Electrosurgery & Gyn Electrosurgery & Gyn Surgery:Surgery:
Get the Point AcrossGet the Point AcrossM. Jonathon Solnik, MD, FACOG FACSM. Jonathon Solnik, MD, FACOG FACSDirector, Minimally Invasive Gynecologic SurgeryDirector, Minimally Invasive Gynecologic SurgeryDept OB/Gyn, Cedars-Sinai Medical CenterDept OB/Gyn, Cedars-Sinai Medical CenterAssistant Clinical ProfessorAssistant Clinical ProfessorDept OB/Gyn, David Geffen School of Medicine at Dept OB/Gyn, David Geffen School of Medicine at UCLAUCLA
What’s the difference ?What’s the difference ?
ElectrocauteryElectrocautery: use of a direct electrical : use of a direct electrical current to heat up a metal conductor current to heat up a metal conductor with a high impedance to flow so that with a high impedance to flow so that the metal becomes physically hot.the metal becomes physically hot.
ElectrosurgeryElectrosurgery: manipulation of : manipulation of electrons through living tissue using an electrons through living tissue using an alternating current with enough alternating current with enough concentration to create heat within the concentration to create heat within the tissue and cause destruction.tissue and cause destruction.
Electrosurgical Generator (ESU)Electrosurgical Generator (ESU)
Machine that creates an alternating Machine that creates an alternating current with enough current density current with enough current density (concentration) to heat and destroy tissue (concentration) to heat and destroy tissue
Sinusoidal waveform that is bidirectionalSinusoidal waveform that is bidirectional
The waveform can be altered to createdifferent surgical
effects
Radio Frequency (RF)The frequency (>100 kHz) is above that which stimulates muscle or nerve
Look Familiar ???Look Familiar ???
How is tissue destroyed ?How is tissue destroyed ?
Electric energy is converted to heat (no net Electric energy is converted to heat (no net change)change)
Each waveform passes through both positive and Each waveform passes through both positive and negative ‘peaks’ – the intracellular polarity is negative ‘peaks’ – the intracellular polarity is interrupted, creating cellular heat.interrupted, creating cellular heat.
44-50 C44-50 C 50-80 C50-80 C 80-100 C80-100 C 100-200 C100-200 C >200 C>200 C
VisibleVisible NoneNone BlanchinBlanchingg
ShrinkagShrinkagee
SteamSteam CarbonizCarbonizeded
DelayeDelayed d
NecrosisNecrosis SloughiSloughingng
SloughinSloughingg
UlcerationUlceration CraterCrater
MOAMOA MetabolisMetabolismm
DenaturDenaturee
DesiccatDesiccatee
VaporizeVaporize CombustCombust
Odell RC. Surgical Energy Sources 2002
WaveformsWaveforms
CUT CUT Continuous Continuous
Simple Simple
UndampedUndamped
High currentHigh current
Low VoltageLow Voltage
Rapid tissue heating Rapid tissue heating vaporization vaporization
Non-contact Non-contact
Less thermal spreadLess thermal spread
COAGCOAGIntermittent Intermittent
Cooling effectCooling effect
DampedDamped
Lower currentLower current
Higher voltageHigher voltage
Less cellular heatLess cellular heat
Contact or non-Contact or non-contactcontact
Risk of thermal injuryRisk of thermal injury
CUT WaveformCUT Waveform
BLEND BLEND Interrupted CUT current with increasing Interrupted CUT current with increasing VoltageVoltage
Blend of surgical effectsBlend of surgical effects
Reduced current/timeReduced current/time
1 – more cut / 3 – more coag1 – more cut / 3 – more coag
Improved hemostasis Improved hemostasis
Requires more time to CUTRequires more time to CUT
COAGULATIONCOAGULATION
Fulguration Fulguration (COAG)(COAG)
Non-contact Non-contact
Coagulates by Coagulates by ‘spraying’‘spraying’
Heat lost to airHeat lost to air
SuperficialSuperficial eschar – eschar – carbonization (HOT)carbonization (HOT)
Oozing surfacesOozing surfaces
Minimal depth of Minimal depth of necrosis (0.5-2mm)necrosis (0.5-2mm)
Stop when bleeding Stop when bleeding stopsstops
Desiccation Desiccation (CUT>COAG) (CUT>COAG)
Contact Contact
All heat transmitted All heat transmitted to tissue to tissue
Deep & wideDeep & wide tissue tissue necrosisnecrosis
Discrete bleederDiscrete bleeder
Gaps in hemostasis - Gaps in hemostasis - can spark thru can spark thru coagulated tissue – coagulated tissue – bipolar betterbipolar better
Electrode can stick to Electrode can stick to tissue as it heatstissue as it heats
Electrode-Surface InterfaceElectrode-Surface Interface
Temperature at which the current heats Temperature at which the current heats the tissue is directly related to the size of the tissue is directly related to the size of the electrode and how it contacts the the electrode and how it contacts the tissuetissue
Temperature ∆ = (i x 2 / r x 4) X R x t
Small electrode (r) – HOT
Dispersive electrode (grounding pad) – minimal tissue change
High tissue tension (R)– affects tissue resistance
Video – CUT vs. COAGVideo – CUT vs. COAG
Monopolar vs. Bipolar CurrentMonopolar vs. Bipolar Current
Resectoscope Loop
Ultra-fineVapor pocketElectrons do the workVapotrodes
aggregation of electrons
Monopolarnonconductive, uncharged
Bipolardoesn’t matter
Thermal Injuries in MISThermal Injuries in MIS
Active electrodes can be longActive electrodes can be longTrue visual field is limited -- flying blind !!!True visual field is limited -- flying blind !!!
Delayed PresentationDelayed Presentation73% of injuries after L/S chole went 73% of injuries after L/S chole went unrecognizedunrecognized11
3-10 days or longer3-10 days or longer22
Evaluate pain, urinary retention, nausea or feverEvaluate pain, urinary retention, nausea or fever
SLS Survey 1995SLS Survey 199513% of surgeons had at least 1 malpractice case13% of surgeons had at least 1 malpractice case
1. Tucker RD, et al. AORN J 19952. Reich H. Surg Laparosc Endosc 1992
The probability of incurring a thermal The probability of incurring a thermal injury during operative hysteroscopy injury during operative hysteroscopy increases with monopolar energy.increases with monopolar energy.
TrueTrue
FalseFalse
Hazards of ElectrosurgeryHazards of Electrosurgery
ZAP !!
Direct injury with active electrode Direct injury with active electrode These are high energy burnsThese are high energy burns
Alternate Ground BurnsAlternate Ground BurnsDivision of current Division of current ECG leads ECG leads
Isolated ground circuitryIsolated ground circuitry
Patient Return Electrodes (dispersive)Patient Return Electrodes (dispersive)Previously accounted for 70% of injuriesPreviously accounted for 70% of injuries
The large size The large size
Low conductivity Low conductivity
Interpolated REMInterpolated REM
PlacementPlacement
Capacitative CouplingCapacitative Coupling
This phenomenon cannot be eliminatedThis phenomenon cannot be eliminated
Abdominal wall often serves as a return to Abdominal wall often serves as a return to groundground
Plastic cannulas may not provide more Plastic cannulas may not provide more protection than metal cannulasprotection than metal cannulas
1. Tucker RD, et al. AORN J 19952. Reich H. Surg Laparosc Endosc 1992
Which setting should be used when Which setting should be used when resecting an intracavitary myoma?resecting an intracavitary myoma?
Bipolar resectoscope using Blend 2Bipolar resectoscope using Blend 2
Monopolar resectoscope using pure CUTMonopolar resectoscope using pure CUT
Monopolar resectoscope using pure COAGMonopolar resectoscope using pure COAG
Bipolar resectoscope using pure COAGBipolar resectoscope using pure COAG
Insulation FailureInsulation Failure
Instantaneous burns with HIGH-power Instantaneous burns with HIGH-power densitydensity
Often occur in Zone 2 (outside of surgical Often occur in Zone 2 (outside of surgical field)field)
Can occur repeatedly causing serious Can occur repeatedly causing serious injuryinjury
Prevention, prevention, preventionPrevention, prevention, prevention
Know and inspect your instrumentsKnow and inspect your instruments
Adjust power according to desired Adjust power according to desired effecteffect
Use a low voltage waveform (CUT)Use a low voltage waveform (CUT)
Use short & controlled burstsUse short & controlled bursts
Practice skill sets in the lab Practice skill sets in the lab
