An alternative pathway electrosurgical unit injury in a dog

Objective: To report esophageal perforation, caused by alternative current pathway from the use of a monopolar electrosurgery unit (ESU), during routine orthopedic surgery in a dog. Study Design: Clinical report. Animals: Two‐year‐old male Labrador retriever. Methods: Medial meniscectomy and lateral suture stabilization were performed on a healthy Labrador retriever with a ruptured cranial cruciate ligament. Monopolar electrosurgery was used during the procedure for hemostasis and tissue dissection. Anesthetic monitoring was augmented with an esophageal electrocardiogram (ECG) probe. The day after surgery, the dog appeared dehydrated. After intravenous fluid therapy, respiratory distress was noted and thoracic radiography and contrast fluoroscopy revealed an esophageal perforation. Results: Exploratory surgery was planned to repair the defect. Cardiac arrest occurred after induction. Gross necropsy findings and histopathologic examination revealed lesions consistent with thermal necrosis of the esophagus and myocardial degeneration. An internal investigation of this medical device accident revealed that multiple factors may have contributed to the injury. Conclusions: An alternative current pathway from the monopolar ESU to the esophageal ECG probe resulted in a full‐thickness esophageal thermal injury and cardiac failure.