Editorial
Radiofrequency Electrical Energy Guidelines for Authors: What’s in a Name? DISCUSS
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-2-JMIG-D-14-00500
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
This issue of JMIG contains the new instructions for authors for submitting manuscripts that discuss instruments and techniques involving radiofrequency (RF) electrical energy (Fig. 1). For the last century, RF instrumentation has evolved to become ubiquitous in surgery in general, but, more recently, it has been critical to the development of endoscopic tools that allow surgeons to precisely cut and coagulate, focally vaporize or transect tissue for reconstructive procedures, and even seal the relatively large blood vessels encountered in gynecologic extirpative surgery. The precision and efficiency of many of these device concepts has led to widespread use in vaginal and laparotomic surgery as well, in some instances effectively accomplishing ‘‘sutureless surgery’’ by replacing the time-honored ‘‘clamp, cut, and suture ligate’’ with the new paradigm of ‘‘seal and cut.’’ However, as with any technology, there are issues related to efficacy, effectiveness, collateral thermal injury, and the risk of complications that make careful, scientifically based evaluation necessary. So what does this have to do with JMIG? As with any scientific process, it is important to have an unambiguous language of communication that allows clinicians, investigators, and other users of RF electrical energy to understand the methodology described in a publication so that they can compare, replicate, or otherwise build upon the results. To date, our RF-related literature has been cluttered with incorrect or imprecise terms like ‘‘cautery’’ and ‘‘Bovie’’ that are used interchangably as nouns, adjectives, and verbs without any apparent consistency. Other incorrect terms, such as ‘‘ground electrode,’’ ‘‘return electrode,’’ and ‘‘mono-’’ or ‘‘bipolar energy’’ permeate the literature, belying an apparent lack of fundamental understanding of the processes involved in contemporary RF electrosurgical instumentation. The example ‘‘ground electrode’’ is almost invariably incorrect because ground-referenced 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.10.014
electrosurgical generator or units have not been sold for operating room use for decades. The term ‘‘return electrode’’ is inaccurate because it misrepresents the nature of alternating circuits that switch polarity 300,000 to 1,000,000 times per second to produce a current of alternating polarity (‘‘alternating current’’) when there is only ionic oscillation and no net directionality of flow. Both electrodes in the circuit, whether they are separate monopolar instruments or integrated into a single bipolar device, allow electrons to travel in both directions. This notion of ionic oscillation is a reflection of the reality that all RF electrosurgery is bipolardthe difference between monopolar and bipolar ‘‘systems’’ is the location, and, for bipolar instruments, the purpose of the second electrode. For some instruments, it is ‘‘dispersive’’ or designed to be inactive, whereas for others, like bipolar RF laparoscopic forceps, both electrodes are designed to be ‘‘active,’’ and therefore, both directly participate in the coagulation and desiccation of tissue. Another requirement for scientific communication is a structured approach to describing the variables involved with RF electrosurgical devices that allow the reader to understand what the authors actually did in their study. The brand and model of the electrosurgical units should be included because output characteristics of these devices can vary, even at similar power settings. Consequently, it is important to include not only the waveform (low-voltage continuous, modulated low voltage, or modulated high voltage), but to also include the device-specific waveform characteristics, such as frequency, peak (or peak-to-peak) voltage, and output power, as well as electrode characteristics and, at least for bench studies, the amount of energy delivered to the tissue in Joules. The reader should be able to understand the technique performed in the experiment or procedure, whether it focuses on vaporization or linear vaporization (cutting), tissue coagulation and desiccation, or fulguration, each of which is a distinct entity unto itself.
Journal of Minimally Invasive Gynecology, Vol 22, No 1, January 2015
2
In addition, and in particular, but not limited to bench-based studies, the endpoint for energy application should be known, and the surface area of the electrode(s), described with calculations of current or power density, should be provided. Manuscripts that do not clearly describe these variables make it difficult for readers to understand how to replicate or further evaluate the process ‘‘described’’ in the methodology. There is little doubt that some will consider these steps to be too technical, too arbitrary, and too confining. However, it should be recognized that these new guidelines elevate descriptions of the application of RF electrical energy from a level of unproductive anarchy to one similar to those previously established for its electromagnetic cousin, laser energy, for which the laser type, output wattage, and power density are expected components of the description of methodology. Like laser energy, RF electrical energy is used to
Fig. 1 Terms used to describe radiofrequency energy based devices in JMIG.
focally vaporize and transect tissue, but unlike the laser, RF systems are also used to coagulate and fulgurate tissue; consequently, these systems demand a similar level of mechanistic description. The goal of the entire process is to improve our understanding of this ubiquitous energy source in a way that will enhance safe and effective use in surgery of the female reproductive tract. Malcolm G. Munro, MD Los Angeles, CA Jason A. Abbott, MD, PhD Sydney, NSW, Australia George A. Vilos, MD London, ON, Canada Andrew I. Brill, MD San Francisco, CA
Radiofrequency Electrical Energy Guidelines for Authors: What’s in a Name? DISCUSS
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-2-JMIG-D-14-00500
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
This issue of JMIG contains the new instructions for authors for submitting manuscripts that discuss instruments and techniques involving radiofrequency (RF) electrical energy (Fig. 1). For the last century, RF instrumentation has evolved to become ubiquitous in surgery in general, but, more recently, it has been critical to the development of endoscopic tools that allow surgeons to precisely cut and coagulate, focally vaporize or transect tissue for reconstructive procedures, and even seal the relatively large blood vessels encountered in gynecologic extirpative surgery. The precision and efficiency of many of these device concepts has led to widespread use in vaginal and laparotomic surgery as well, in some instances effectively accomplishing ‘‘sutureless surgery’’ by replacing the time-honored ‘‘clamp, cut, and suture ligate’’ with the new paradigm of ‘‘seal and cut.’’ However, as with any technology, there are issues related to efficacy, effectiveness, collateral thermal injury, and the risk of complications that make careful, scientifically based evaluation necessary. So what does this have to do with JMIG? As with any scientific process, it is important to have an unambiguous language of communication that allows clinicians, investigators, and other users of RF electrical energy to understand the methodology described in a publication so that they can compare, replicate, or otherwise build upon the results. To date, our RF-related literature has been cluttered with incorrect or imprecise terms like ‘‘cautery’’ and ‘‘Bovie’’ that are used interchangably as nouns, adjectives, and verbs without any apparent consistency. Other incorrect terms, such as ‘‘ground electrode,’’ ‘‘return electrode,’’ and ‘‘mono-’’ or ‘‘bipolar energy’’ permeate the literature, belying an apparent lack of fundamental understanding of the processes involved in contemporary RF electrosurgical instumentation. The example ‘‘ground electrode’’ is almost invariably incorrect because ground-referenced 1553-4650/$ - see front matter Ó 2015 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.10.014
electrosurgical generator or units have not been sold for operating room use for decades. The term ‘‘return electrode’’ is inaccurate because it misrepresents the nature of alternating circuits that switch polarity 300,000 to 1,000,000 times per second to produce a current of alternating polarity (‘‘alternating current’’) when there is only ionic oscillation and no net directionality of flow. Both electrodes in the circuit, whether they are separate monopolar instruments or integrated into a single bipolar device, allow electrons to travel in both directions. This notion of ionic oscillation is a reflection of the reality that all RF electrosurgery is bipolardthe difference between monopolar and bipolar ‘‘systems’’ is the location, and, for bipolar instruments, the purpose of the second electrode. For some instruments, it is ‘‘dispersive’’ or designed to be inactive, whereas for others, like bipolar RF laparoscopic forceps, both electrodes are designed to be ‘‘active,’’ and therefore, both directly participate in the coagulation and desiccation of tissue. Another requirement for scientific communication is a structured approach to describing the variables involved with RF electrosurgical devices that allow the reader to understand what the authors actually did in their study. The brand and model of the electrosurgical units should be included because output characteristics of these devices can vary, even at similar power settings. Consequently, it is important to include not only the waveform (low-voltage continuous, modulated low voltage, or modulated high voltage), but to also include the device-specific waveform characteristics, such as frequency, peak (or peak-to-peak) voltage, and output power, as well as electrode characteristics and, at least for bench studies, the amount of energy delivered to the tissue in Joules. The reader should be able to understand the technique performed in the experiment or procedure, whether it focuses on vaporization or linear vaporization (cutting), tissue coagulation and desiccation, or fulguration, each of which is a distinct entity unto itself.
Journal of Minimally Invasive Gynecology, Vol 22, No 1, January 2015
2
In addition, and in particular, but not limited to bench-based studies, the endpoint for energy application should be known, and the surface area of the electrode(s), described with calculations of current or power density, should be provided. Manuscripts that do not clearly describe these variables make it difficult for readers to understand how to replicate or further evaluate the process ‘‘described’’ in the methodology. There is little doubt that some will consider these steps to be too technical, too arbitrary, and too confining. However, it should be recognized that these new guidelines elevate descriptions of the application of RF electrical energy from a level of unproductive anarchy to one similar to those previously established for its electromagnetic cousin, laser energy, for which the laser type, output wattage, and power density are expected components of the description of methodology. Like laser energy, RF electrical energy is used to
Fig. 1 Terms used to describe radiofrequency energy based devices in JMIG.
focally vaporize and transect tissue, but unlike the laser, RF systems are also used to coagulate and fulgurate tissue; consequently, these systems demand a similar level of mechanistic description. The goal of the entire process is to improve our understanding of this ubiquitous energy source in a way that will enhance safe and effective use in surgery of the female reproductive tract. Malcolm G. Munro, MD Los Angeles, CA Jason A. Abbott, MD, PhD Sydney, NSW, Australia George A. Vilos, MD London, ON, Canada Andrew I. Brill, MD San Francisco, CA
