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It was reported that during a laparoscopic surgery, a monopolar spatula was connected to a valleylab ft10 and initially used with a power platform set at 20 w for pure cut and coagulation.As the energy output was considered insufficient to achieve the desired tissue effect, the surgeon requested an increase in power to 30 w.Upon activating the energy using the monopolar pedal, ignition (spark/fire) occurred at the monopolar instrument.The instrument was immediately removed from the patient's cavity and its use was discontinued.A ligasure maryland device was then introduced as a substitute.However, upon activating the energy with the ligasure device inside the patient's cavity, an energy overload occurred in the device, resulting in thermal damage (burns) to the surgical cannula.Following the event, an exploratory inspection of the patient's abdominal cavity was performed using the laparoscope.The inspection revealed: thermal injuries to the patient's abdominal wall, attributed to the energy overload caused by the ligasure device.Presence of melted polymeric debris within the cavity, originating from the compromised cannula structure.Corrective actions / clinical outcome: due to these complications, the failure of the surgical supplies, and in order to ensure patient safety, the surgical team made the clinical decision to convert the laparoscopic procedure to an open surgery.Based on this information the case is deemed reportable.
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