Surgical Trainees in Sri Lanka Show Alarming Gaps in Energy Device Safety Knowledge

Every day, in operating theatres around the world, surgeons rely on an arsenal of energy-based devices to cut tissue, seal blood vessels, and control bleeding. Electrosurgical units, ultrasonic dissectors, and vessel-sealing systems have transformed modern surgery, making operations faster and less bloody than any previous generation could have imagined. Yet the very instruments that make surgery safer when used correctly can inflict devastating injuries when used incorrectly. A new cross-sectional study from Sri Lanka, published in Global Surgical Education, the journal of the Association for Surgical Education, suggests that the surgeons of tomorrow may be learning to wield these powerful tools largely by trial and error, with potentially serious consequences for patient safety.

The research team, led by J. K. G. Madhawa of the National Hospital of Sri Lanka and Kanchana Wijesinghe of the University of Sri Jayewardenepura, surveyed postgraduate surgical trainees enrolled under the Postgraduate Institute of Medicine at the University of Colombo. Their goal was straightforward but important: to measure how much these trainees actually know about the safe use of surgical energy devices, to examine how they behave in practice, and to identify where the training system is failing them. The findings paint a picture that is unlikely to comfort anyone who has recently been on an operating table.

The most striking statistic concerns formal education. Only 40 percent of respondents reported ever having received official instruction on how to use surgical energy devices safely. In other words, the majority of future surgeons in this cohort are expected to master equipment that delivers high-frequency electrical current or ultrasonic energy to living tissue without any structured teaching whatsoever. Their knowledge, where it exists, has been picked up informally from senior colleagues, from observation, and from their own experience. The study’s authors argue that this experiential model of learning is fundamentally insufficient to address the gaps they documented.

How large are those gaps? The average knowledge score across the cohort was 12.1 points with a standard deviation of 2.4, corresponding to 63.7 percent of the maximum. That figure sits uncomfortably close to the threshold where competence becomes questionable. The researchers found that trainees performed reasonably well on certain clinical safety procedures. Awareness was high regarding the correct placement of dispersive electrodes, the return pads that complete the electrical circuit in monopolar electrosurgery and prevent burns at the skin interface. Trainees also showed solid understanding of how to manage patients with implanted cardiac devices, such as pacemakers and defibrillators, which can malfunction or be reprogrammed inappropriately when electromagnetic interference from electrosurgical instruments is not properly controlled.

But when the questions turned to basic electrophysical principles, performance deteriorated markedly. This is the technical heart of the problem. Electrosurgery depends on an understanding of concepts such as current density, the difference between cutting and coagulation waveforms, the role of insulation, and the mechanisms by which stray energy can escape from the intended circuit. Capacitive coupling, for example, occurs when electrical energy induces current in nearby conductive objects, such as a laparoscopic instrument passing through a metal trocar, potentially burning tissue far from the active electrode. Direct coupling and insulation failure represent related hazards. A surgeon who does not understand these mechanisms cannot recognize the situations that create them, and the study found that fundamental knowledge of exactly these principles was deficient among the Sri Lankan trainees.

Perhaps the most sobering finding is that knowledge scores did not improve with seniority. The statistical analysis showed no significant difference in knowledge ratings between training levels, with a p-value of 0.725 indicating a striking absence of any relationship. In a well-functioning training system, one would expect knowledge to accumulate as trainees progress through their programs. The absence of such a gradient suggests that experience alone, at least within the current structure, does not teach these surgeons what they need to know. This echoes a growing international literature. A landmark 2012 study by Feldman and colleagues concluded bluntly that surgeons do not know what they do not know about the safe use of energy in surgery, and subsequent multicenter studies in Japan, Turkey, and across multiple countries have confirmed that the knowledge gap persists worldwide.

The behavioral findings are equally concerning. More than half of the trainees reported that they do not routinely check the insulation integrity of instruments before use. Insulation failure is one of the classic mechanisms of electrosurgical injury, particularly in minimally invasive surgery, where a break in the insulation along the shaft of a laparoscopic instrument can deliver current to unintended tissue inside the patient’s body, often out of the surgeon’s direct view. Pre-use inspection is a simple, low-cost safety behavior, and the fact that a majority of trainees skip it points to a culture in which device safety checks are not embedded in routine practice.

Then there is the issue of speaking up. Nearly one in three trainees, 32.3 percent, indicated reluctance to voice concerns when they observed unsafe energy practices in the operating theatre. This finding touches on a broader and well-documented problem in surgical culture: hierarchy and communication. Operating theatres are traditionally steep environments of authority, and junior members of the team may hesitate to challenge a senior surgeon even when a genuine safety hazard is unfolding. Patient safety science has long recognized that such silence is a critical failure mode in high-reliability organizations. A training system that leaves a third of its trainees unwilling to flag unsafe practice is not merely under-informing them; it is failing to create the psychological safety that modern surgical teams require.

The stakes are not hypothetical. Injuries and fatalities related to surgical energy devices have been reported to the U.S. Food and Drug Administration, and analyses of those reports by Overbey and colleagues in 2015 documented a substantial burden of harm. Complications range from unintended thermal burns and bowel injuries, which can present days after an operation when delayed thermal injury becomes apparent, to fires in the operating theatre and interference with implanted electronic devices. In laparoscopic surgery, where the surgeon’s view is limited and energy can travel along instruments in unexpected ways, the risk of unrecognized injury is particularly acute. Preventing these events depends heavily on the operator understanding the device, the tissue, and the physics connecting them.

What should be done? The Sri Lankan authors recommend the implementation of formal, structured instruction on surgical energy safety within postgraduate training programs. Internationally, the most developed model is the Fundamental Use of Surgical Energy program, known as FUSE, developed under the Society of American Gastrointestinal and Endoscopic Surgeons. FUSE arose from a multi-institutional needs assessment led by Madani, Jones, Fuchshuber, Robinson, and Feldman, and it provides a standardized curriculum covering the physics of energy devices, their appropriate clinical applications, and the prevention of device-related injuries. Studies of the program have shown that structured education of this kind can measurably improve knowledge among surgical trainees and practicing surgeons alike. Adapting such a curriculum to local contexts, including resource settings like Sri Lanka, would be a logical next step, and the authors frame their findings as evidence that the current apprenticeship model cannot be relied upon to deliver this content on its own.

The study has the limitations inherent to cross-sectional survey research. It captures a snapshot of one cohort of trainees in one country’s training system, and self-reported practices may not perfectly match actual behavior in the operating theatre. The questionnaire was developed following established educational research guidance, and the analysis was reported in line with consensus standards for survey studies, but a survey can only measure what respondents are willing and able to report. Still, the consistency of the Sri Lankan findings with those from Japan, Turkey, the United States, and international collaborations suggests that this is not a local anomaly but a global structural weakness in surgical education.

That consistency is, in a strange way, the most encouraging aspect of the story. If surgeons everywhere share the same blind spots, then the remedy is also likely to be universal: explicit, structured, testable education in surgical energy safety, integrated into training curricula rather than left to the accidents of apprenticeship. The Sri Lankan study adds a clear data point to a growing international case. For the trainees who will hold the electrodes of the future, and for the patients under their hands, the hope is that the next generation will not have to learn the physics of burning tissue by causing it.

Subject of Research: Knowledge and safe-practice gaps in surgical energy device use among postgraduate surgical trainees in Sri Lanka

Article Title: Knowledge and practices of surgical trainees in Sri Lanka regarding the safe use of surgical energy devices: a cross-sectional study

Article References: Knowledge and practices of surgical trainees in Sri Lanka regarding the safe use of surgical energy devices: a cross-sectional study. (n.d.). https://doi.org/10.1007/s44186-026-00612-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00612-5

Keywords: surgical energy devices, electrosurgery, surgical training, patient safety, Sri Lanka, surgical education, postgraduate trainees, FUSE program, insulation failure, capacitive coupling, cross-sectional study, operating theatre safety