This document provides information on various techniques and technologies used in electrosurgery. It discusses the history and evolution of electrosurgery from the 1920s to present. Key aspects covered include the differences between electrocautery, electrosurgery, monopolar vs bipolar methods, and tissue effects. Complications are reviewed. Newer energy sources and technologies are introduced, such as advanced bipolar devices from Gyrus ACMI, Ethicon Endo-Surgery, and Covidien.
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1.
Dr.
James
Bentley
Professor
Department
of
Obstetrics
and
Gynecology
Dalhousie
University
Halifax
NS
Thanks:
Dr
N
VanEyk
Assistant
Professor
Dalhousie
University
4. Electrocautery
— Direct
Current
(electrons
flowing
in
1
direction)
— Heats
an
alloy
(metal)
which
is
then
applied
to
tissue:
does
not
flow
through
patient
5. Electrosurgery
History
In
1926
Harvey
Cushing,
consulted
with
a
physicist
connected
with
the
Harvard
Cancer
Commission,
William
T.
Bovie.
Together
they
worked
to
create
the
most
effective
circuits
and
electrodes,
which
were
introduced
into
surgery
in
October
of
1926.
6. Electrosurgery
Evolu;on
1920s Present
60hz Grounded Circuit >200 000hz Isolated Circuit
Alternate Site Burns No Alternate Site Burns
Return Electrode Burns Return Electrode Burns Still
Possible
7. Electrosurgery
— High
frequency
— Alternating
Current
— Current
enters
patient s
body
as
part
of
the
circuit
8. Ohm s
Law:
I=V/R
— Current
=
I:
flow
of
electrons/time
(amps)
— Resistance
(impedance)
=
R
:obstacle
to
the
flow
of
current
(ohms)
— Voltage
=
V:
force
pushing
current
through
the
resistance
(volts)
— Power
=
V
x
I
(watts)
9. Monopolar
vs.
Bipolar
• Cut/coag
• ↑
dissection
• ↑
current
density:
↓
thermal
spread
• ↓
“stick”
• ↓impedance
à
↓voltage
à
↓
heat
• no
grounding
pad
• ↓
coupling
• ↓
smoke
• ↑hemostasis
• wet
OK
• implants
OK
Safer
11. Tissue
Effects
— Cutting=
Vaporisation
— Fulgaration
— Coagulation=Dessication
— The
difference
between
cutting
and
coag
is
the
rate
at
which
the
tissue
heats
up.
— This
is
manipulated
by
varying
the
current
density
(surface
area)
16. Energy
Sources:
The
New
Genera;on
— Higher
Current,
Less
voltage
— Less
thermal
spread
— Plug
&
Play
:
output
&
power
preset
— Impedance
feedback
&
adjustments
— Grasp,
dissect,
coagulate
&
transect
with
one
instrument
— Disposable:
safer,
more
efficient
but
↑$
18. Gyrus
ACMI
— PK
(plasma
kinetic)
energy
delivered
in
a
series
of
pulses
(VPC
=
vapor
pulse
coagulation)
à
boil
fluid
in
tissue
à
steam
creates
vapor
pockets
which
coalesce
to
form
vapor
zones
— High
resistance
within
zone,
low
at
periphery
à
highest
current
density
at
edges
where
tissue
moist/not
coagulated
19. Gyrus
ACMI
— Pulse/cool
off
period
cools
instrument
à
reduces
drying
and
electrode
sticking
— Pulses
repeated
until
tissues
don t
absorb
fluid
=
uniformly
coagulated
à
audible
and
visual
impedance
end
point
indicators
— Vessel
sealing
capacity
20. Gyrus:
PKS
laparoscopy
instruments
— Cutting
Forceps
— L-‐Hook
— Plasma
J-‐Hook
— PlasmaSORD™
Bipolar
Morcellator
— PlasmaSpatula®:
coag
with
one
surface,
rotate
90
degrees
and
cut
21. Enseal
— Adjusts
energy
simultaneously
to
various
tissue
types
in
a
tissue
bundle
(each
with
own
impedance
characteristics)
— Proprietary
electrode
with
millions
of
nanometer
sized
conductive
particles
embedded
in
a
temperature
sensitive
material
( Smart
electrode
technology );
each
particle-‐discrete
thermostatic
switch
— To
keep
temperature
from
rising
dangerously
–
each
particle
interrupts
current
flow
to
a
specific
tissue
region.
When
temperature
dips
below
optimal
fusion
level,
particle
turns
back
on;
temp
maintained
~
1000
C
22. Enseal
— Process
continues
until
entire
tissue
segment
is
uniformly
fused
without
charring
or
sticking
— Less
heat
required-‐tissue
volume
reduced
by
compression;
limits
lateral
thermal
spread
—
Vessel
walls
fused
by
compression,
protein
denaturation,
then
renaturation
— up
to
7mm
vessel
diameter
— withstand
up
to
7
x
systolic
pressure
24. Ligasure
— Electrosurgical
Collagen
Welding :
Combination
of
pressure
and
energy;
denature
collagen
and
elastin
to
reform
a
permanent
seal;
hydrothermal
rupture
of
hydrogen
cross
links
by
elevating
to
60-‐95
ºC
— Cooling
allows
renaturation
of
entangled
unwound
collagen
strands;
high
uniform
mechanical
compression
increases
entanglement/recrosslinking
upon
thermal
relaxation
— Permanently
fuses
vessels
and
tissue
bundles
without
dissection
or
isolation
26. Ligasure
— Average
seal
cycle
is
2
to
4
seconds*
— up
to
7
mm
vessel
diameter
— withstand
up
to
3
x
systolic
blood
pressure
— Impedance
feedback
–
adjusts
energy
output
based
on
real
time
measurements
of
tissue
impedance
3333
times/second
— Feedback-‐controlled
response
system
automatically
discontinues
energy
delivery
when
the
seal
cycle
is
complete
29. Harmonic
Scalpel
— Amount
of
blade
excursion
modifies
tissue
effect;
cutting
speed
increases
with
higher
settings
(1
-‐
5)
— No
electrical
energy
à
no
risks
coupling
— No
smoke
(steam
only)
— Minimal
lateral
thermal
spread
— Small
–
medium
vessels:
up
to
5mm
33. Comparison:
Mean
Burst
Pressure
Newcomb et al. Comparison of blood vessel sealing among new
electrosurgical and ultrasonic devices. Surg Endosc 2009; 23 (1):90–96
36. Comparison:
Temperature
Range
F. J. Kim et al. Temperature safety profile of laparoscopic devices: Harmonic ACE (ACE), Ligasure V (LV),
and plasma trisector (PT). Kim et al. Surg Endosc 2008; 22:1464–1469
38. Histologic
effects
A:Harmonic Scalpel
B: Gyrus PKS cutting forceps
C: Ligasure V with forced triad Generator
D: Ligasure V with vessel sealing generator
E: Gyrus Plasma Trissector
39. What
do
you
want/not
want?
— Tissue
Handling
— Grasper,
Elevator
— Dissector
— Vessel
Sealing
— Hemostasis
— Handpiece
expandability
— Tissue
Products
— Plume,
Smoke,
Steam
— Heat
— Carbon,
Stick
— Response
to
fat
— Response
to
tension
40. What
do
you
want/not
want?
— Handpiece
— Activation:
hand
vs.
foot
pedal
— Blade
activation:
on
closing
vs.
separate
trigger
vs.
none
— Rotational
tip/shaft
— Jaw
design:
shape,
length,
width
— Size:
5mm,
10mm
— Cost
41. Summary
— Electrosurgical
Principles:
— Use
lowest
voltage
possible
for
the
shortest
time
possible
— Bipolar
safer
than
monopolar
— If
monopolar,
cut
safer
than
coag
— Advanced
Electrosurgical
Instruments
— Understand
their
mechanisms
of
action
— Assess
what
you
need
them
to
do
— Trial
them:
look,
hold,
use
— Cost
feasibility