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Electro surgery in laparoscopy

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M
Med Elsayed

This document discusses electro-surgery and its use in laparoscopic surgery. It describes the basic electro-surgical circuit and how high current density at the active electrode creates heat to cut or coagulate tissue. It discusses different wave forms and their effects. Safety issues are also covered, including ensuring proper placement of the patient return electrode to avoid burns and understanding how capacitive coupling through instruments can lead to thermal injuries during laparoscopic procedures.

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Electro-Surgery in laparoscopic surgery RCMC.BASIC LAPAROSCOPIC COURS Dr.Medhat M. Ibrahim Consultant pediatric surgeryand Minimal access surgery.
Introduction Many energy sources are avilable to: Cut, Coagulate, evaporate tissue , The objective of this study is; understanding the energy source
Basic electro-surgical circuit (Monopolar) Surgeon Source - Gen Patient Active cable/Path Return cable/path Power supply Patient Return Electrode
High current density at the narrowing of an electrical conductor creates heat 220 Volt 50 Hz
Tissue on plate is part of the circuit High current density = heat development in tissue Active Electrode Low current density / No heat development in tissue Return Electrode 220volt/50Hz
Why not 50 Hertz Alternating current at frequencies from 1 to 100,000 Hertz will interfere with the neuro-muscular system. Above 100,000 Hertz these stimuli occur too quickly to affect the neuro-muscular system.
350 KHz to 3.3 MHz Electrosurgery Household Purposes Neuromuscular Stimulation ceases AM Radio FM Radio TV 50 Hz 550 Khz 1550 Khz 54 880 MHz 100 Khz Below 100 Khz Electrical shock Above 100 Khz - No electrical shock
What it does? Vapourises & De-Hydrates across almost all tissue types
Basic electro-surgical circuit - Monopolar Source - Gen Patient Active cable/Path Return cable/path Surgeon Power supply Patient Return Electrode
Vaporization & De-Hydration Cut/Vaporization: High current concentration at active electrode causes intense heat in tissue (above 100c) Coagulation (Dessication) Intermittent supply of current to a larger electrode causes less intense heat into tissue (below 100c), allows heat dispersion
Coagulation Cut Energy Intense Energy Dehydration through heating Coagulated cell Cell expands through increase in pressure Exploded cell
Wave forms pure cut blend cut desiccation fulguration Pure cut uses the lowest level of voltage
Monopolar Electrosurgery Cut Pure Blend Coagulation Fulguration Dessication
Pure cut Blend Fulguration/non contact coag
Dessication 1
Dessication 2
Dessication 3
Spray coagulation or fulguration Blade electrode Principle: Bleeding vessel Current follows Path of least resistance
Limiting power settings by limiting contact Blade electrode Micro Needle electrode Choice of electrode & technique determines tissue effect Forceps - tips
The electrosurgical effect is influenced by: 1. Contact Time 2. Power Settings of Generator 3. Type of electrode used (Current Density) 4. Whether Cut or Coag activated 5. Tissue Impedance 6. Distance from Active to Return
Bipolar electrosurgery in egg white/glass
Bipolar Forceps coagulation Saline Correct Correct Incorrect Incorrect
Some Issues Usually, a very safe device to use, however, these machines are often seen as the most hazardous device used in an OR! WHY?
The patient return electrode General rules for safe practice Minimally Invasive Surgery issues
Pad site burns are prevented by assuring optimal conditions at the pad-patient interface. High current concentration/density Low current concentration/density
Pad site burns are caused by adverse conditions at the pad-patient interface which result in increased current density. Current density increases when current removal area is too small heat is applied for too long power setting is too high High current concentration/density
Plate Burns !!!
A burn under the patient plate is ALWAYS negligence
Monitoring Current RF Current RF Current
Basic rules 1. Position plate as close as possible to surgical site 2. Check contact of plate throughout procedure
Avoid the following patient plate locations Scar tissue Metal implants Pacemakers Bony structures Monitoring electrodes Areas of moisture concentration
Electro surgery in laparoscopy
Glove burn (Bovie-bite)
Result glove burn !! Whoops???
Causes of glove burn Activation of fulgurate or spray output High power settings Surgeons technique Open circuit activation Removal of forceps whilst activating Carbonisation causes higher leakage current due to increased resistance Quality of gloves Recommendation: Use Cut or Dessicate
Other Complications Bowel gas ignition Staple line/clip conductivity Current Density Complications Prep fluid
Electrosurgery Safety Considerations for Minimally Invasive Procedures
Direct Coupling Laparoscope View Active Electrode Telescope with Camera Metal Instrument Bowel
Insulation Failure Abdominal Wall Electrode Insulation Failure Electrode Tip Laparoscopic View Metal Trocar Cannula Bowel
Insulation Failure
Thermal injury caused by Insulation Failure of electro-surgical instrument during Laparoscopic Cholecystectomy
Intended Current Flow Induced Current Metal Coil Conductor Air (Insulator Metal Coil Conductor Capacitor
Capacitance Increases with Use of Longer instruments Higher voltages Narrower diameter cannulas L
Instrument/Metal Cannula Configuration Creating a Capacitor Abdominal Wall Conductor (Electrode Tip) Conductor (Metal Cannula) Insulator (Electrode Insulation) Laparoscopic View
Instrument/Plastic Cannula Configuration Can capacitive coupling occur? Abdominal Wall Conductor (Electrode Tip) Insulator (Plastic Cannula) Insulator (Electrode Insulation) Laparoscopic View
Instrument/Hybrid Cannula Configuration Capacitively Coupled Fault Condition Capacitively Coupled Energy to Metal Cannula Electrode Tip Plastic Collar Bowel
Energy dispertion Energy Dispertion
Hybrid Trocar/Cannula System You make one yourself.
Conclusion Electro-Surgical devices can be a potential hazard in an Operating Room. However, they can also be very safe, its always the driver in control!

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Electro surgery in laparoscopy

  • 1. Electro-Surgery in laparoscopic surgery RCMC.BASIC LAPAROSCOPIC COURS Dr.Medhat M. Ibrahim Consultant pediatric surgeryand Minimal access surgery.
  • 2. Introduction Many energy sources are avilable to: Cut, Coagulate, evaporate tissue , The objective of this study is; understanding the energy source
  • 3. Basic electro-surgical circuit (Monopolar) Surgeon Source - Gen Patient Active cable/Path Return cable/path Power supply Patient Return Electrode
  • 4. High current density at the narrowing of an electrical conductor creates heat 220 Volt 50 Hz
  • 5. Tissue on plate is part of the circuit High current density = heat development in tissue Active Electrode Low current density / No heat development in tissue Return Electrode 220volt/50Hz
  • 6. Why not 50 Hertz Alternating current at frequencies from 1 to 100,000 Hertz will interfere with the neuro-muscular system. Above 100,000 Hertz these stimuli occur too quickly to affect the neuro-muscular system.
  • 7. 350 KHz to 3.3 MHz Electrosurgery Household Purposes Neuromuscular Stimulation ceases AM Radio FM Radio TV 50 Hz 550 Khz 1550 Khz 54 880 MHz 100 Khz Below 100 Khz Electrical shock Above 100 Khz - No electrical shock
  • 8. What it does? Vapourises & De-Hydrates across almost all tissue types
  • 9. Basic electro-surgical circuit - Monopolar Source - Gen Patient Active cable/Path Return cable/path Surgeon Power supply Patient Return Electrode
  • 10. Vaporization & De-Hydration Cut/Vaporization: High current concentration at active electrode causes intense heat in tissue (above 100c) Coagulation (Dessication) Intermittent supply of current to a larger electrode causes less intense heat into tissue (below 100c), allows heat dispersion
  • 11. Coagulation Cut Energy Intense Energy Dehydration through heating Coagulated cell Cell expands through increase in pressure Exploded cell
  • 12. Wave forms pure cut blend cut desiccation fulguration Pure cut uses the lowest level of voltage
  • 13. Monopolar Electrosurgery Cut Pure Blend Coagulation Fulguration Dessication
  • 14. Pure cut Blend Fulguration/non contact coag
  • 18. Spray coagulation or fulguration Blade electrode Principle: Bleeding vessel Current follows Path of least resistance
  • 19. Limiting power settings by limiting contact Blade electrode Micro Needle electrode Choice of electrode & technique determines tissue effect Forceps - tips
  • 20. The electrosurgical effect is influenced by: 1. Contact Time 2. Power Settings of Generator 3. Type of electrode used (Current Density) 4. Whether Cut or Coag activated 5. Tissue Impedance 6. Distance from Active to Return
  • 21. Bipolar electrosurgery in egg white/glass
  • 22. Bipolar Forceps coagulation Saline Correct Correct Incorrect Incorrect
  • 23. Some Issues Usually, a very safe device to use, however, these machines are often seen as the most hazardous device used in an OR! WHY?
  • 24. The patient return electrode General rules for safe practice Minimally Invasive Surgery issues
  • 25. Pad site burns are prevented by assuring optimal conditions at the pad-patient interface. High current concentration/density Low current concentration/density
  • 26. Pad site burns are caused by adverse conditions at the pad-patient interface which result in increased current density. Current density increases when current removal area is too small heat is applied for too long power setting is too high High current concentration/density
  • 28. A burn under the patient plate is ALWAYS negligence
  • 29. Monitoring Current RF Current RF Current
  • 30. Basic rules 1. Position plate as close as possible to surgical site 2. Check contact of plate throughout procedure
  • 31. Avoid the following patient plate locations Scar tissue Metal implants Pacemakers Bony structures Monitoring electrodes Areas of moisture concentration
  • 34. Result glove burn !! Whoops???
  • 35. Causes of glove burn Activation of fulgurate or spray output High power settings Surgeons technique Open circuit activation Removal of forceps whilst activating Carbonisation causes higher leakage current due to increased resistance Quality of gloves Recommendation: Use Cut or Dessicate
  • 36. Other Complications Bowel gas ignition Staple line/clip conductivity Current Density Complications Prep fluid
  • 37. Electrosurgery Safety Considerations for Minimally Invasive Procedures
  • 38. Direct Coupling Laparoscope View Active Electrode Telescope with Camera Metal Instrument Bowel
  • 39. Insulation Failure Abdominal Wall Electrode Insulation Failure Electrode Tip Laparoscopic View Metal Trocar Cannula Bowel
  • 41. Thermal injury caused by Insulation Failure of electro-surgical instrument during Laparoscopic Cholecystectomy
  • 42. Intended Current Flow Induced Current Metal Coil Conductor Air (Insulator Metal Coil Conductor Capacitor
  • 43. Capacitance Increases with Use of Longer instruments Higher voltages Narrower diameter cannulas L
  • 44. Instrument/Metal Cannula Configuration Creating a Capacitor Abdominal Wall Conductor (Electrode Tip) Conductor (Metal Cannula) Insulator (Electrode Insulation) Laparoscopic View
  • 45. Instrument/Plastic Cannula Configuration Can capacitive coupling occur? Abdominal Wall Conductor (Electrode Tip) Insulator (Plastic Cannula) Insulator (Electrode Insulation) Laparoscopic View
  • 46. Instrument/Hybrid Cannula Configuration Capacitively Coupled Fault Condition Capacitively Coupled Energy to Metal Cannula Electrode Tip Plastic Collar Bowel
  • 48. Hybrid Trocar/Cannula System You make one yourself.
  • 49. Conclusion Electro-Surgical devices can be a potential hazard in an Operating Room. However, they can also be very safe, its always the driver in control!