Knowledge Assessment Among Surgeons About Energy Devices Safe Use: A Multicenter Cross-Sectional Study

Surgeons in different surgical specialties have used energy devices to perform surgical procedures.¹ The continued use of electrical devices has increased significantly in operating theaters. The first recorded use of an energy device to control hemorrhage in the treatment of tumors was in almost 3000 BCE, but the widespread application of these devices for different purposes only became popular within the past century.² In the United States, electrical devices were introduced into clinical practice approximately 85 years ago when an electrosurgical unit was used to achieve cutting and coagulation by altering the current that passed through the body.³

Electrosurgery (ES) is the use of high-frequency electrical energy to achieve cutting and coagulation. This method has become ubiquitous worldwide for the purpose of achieving rapid hemostasis and the rapid dissection of tissues.⁴ A large number of procedure rooms currently have facilities for endoscopy and radiofrequency ES techniques. Recently, there has been a vast array of advances in the design of surgical energy devices that has had a significant impact on the technological development and advancement of surgical procedures.³ In minimally invasive and complicated surgical procedures, ES has resulted in greater hemostasis control. This progress was made despite difficulties due to a combination of the magnitude of electrical current and heat generation. Furthermore, the interaction of these devices with other surgical tools in the operating field has resulted in more severe complications and problems. A direct consequence of the use of electrosurgical devices is potential injury to the patient's body tissue, such as the bowel, as a result of the contiguous spread of thermal heat to adjacent tissues from the primary tissue in which electrical impulses have been applied during surgery, thereby leading to an unfavorable patient outcome.⁵ The risk of surgical burns and operating room fires also constitute other possible significant adverse effects of ES in clinical practice. Electrosurgical devices can interfere with inserted pacemakers,⁶ often with deadly consequences to the patient. According to data from the Food and Drug Administration, the use of electrosurgical devices has resulted in almost 3553 injuries, 279 operating room fires, and 178 deaths.⁷ The incidence of injuries due to energy devices in laparoscopy has been estimated by one study to be 39% in 2015, and the prevalence of injuries due to energy devices during laparoscopic surgery ranged from 1 to 2 injuries per 100,000 patients in 1994.^8,9

These adverse events may be attributed to the surgeons lacking knowledge and understanding of the proper and safe uses of these electrosurgical devices. Therefore, it is important for clinicians and surgical trainees alike to understand the principle of working with electrosurgical devices and the risks associated with their use to maximize the benefits of these devices, improve patient outcomes, and improve the safety of surgical procedures.⁵ Surgeons should also have an awareness of how to properly set up the devices for each procedure and how the device interfaces with other devices.¹ In view of this, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed a program, Fundamental Use of Surgical Energy (FUSE), to tackle these problems¹⁰ and promote a high safety culture for the use of energy devices among surgeons. The FUSE program was developed as a form of empowerment for surgeons to receive continued education so that they can follow the guidelines set for the use of energy devices to reduce the risk of patient injury.¹¹

FUSE is an online global educational program that includes a multimedia curriculum and validated evaluation, complemented with multiple-choice certification examinations.⁵ In addition, these examinations assess the knowledge of participants concerning the safe use of electrosurgical devices. Successful completion of the certification examination by health care professionals also leads to the award of Continuing Medical Education and Continuing Education Units to surgeons.¹² Feldman et al¹ reported that health care providers who attended the pilot FUSE course for a half-day to learn about surgical energy devices showed an improvement in their performance after completing the course. In addition, Watanabe et al² conducted the first multicenter cross-sectional study among surgeons to assess their level of knowledge regarding the safe use of surgical energy devices. Watanabe et al² reported that surgeons and trainees with varying years of experience who completed the FUSE curriculum had a knowledge gap regarding the safe use of energy devices. Therefore, the present study aimed to assess the knowledge of surgeons about the safe use of energy devices and assess their perceptions regarding the safe use of electrosurgical devices in Saudi Arabia.²

Materials and Methods

We performed an institutional-based cross-sectional survey at 2 tertiary hospitals in the Riyadh region. The cross-sectional survey was sent electronically through a hyperlink (due to health precautions during the COVID-19 pandemic) to general surgery trainees in 2 tertiary hospitals (Prince Sultan Military Medical City and National Guard Hospital) to assess their knowledge about the safe use of energy devices. The study period was from July 2020 to January 2021. The questionnaire included multiple-choice questions developed according to the objectives and blueprints of the SAGES FUSE curriculum. A well-designed questionnaire was sent by e-mail and filled out anonymously to maintain confidentiality by all senior residents and junior residents. Participants were also given the option of opting out of the study if they wished.

Results

A total of 51 general surgical trainees from 2 academic hospitals completed the assessment. Regarding the demographic characteristics of the participants, we found the mean age of the study participants to be 29 years with an SD of 1.98 years. The age variable was categorized as a binary variable based on a cutoff of 30 years; 82.4% (n = 42.0) of the study participants were younger than 30 years, and 17.6% were 30 years or older. With respect to place of work, 50.98% (n = 26) of the participants reported working in the Military hospital, and approximately half of the participants (n = 25) reported working in the National Guard hospital. Regarding the surgeon region, almost 100% of the participants reported working in the central region, and the same proportion (100%) reported working as general surgeons. In terms of level or hierarchy as surgeons, 33.0% (n = 17.0) were junior residents, and 66.7% (n = 34.0) were senior residents. Only 9.8% (n = 5) of the participants had a FUSE certification, whereas approximately 90% of the study participants were not certified, as shown in Table 1.

Table 1 Demographic and other characteristics of study participants regarding training and their skills (n=51)

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We assessed the knowledge of the surgeons regarding various aspects of surgery by developing multiple-choice questions regarding various domains of surgery. Figure 1 shows the proportion of participants who answered correctly to different numbers of questions. The graph shows that approximately half of the participants (47%) provided 11 to 15 correct answers. Moreover, 31% responded correctly to 16 to 20 questions, whereas only 10% responded correctly to more than 25 questions, as shown in Figure 1. Furthermore, 6% responded correctly to fewer than 10 questions, and another 6% responded correctly to 21 to 25 questions.

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Figure 2 is a pie chart showing the proportion of participants with different levels of understanding based on a cutoff score for correct answers. It was found that 15.69% of the participants correctly answered 30 of 35 questions, meaning that 15.69% of the study participants had the highest level of understanding. Approximately 39.22% of the study participants responded correctly to 20 of 35 questions, meaning they had a moderate level of understanding about the safe use of ES or energy devices. The largest proportion of the participants responded correctly to fewer than 20 questions, and were judged to have a low level of understanding, as shown in Fig. 2.

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Table 2 shows the differences in the level of understanding regarding the safe use of ES by demographic characteristics and clinical experience. It was found that 9.1% of participants with a low level of understanding were 30 years old, whereas 37.5% of the older individuals with the highest level of understanding were older than 30 years. However, the difference in the level of understanding was not statistically significant between age groups (P value: 0.166). It was found that 52.2% of the individuals with a low level of understanding were junior residents, whereas 87.5% of the participants with the highest level of understanding were senior residents, which was a significant difference with a P value of 0.04. We did not find any differences between the level of understanding based on FUSE certification (P value: 0.074) or type of hospital (0.275), as shown in Table 2.

Table 2 Level of understanding regarding the safe use of electrosurgery by demographic characteristics and clinical experience (n = 51)

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The number of participants who responded correctly or incorrectly to different numbers of questions related to the secure use of energy devices is shown in Fig. 3 and Fig. 4. For example, while assessing knowledge regarding “the infant's back is an appropriate place for the dispersive electrode,” it was found that 31 participants provided correct answers. Likewise, regarding “using a bipolar instrument in neonate less than 1lb,” 36 respondents provided correct answers. Regarding “decreased current flow through the tissue between the jaws of the instrument when the tissue is completely desiccated,” 14 individuals answered correctly, as shown in Fig. 3. Similarly, regarding “uses of radiofrequency energy to induce intracellular tissue effects,” only 15 study participants responded to the question. When assessing their knowledge on “uses a continuous low voltage waveform,” 24 answered correctly, as shown in Figure 4 and Table 3.

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Table 3 The knowledge regarding electrosurgery and safety in the operating room

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Discussion

The use of electrosurgical devices in clinical practice has continued to gather more momentum globally. Such devices can either aid in performing complex, safe, and expeditious surgeries or result in severe problems. To this end, our aim was to ascertain the level of knowledge among surgeons about the safe use of energy devices in Saudi Arabia. Surprisingly, we found an appreciable deficiency in knowledge regarding the use of energy devices among surgeons. Surgeons who participated in the study lacked knowledge and understanding of energy devices and ES. Based on the questionnaire that was administered to assess this knowledge, only 10% of the study participants provided correct answers to more than 25 of 35 questions, and most participants responded correctly to only 11 to 15 questions. For example, while assessing knowledge regarding the “coagulation” mode of the electrosurgical unit, we found that 39.2% of the participants provided answers correctly; however, for knowledge regarding fire safety in the operating room, approximately 68% of the respondents provided correct answers. We also found that 16% of the participants answered correctly in the assessment of electrosurgical burns to the surgeons. Nonetheless, 71% of the respondents provided correct answers regarding knowledge about avoiding areas while placing the dispersive electrode. This indicates that most surgeons at both the senior and junior levels need to update their knowledge about different components regarding the usage of energy devices. Such gaps in knowledge permeated almost all aspects of ES, such as the fundamental tenets, adverse events, monopolar and bipolar devices, pediatric considerations, and interference with implantable devices. We also assessed the level of understanding by demographic and clinical characteristics and found that junior residents had a lower level of understanding than senior residents; however, we did not find differences by age, type of hospital, or FUSE certification.

These findings are consistent with other similar studies conducted across the world. For example, a study conducted in Japan found similar results with huge gaps in the knowledge of surgeons at all levels.² Furthermore, the same study also highlighted the gaps in knowledge across different aspects of ES.² Likewise, another study conducted in North America also confirms the findings of our study, with similar gaps in knowledge.¹ Similarly, a study conducted by Ally Ha et al¹³ found that surgeons in all specialties, such as general surgery, orthopedics, gynecology, and neurosurgery, have the same issue of knowledge gaps regarding the usage of ES. Another study was conducted in 2 large hospitals in Pakistan, where researchers also reported substantial unawareness about the surgical technique and indications for using a simple electrosurgical apparatus, which warrants increased understanding and further training.¹⁴ In addition, there has been a plethora of research in the past couple of years pointing out the deficiencies of surgeons regarding the use of electrosurgical devices.¹⁵

These findings regarding gaps in knowledge reveal that this issue of inadequate knowledge is a common problem, irrespective of geographic setting. This concordance across different studies highlights the need for formal training regarding the use of ES in Saudi Arabia. The findings can be explained by inadequate training in the FUSE program, as reflected by the small proportion (9.8%) of surgeons who were certified for this course. This also implies that surgeons and junior surgeons obtain training informally either by observations in the operating rooms or via sponsorship by pharmaceutical companies. However, we did not explore the reasons for the low certification rate for FUSE in our study and did not explore the reasons for the low level of knowledge, as this was not the objective of the current cross-sectional study. The findings regarding differences in the level of understanding by type of resident can be explained by the fact that senior residents have more exposure to knowledge, and they might be more skillful than junior residents.

The findings of the study inform various interventions to be designed in Saudi Arabia. Because gaps in knowledge or inadequate knowledge regarding the safe usage of energy devices may increase the risk of problems, mainly for patients, it is important and urgent that hospital administrations take actions to provide the required training to surgeons through different methods. One possible technique to tackle this issue of inadequate knowledge is to develop educational curricula to enable surgeons to understand and embrace best practices that can reduce the possibility of injury while using energy devices. This can be done by integrating FUSE training in the existing curricula because the literature illustrates that the FUSE program can fill this gap effectively through either online training or workshops.^16,17 For example, the findings of a randomized controlled trial revealed that the FUSE-integrated training curriculum resulted in an improvement in the knowledge of junior surgeons regarding the safe use of electrosurgical devices.¹⁷ Currently, the Federation of Visceral and Digestive Surgery has demonstrated that surgeons are satisfied with the program after taking the FUSE course.¹⁸ Furthermore, according to the Society of Laparoendoscopic Surgeons, there is a need to improve the knowledge and awareness of principles related to ES, and improved credentialing was needed approximately 10 years ago.¹⁹ Nevertheless, no standardized guidelines exist on training surgeons and other related staff about the use of ES and other energy devices. In addition, there is no well-defined requirement to reveal proficiency after training.

Conclusion

Most general surgery residents enrolled in the Saudi Arabian Board of Surgery lack adequate knowledge about the safe and efficient use of surgical energy devices. The level of understanding is lower among junior residents than senior residents. The gaps in knowledge might not improve even after gaining experience. There is a need to implement formal education or awareness programs in the existing curriculum with refreshers by conducting online courses or workshops for surgeons. Such a program should become a requirement for surgeons. The gap in knowledge and a pervasive absence of proper training indicates the necessity for a regulated and more proper program, such as FUSE, to tackle the lack of knowledge among surgeons about the safe use of energy-based devices in surgical procedures.