
activated.(8)
Unfortunately, there are no holsters available for laparoscopes at
the present time.

The burn in this case
was related to individual mishandling of the laparoscope. When the
surgeon removed the laparoscope from the body and placed it on the
surgical drapes, she should have handed it to the scrub nurse/tech
or the first assistant to hold away from the patient and drapes.
Another option would have been to turn off the light source when
the laparoscope was placed on the drapes. This would have
eliminated the light and, therefore, the heat being emitted at the
distal tip. Also the light cord could have been disconnected from
the scope and held away from the drapes when the laparoscope was
removed from the body. Fortunately, the drapes only melted when
exposed to the high temperatures; they could have easily been set
on fire. These types of complications can be avoided by a few
simple measures. If the heat source (the laparoscope or light
cable) is kept away from the fuel (the patient or the drapes)
within the oxygen-rich environment of the operating room or
laparoscopic suite, fires and burns can be eliminated.

Kay Ball, RN, MSA
Perioperative Consultant/Educator

References

1. Dennis V, Grimes
B. Managing a new class of electrosurgical risk: active electrode
monitoring. Infection Control Today Web site. October 2000.
Available at: [ go to related site ]. Accessed September 16,
2004.

2. Liano, C. Curbing
laparoscopy burns. United Press International. The Washington Times
Web site. June 21, 2004. Available at: [ go to related site ]. Accessed October 5,
2004.

3. Sentinel Event
Alert. Joint Commission on Accreditation of Healthcare
Organizations Web site. Issue 29. June 24, 2003. Available at: [
go to related site ]. Accessed September 16,
2004.

4. ECRI. OR fires
caused by fiberoptic illumination systems [hazard]. Health Devices.
1982;11:148-9.

5. Mishra RK. Light
cable and light source and future of laparoscopy. Laparoscopy
Hospital Web site. Available at: [ go to related site ]. Accessed September 16,
2004.

6. Ball KA.
Endoscopic Surgery. St. Louis, MO: Mosby's Perioperative Nursing
Series; 1997:121.

7. Ball KA. Surgical
modalities. In: Rothrock J, ed. Alexander's care of the patient in
surgery. 12th ed. St. Louis, MO: Mosby;
2003:43-44.

8. AORN. 2004
Standards, recommended practices, and guidelines. Denver, Co: AORN;
2004:248,270.

9. ECRI. Only you can
prevent surgical fires. Surgical fire poster. Available at: [
go to related site ]. Accessed September 16,
2004.