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SEJARAH BEDAH LISTRIK

MILLENNIUM PAPER
The History of Electrosurgery
Sheldon V. Pollack, FRCPC,* Alastair Carruthers, FRCPC, and Roy C. Grekin, MD

Dermatologic Surgery 26  (10), 904-908
© American Society for Dermatologic Surgery

Although used by most dermatologists on a daily basis, high-frequency electrosurgery (often referred to as “radiosurgery”) could not have been developed if certain major advances in the knowledge of electricity had not occurred. In order for alternating current electricity to be utilized for medical purposes, it was necessary that high-frequency currents be produced. A generator that could provide such current was developed in 1889 by Thompson, who noted heat in his wrists when current was passed through his hands immersed in saline solution.1 Experiments conducted by Jacques Arsene d'Arsonval in 1891 established that the application, in human subjects, of electric currents with frequencies greater than 10,000 cycles per second [10,000 hertz (Hz)] failed to cause neuromuscular stimulation and the associated tetanic response.2,3 Also in the 1890s, Oudin, following some modification to d'Arsonval's equipment, was able to generate a spray of sparks that caused superficial tissue destruction.

During the next few years, the major forms of high-frequency electrosurgery were elucidated and described. Riviere, at the turn of the 20th century, conceived the notion of using very small treatment electrodes in order to concentrate the current density. This would enable one to treat a skin lesion with an electric spark.4 In 1900 he reported the treatment of an ulcer (probably a squamous cell carcinoma) on the dorsum of a musician's hand using high-frequency sparks. In 1907 Walter de Keating-Hart and Pozzi5 introduced the term fulguration (from Latin fulgur, lightning) referring to the superficial carbonization resulting when the spark from the Oudin coil was used to treat skin. They claimed that this modality was ideal for treating skin cancer and that the spark could selectively destroy tumor cells by interfering with their source of nutrition.

In 1909 Doyen6 introduced the term electrocoagulation (from Latin coagulare, to curdle) to describe a different form of electrosurgery in which tissue was touched directly with the treatment electrode and an indifferent electrode was added to the circuit. The indifferent electrode allowed for direct removal of the electricity entering the patient and caused this to flow back into the electrosurgical device. By removing this static energy buildup, shocks were avoided in surgeons and other bystanders. The amperage was effectively increased, while the “recycling” of electrical current allowed for lower voltages to be utilized. The current produced with this biterminal arrangement penetrated more deeply than fulguration and directly coagulated tissues rather than causing only surface carbonization. Doyen claimed that this more deeply penetrating current was more likely to be effective in the destruction of tumor cells.

In 1911 William Clark7 reported on the use of an electrosurgical output that caused dehydration of tissue without carbonization at the surface. He substituted a multiple spark gap for the usual single one in a monoterminal Oudin current generator. This provided a smoother current that resulted in the production of fine sparks as opposed to the long, thick sparks seen with electrofulguration. Clark used the term desiccation (from Latin desiccare, to dry out) to describe this action.

The next major event in the development of electrosurgery came in 1923 when Dr. George A. Wyeth,8 a noted tumor surgeon, used electrosurgery for cutting tissues. His apparatus, which he termed an “endotherm knife” (Greek endo, within; thermé, heat), used a thermionic vacuum tube instead of a spark gap.9 Wyeth called the technique “electrothermic endothermy.” He believed that the technique was particularly applicable to tumor surgery since it sealed off not only the smaller blood vessels but also the lymphatics that might otherwise cause dissemination of metastatic disease.

A Harvard physicist, William Bovie, probably made the most important contribution to the development of electrosurgery. With financial assistance from the Liebel-Flarsheim Co. of Cincinnati, he built an operating room electrosurgical device that offered both coagulation and cutting currents.10 Dr. Harvey Cushing, a distinguished neurosurgeon, became quite interested in these techniques and, with Bovie at the controls, began using electrosurgery for stopping bleeding and cutting through tissues during surgical procedures at Peter Bent Brigham Hospital in 1926. Dr. Cushing's favorable impressions of electrosurgery ensured acceptance of electrosurgery by the surgical world. The subsequent impact of Bovie's machine on medicine was so great that the word “bovie” is still used generically as a noun to refer to an electrosurgical apparatus or even as a verb to describe the act of performing electrosurgery.11 Ironically Bovie, who sold his patent to Liebel-Flarsheim for $1.00, was not granted tenure at Harvard University due to his poor publication record and reputedly died a poor man.

Another early proponent of this physical modality was Dr. G. E. Ward,12 a surgeon who defined electrosurgery as “the use of heat generated in body tissue through tissue resistance to high-frequency alternating current for the destruction and removal of diseased tissue or for cutting through normal tissue with minimal bleeding.”


Dermatologists and Electrosurgery

Hazards of Electrosurgery  References 

During the early years in the development of electrosurgery (which was often referred to as “surgical diathermy” or “endothermy”) the modality was often used inappropriately by untrained physicians. Charlatans “pushed the envelope” of this new technique, leading to its becoming discredited in some medical circles. Electrosurgery continued to be used in operating rooms by some surgeons for hemostasis as a replacement for more primitive electrocautery and as a direct method of removing diseased tissue with a minimum of bleeding. However, the champion of electrosurgery in the modern era became the dermatologic community.

Some 50 years ago, Sulzberger and Heinlein13 listed multiple benign and malignant skin lesions sometimes amenable to various forms of electrosurgery. Over the years this list has gradually expanded in length as others have added to it.14–17 Generations of dermatologists (and nondermatologist colleagues) have learned the art and science of electrosurgery through monographs written by dermatologists including K. H. Burdick,18 J. E. Sebben19(Figure 1), and S. V. Pollack20(Figure 2). In addition, the latter author has directed numerous hands-on workshops in at least a dozen countries to familiarize medical practitioners worldwide with electrosurgery using radiofrequency alternating current (“radiosurgery”).

Many other dermatologists have written book chapters and/or lectured on the general principles of electrosurgery, and these have served to familiarize the dermatologic world with this exciting modality. Included in this group are H. Crumay,21 G. L. Popkin,22 M. L. Blankenship,23 J. L. Elliott,24 and fellow Canadian, R. Jackson.25 Due to the efforts of some of our dermatologic colleagues, we have been reintroduced to and encouraged to use specialized forms of electrosurgery. E. L. Bodian,26 for example, has written on bipolar modalities in electrosurgery. Excisional electrosurgery was discussed by E. P. Schoch.27 A new technique termed “electrosurgical dissection” was described by W. B. Shelley.28

Whereas most surgeons continue to excise cutaneous malignancies of all sizes and types, dermatologists heeded the pioneering work of their surgical colleagues, and electrosurgery, usually combined with curettage, has become one standard dermatologic treatment for skin cancer. Among the most active early proponents of this technique were N. N. Epstein,29 J. T. Crissey,30 J. M. Knox,31 and G. L. Popkin.32 In addition, electrosurgery continues to be used routinely for treatment of a variety of benign dermatologic conditions. Epilation, the process of removing unwanted hairs, is one such application. Dermatologists K. H. Burdick,18 C. T. McKinstry,33 A. M. Kligman,34 K. A. Barber,35 R. F. Wagner,36 and T. Kobayashi37 have again led the way in exploring and improving this procedure. The latter has written extensively on the use of insulated needles for scarless removal of excess body hair. Cosmetic uses of electrosurgery have been reviewed by Pollack and Kobayashi.38

The newest innovative use of electrosurgery is for facial skin resurfacing. While the use of modern dermatologic lasers has led to improved and expanded treatment of facial wrinkles, these modalities are also associated with significant disadvantages and limitations. High-energy CO2 lasers are costly and may be associated with persistent erythema, hypo- and hyperpigmentation, and hypertrophic scarring. Less aggressive Er:YAG technology eliminates most of these side effects, but has generally proved inadequate for more than mild wrinkles.

Radiofrequency (RF) resurfacing is a promising new modality that may help overcome many of the drawbacks of existing laser procedures. RF resurfacing employs a novel method of tissue removal that replaces the thermally damaging pyrolysis of standard electrosurgery and heat-based lasers with a substantially cooler, and more controlled, dissociative process referred to as “coblation” (controlled ablation).39 An electrically conductive medium, generally isotonic saline, forms a microfine layer between the tip of the handheld bipolar electrode-tipped wand and the target tissue. When an appropriate level of current is applied through the activated wand, the electrically conductive fluid is converted into an ionized vapor layer, known as “plasma.” Charged particles accelerate across this gradient toward the tissue. At sufficiently high gradients, these particles gain adequate energy to cause dissociation of the molecular bonds within tissue structures, which ultimately leads to collagen deposition and improves skin appearance. This effect is achieved at temperatures that are dramatically lower than those associated with heat-dependent approaches (80–90°C compared with 300–600°C with CO2 lasers). This mode of action is associated with a low degree of thermal injury to surrounding tissue, presumably with lower risk for scarring or persistent erythema and a less intense postoperative course. The technique was initially clinically applied and continues to be developed by a number of dermatologic surgeons including W. D. Tope,40 A. Carruthers39(Figure 3), S. V. Pollack, and R. C. Grekin (Figure 4).


Hazards of Electrosurgery

Dermatologists and Electrosurgery  References 

 

As with any other modality, electrosurgery may have certain hazards attached to its use.41 These potential problems have been thoroughly examined by dermatologists. The most important of these is the potential spread of infection via electrosurgery. Publications by E. F. Sherertz,42 B. J. Berberian,43 G. B. Colver,44 W. S. Sawchuk,45 and R. G. Bennett46 have provided evidence for potential viral and bacterial transmission during electrosurgery and have offered solutions including strict electrode sterilization, and careful and close smoke plume evacuation. In the past there has been significant concern about using electrosurgery in the presence of cardiac pacemakers, as was expressed by E. A. Krull.47 Fortunately, however, most modern pacemakers are well shielded from external radiation. Sebben48 has offered helpful guidelines when electrosurgery is used in the presence of cardiac pacemakers. These include the avoidance of this modality in particularly unstable cardiac patients and the delivery of many short bursts of energy instead of one long one. There is a definite potential for interference with implantable cardioverter-defibrillators (ICDs). This topic has been reviewed recently by J. G. LeVasseur et al.,49 who make several suggestions including review of cardiologist recommendations and possible inactivation of ICDs prior to surgery.



Summary

As one of the original surgical procedures performed by dermatologists, electrosurgery has been integrated into essentially all dermatologic practices. Since skin lesions are so readily accessible for externally delivered therapy, it was natural that dermatologists were the ones to embrace and further develop this useful group of techniques: electrodesiccation, electrofulguration, electrocoagulation, and electrosection. Although taken for granted for many decades, this modality appears to have undergone something of a renaissance with the development of CO2 laser surgery in the 1970s. At that point dermatologists realized that “the poor man's laser” was already at hand, quietly capable of performing superficial ablations, deep ablations, incisions, and excisions. This has greatly expanded the use of electrosurgery in medicine. Recently the development of radiofrequency surgery for skin resurfacing has provided yet another direction for electrosurgery to follow in the 21st century. Dermatologists are encouraged to continue to nurture and develop this valuable and varied modality.

 


References

Dermatologists and Electrosurgery  Hazards of Electrosurgery 

 









 

 

Sheldon V. Pollack, FRCPC,
Alastair Carruthers, FRCPC, and
Roy C. Grekin, MD

 

Affiliations
*Division of Dermatology, University of Toronto, Toronto, Ontario,

Division of Dermatology, University of
British Columbia, Vancouver, British Columbia, and Department of Dermatology, University of California,
San Francisco, California

 

Address correspondence and reprint requests to: Sheldon V. Pollack, MD, FRCPC, Toronto Cosmetic Skin Surgery Center, Suite 218, 200 St. Clair Ave. West, Toronto, Ontario, Canada M4V 1R1.

S. V. Pollack, FRCPC, A. Carruthers, FRCPC, and R. C. Grekin, MD have indicated no significant interest with commercial supporters.

 

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Figure 1.  Jack E. Sebben, MD....


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Figure 2.  Sheldon V. Pollack, MD, FRCPC....


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Figure 3.  Alastair Carruthers, FRCPC....


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Figure 4.  Roy C. Grekin, MD....

 

 

 

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