ENERGY SOURCES IN SURGERY

(The Archaic to Modern ERA)

-Dr. R.V.M. unit

History
Celsus : described ligature
Albucasis : used iron rod to control
bleeding
Vigo : used hot oil
Pare : used ligature and hot oil both
William Bovie and Harvey Cushing
invented the electrosurgical unit.
 INVENTORS OF ELECTROSURGICAL
UNIT

Dr. William T Bovie First ESU Dr. Harvey Cushing

(Physicist) (Neurosurgeon)
 TYPES OF ENERGY SOURCES
 Radiofrequency Electrosurgery :
• Monopolar Cautery
• Bipolar Cautery
 Ultrasonic energy system
• Harmonic scalpel
 Laser
RADIOFREQUENCY
ELECTROSURGERY
Electromagnetic spectrum

Electrosurgery uses frequency in

the range of 300kHz to 5 MHz
 Electrical process requires:
 Source of current
 Connecting wires
 Electrodes and circuits
Current Source and Connecting Wires

ESU/Bovie helps in converting the frequency in the plug

point to that required in the electrosurgery
Cost : Rs 35.000
 Types of Electrodes and Circuits

Monopolar Cost : Rs 250 Bipolar Cost : Rs 3500

Tissue effects of Electrocautery
 Thermal Effects of Area of Electrode

Area is inversely proportional to the concentration of current

 Thermal effect of waveform

Cutting Coagulation

Pure cut Desiccation Fulguration

Blend
≥100℃ ≥90℃ ≥250℃
 ELECTROSURGICAL INJURIES
ASSOCIATED WITH MONOPOLAR
CAUTERY
NOT ALWAYS DUE TO SURGEON ERROR

OPEN ACTIVATION
DIRECT COUPLING
INSULATION FAILURE
INDIRECT COUPLING
TISSUE IMPEDANCE
 Safety concerns with Monopolar circuits
 Open activation – Deliberate activation
of the active electrode prior to contact
with the tissue.
 Safety concerns with Monopolar circuits
 Direct coupling – when an
active electrode comes in
contact with a conductive
instrument which channels the
radiofrequency energy to
another site.
 Safety concerns with Monopolar circuits
 Insulation Failure - A
break in insulation
covering the shaft leading
to radiofrequency energy
discharging through these
breaks.
 Safety concerns with Monopolar circuits
 Capacitive coupling – When
two conductors are in proximity
to one another with insulation in
between.
 Safety concerns with Monopolar circuits
 Tissue Impedance: It is the A B
resistance offered to the flow of
radiofrequency energy.
 Types of Bipolar Devices
1st Generation 2nd Generation

 Safer than monopolar  Combines tissue desiccation

 Only desiccation and vaporization.
 Thermal spreading effect
 Reduce the thermal spread,
tissue carbonization .
 Excessive desiccation –
amalgam
 Plasma Kinetic Technology,
EnSeal, Ligasure,
Thunderbeat.
 Ligasure
 Uses both electrical energy and pressure.
 Both elastin and collagen are
denaturated.
 Cutting blade to cut the sealed tissue.
 Can be used in tissues upto 7mm in
diameter.
 Helps in hemostasis.

Cost : Rs. 30,000

 EnSeal Technology
 Much more efficient and
stronger.
 Lesser thermal conductivity.

Cost : Rs60,000
 Thunderbeat
 Similar to Ligasure and EnSeal
technology.
 Uses Ultrasonic Energy System for
Cutting.

Cost : Rs. 3,00,000

 Plasma Kinetic Technology
 Less heat but adequate to cause collagen
denaturation without desiccation.
 Pulses of radiofrequency energy
 Cooling is seen in between to allow
renaturation.
 Eg : knife blade
 Practical Aspects Of Using Electrosurgery
 Why do you get a burn while using a monopolar cautery when your
glove is torn ?
 Practical Aspects Of Using Electrosurgery
 Why does the muscle twitch while using cautery on it?
 Practical Aspects Of Using Electrosurgery
 Why are bowel injuries missed?
 Practical Aspects Of Using Electrosurgery
 What type of cautery in used when a metallic device is in the
electrical field?
 Practical Aspects Of Using Electrosurgery
 Why do some artery forceps not conduct radiofrequency energy?
 Electrosurgical application in Operative
hysteroscopy
 Hysteroscope uses laser and electrosurgery
 The distension medium can be ionic or non ionic depending upon
the cautery
 THERAPEUTIC APPLICATIONS
 Removal of polyps
 Removal of submucous leiomyoma,
thick muscular septum.
 Division of septa
 Endometrial ablation
 Electrosurgical application in Operative hysteroscopy

MONOPOLAR DEVICES:
 Fluid used is non ionic such as mannitol, glycine or sorbitol
 Used for : endometrial loop resection
 Complications:
Electrolyte imbalance
Uterine perforation
Burns to vagina or perineum
 Electrosurgical application in Operative
hysteroscopy
BIPOLAR DEVICES:
 Used in saline environment
 Inherit all safety features of bipolar electrosurgery
 Can lead to gas embolism
 NOVEL APPLICATIONS OF
RADIOFREQUENCY
THERMIVA
 Non invasive , temperature controlled
treatment.
 Gently heats vulvovaginal tissue.
 Causes collagen fibrils to denaturate
and contract.
 Uses : vaginal and vulval laxity
 Viveve uses similar mechanism.

Cost : Rs. 1.5 to 2L

 MICROWAVE ABLATION

8mm reusable probe

Used in dysfunctional uterine
bleeding and for tumor ablation
Can ablate larger areas in lesser
amount of time
Earthing risks are reduced
No distention media required
ULTRASONIC ENERGY SYSTEM
ULTRASONIC ENERGY SYSTEMS
 First developed in the early 1990s
 This system use a frequency of 23-55kHz
 Tissue Effects:
 Desiccation by heat generation.
 Cutting by mechanical oscillations and cavitation
 Cellular vaporization occurs at a much lower temperature
 Seals vessels upto 7mm in diameter with MINIMUM lateral thermal
spread

EFFECTS ARE SIMILAR TO ELECTROSURGERY MINUS

THE RISKS
 Practical aspects:
 2 Settings- MIN & MAX
 When to use which setting?
 Practical aspects:
 2 jaws- Passive articulated jaw and Oscillating jaw
 Placement of these jaws

 2 jaws- Passive articulated jaw and

Oscillating jaw
 Placement of these jaws
 ELECTROSURGERY ULTRASONIC SHEARS

 Grounding Electrode: YES NO

 Smoke generation: YES NO
 Pacemaker reference YES NO
 Heat Generation CONSTANT TIME DEPENDENT
 Thermal spread MODERATE MINIMAL
 Cost LOW/INTERMEDIATE INTERMEDIATE/HIGH
 Complications DIRECT/ THERMAL INJURY
CAPACITIVECOUPLING
TISSUE STICKING
LASERS IN GYNAECOLOGY
 LASERS IN GYNAECOLOGY
 Light amplification by stimulated emission of radiation. (LASER)
 Emits light through a process called stimulated emission of
radiation thereby causing increase in the intensity of light.
 Lasers are coherent, monochromatic and collimated.
 LASERS PHYSICS
 Stimulated absorption
occurs as a photon impacts
on an electron, driving it
into a higher orbit.
 PRINCIPLES OF LASER TECHNOLOGY
 Wattage
 Time
 Spot size of the beam
 Power density
 CLASSIFICATION
 Gas laser  Liquid
CO2 Rodamine
Argon gas Coumarin
 Solid state laser  Semi conductor
Nd YAG Diode
KTP
 Types of Laser
CO2 LASER
 Maximum wavelength
 Minimum tissue penetration (0.1mm)
 Lateral thermal spread 0.5mm.
 Maximum smoke production
 Used near vital organs
 Most commonly used in gynaecology
 NOVEL APPLICATIONS OF CO2 LASER
 FemTouch / MonaLisa
It creates micro injuries in the vaginal mucosa and causes regeneration
of vaginal tissue.
It triggers collagen production
 Types of Laser
ND-YAG LASER
 Maximum penetration (3-4mm)
 Poor vaporisation effect
 More thermal damage
 Used in endometrial ablation
 Types of Laser
KTP AND ARGON LASER
 Selective absorption by hemoglobin and other pigmented tissues
 Less smoke production
 Minimum wavelength
 LASER CHARACHTERISTICS
TYPE WAVELENGTH(nm) COLOR DEPTH OF PENETRATION
Argon 488-512 Blue- green 0.5mm
KTP 532 Green 1-2mm
Nd-YAG 1064 Near infrared3-4mm
CO2 10600 Infrared 0.1mm
 COMPARISON OF THERMAL
SPREAD

3.5

2.5

1.5

0.5

0
MONOPOLAR BIPOLAR ULTRASOUND LASER
CAUTERY CAUTERY
 Conclusion
 The whole operating team should know the basic information of application of
energy sources which represents the crucial point for the safety of patients.
 It helps to notice And prevent potential complications.
 The advantages and shortcomings of different energy systems have to be taken
into account while we use a special mode.
 To use the most modern technologies with effective hemodynamic
characteristics.