Brief Summary of various energy devices/sources used in modern surgery.

1. NEWER ENERGY SOURCES IN
SURGERY
Dr. Alangsungyu Ajem

2. History
• 3000 B.C- Egyptians used heat to treat tumour (Firedrill)
• 1881: Morton- 100,000 Hz does not produce shock
• Origin of Electrosurgery :Dr P Bozzini - Electrocauterization (1887)
• First high frequency current used - 1893
• Dr William Bovie and Dr Cushing -Pioneer of Modern Electrosurgery(1926)
Dr Bovie 1920Dr Cushing

4. Energy Sources & Its devices
RF Electrosurgery •Monopolar
•Bipolar
i. Ligasure
ii. Gyrus PK
iii. Enseal
iv. Caiman
Ultrasonic •Harmonic ACE
•CUSA
•HIFU
Integrated Thunderbeat
LASER Nd:YAG
KTP
Argon
CO2
Radiofrequency Ablation (Habib Knife)
Irreversible Electroporation/Nanoknife
Energy Sources & Its devices..
Argon Beam Coagulation
Starion
Aquamanty
Microwave Coagulation
Gamma Knife/Cyber Knife
Floating ball
Hydrojet devices
Photodynamic Therapy
Cryoablation

6. Properties of electricity
Ohms Law
V=I x R
Where V=Voltage
I=Current(I)
R=Resistance
•The passage of high frequency
electric current through tissue
creates the desired clinical effect.
•Path of Least resistance
•Electrocautery ≠ Electrosurgery

7. Electrosurgical Generators
60 Hz 500 KHz- 3.3MHz
Generator
•Nerve and Muscle stimulation ceases at 100kHz
•RF-200 KHz-3.3 MHz (Electrosurgery)
RF Energy
Monopolar Bipolar

8. TISSUE EFFECTS WITH WAVEFORM MODIFICATION
I) CUT WAVEFORM:
 “On” time is high
Produces heat very rapidly
Cut tissues
II) COAGULATION WAVEFORM
Modulated Intermittent-”On”
time reduced
Less heat produced
Coagulum produced
III) BLENDED CURRENT
Modulation of ≥2 waveforms
Intermittent bursts
Cut + Variable hemostasis
Only Variable that determine vapourization
or Coagulation is RATE OF HEAT
High heat, More rapidly: Vapourization
Less heat, More slowly: Coagulation

9. Electrosurgical Tissue Effects
Cutting
Fulgration
•Divide tissue with electric sparks that focus intense
heat at surgical site
•Vapourization → Cell explosion
•Coagulation waveform: No contact, Only sparking
•Coagulates and chars the tissue(Eschar)
•Electrode in direct contact with the tissue
(Most efficient with Cutting current)
•It reduces current concentration, results in
less heat(Hence, no cutting action)
•Cells dry out and forms a coagulum
Dessication
Coagulation

10. Variables impacting Tissue Effects
Size of electrode
Time
Placement of electrode
Eschar
Vascular < GI lining < Muscles < Skin < Fat < Bone

11. Effect of Temperature on tissue
Temperature Effects
45 ◦C Collagen uncoils and reanneal
60 ◦C Irreversible protein denaturation, Coagulation necrosis begins;
blanching
80 ◦C Carbonization starts; Drying and shrinking of tissues
100 ◦C Complete cellular destruction by Vaporization
125 ◦C Complete oxidation of proteins and lipids; Eschar formation
200 ◦C Carbonization and Fulgration

12. Monopolar electrosurgery
Generator
(ESU)
Active electrode
PatientReturn electrode
Four components

13. Bipolar electrosurgery
Bipolar circuit
The two tines forceps functions as active and
return electrodes
Grasped tissue completes the circuit
Coagulation
Less thermal injury

14. Monopolar
Advantages
*Simple: Easy to use
*Cheaper
*Best for Skin Incision
Disadvantages
*Patient ES Injury
*Interference with
pacemaker
*OR fire/Smoke
*Significant thermal
spread

15. Bipolar
Advantages
*Minimal thermal
spread
*Good Vessel sealing
*Less Smoke
Disadvantages
*Longer Operation time

16. Patient Return Electrode
Two important
parameters: Size of contact
and Conductivity over
applied surface
↓Contact area
↑Current
concentration
↑Temperature
(Burn)
↑Impedance
↑Current
Concentration
↑Temperature
(Burn)

17. Return Electrode Contact Quality Technology(RECQM)
•
Monitors impedance at patient/pad
interface
System gets deactivated if impedance is
high (Skin temperature >2⁰C)
Prevents pad site injury

18. Electrosurgical injury
.
Direct coupling
Prevented by Active Electrode
Monitoring Technology(AEM)
Insulation failure
Capacitive coupling

19. Active Electrode Monitoring
Electroshield: Extra Insulation
Layer
Continuously direct stray energy
away from the patient
Detects smallest full thickness
insulation breaks
When Insulation failure/
Capacitive energy reaches
dangerous levels, ESU shuts down
automatically and alerts via
Audiovisual alarm

20. VESSEL
SEALING
DEVICESLigasure
Plasma Kinetic Gyrus
Enseal
Caiman

21. LIGASURE
Advance Bipolar Device
Combination of Pressure
and Energy
Feedback Controlled
System
1
• Rachet Grips Vessels tightly
2
• Measures resistance in tissue
and sends to generator
3
• Continues till vessel is sealed

22. Seal time: 2-4 seconds
Seals vessel upto 7 mm
Tolerates 3 times SBP
Max. Temperature 60-90⁰C
Thermal Spread 4.5 mm

23. Plasma Kinetic Gyrus
•Plasmacision
•Bipolar PK Technology
•Serrated Jaw
•No Feedback Controlled System
but an audio alarm

24. PK GYRUS:
2 MODES
PK Tissue Cutting Vapour Pulse Coagulation
1
• Pulsed Low RF Energy
2
• Forms Vapour zones
• Current passes around the
vapour zones
3
• Vessel sealing
1
• RF electrical arc
• Plasma corona forms
2
• Vaporization
• Cutting
•Seals upto 7 mm
•Max temperature <100⁰C

25. ENSEAL
Only System Control energy
deposition
Nanopolar thermostat in jaws
Adjusts energy according to
tissue impedance
Less heat required: Tissue
Volume reduced by compression

26. Seals vessel 1 to 7 mm
Tolerates 7 times SBP
Seal Temperature 100⁰C
Thermal Spread 1 mm

27. CAIMAN
Tip first closure:
Retains tissues within the
jaws for improved
compression
Advanced Bipolar Seal
& Cut technology
80⁰Articulating Jaw
Seals vessels 7 mm
Thermal spread <1mm

28. AQUAMANTY’S BIPOLAR VESSEL SEALERS
 Transcollation technology,
combining radiofrequency (RF)
energy and saline to provide
hemostatic sealing of soft tissue
and bone
LED light at tip: Better viewing
Achieve hemostasis before
dissection
Best for achieving hemostasis of
retracted vessels
MC used in Orthopedic and Spinal Surgery

29. STARION TISSUE WELDING SYSTEM
Based on direct heat
production
Active heating element at
the tip
Tissue Welding
Technology: Combines
pressure and heat to
simultaneously seal vessels
and tissue structures fused
Used in:
Hemorrhoids
Tonsillectomy
Thyroid surgery
Starion TLS2 Disposable device (14 cm)

30. Ultrasonic
Devices

31. Harmonic ACE
Ultrasonic Energy Mechanical Energy
Piezoelectric crystals: 55,000 vibrations per second
Adaptive Tissue Technology
1
• Blade: Upper and Lower Jaw
• Friction : Generates Heat
2
• Lysis of H-bond
• Protein Denaturation
3
• Coagulum forms

33. • Settings of Harmonic Scalpel:
HIGH POWER SETTING (5) MORE MECHANICAL ENERGY CUTTING
LOW POWER SETTING (3) LESS MECHANICAL ENERGY COAGULATION
HARMONIC
ADVANTAGES
*Minimal Thermal
Spread
*No dessication/tissue
charring
*No smoke/risk of
electrical injury
DISADVANTAGES
*Cannot coagulate >5mm*
*↑Cost
*Operator dependence on settings
of the blade according to tissue

34. Cavitron Ultrasonic Surgical Aspirator(CUSA)
.

35. Cavitron Ultrasonic Surgical Aspirator
.
Ultrasonic vibrations
Oscillating tip
Fragmentation
Heat
Water cooling system
Maintain 40 degreeIrrigate and aspirate
Cavitation at cell surface
Electromagnetic Energy Vibrations
(23-36 KHz)
Reserve Power: Maintains Oscillations
Minimal hemostasis(↓Versatility)
Liver resection

37. THUNDERBEAT
World’s 1st and only
integrated energy system
Combines 2
energy
Ultrasonic
Rapid
Dissection and
Cutting
Bipolar
Reliable Vessel
sealing(≤7mm)

39. THUNDERBEAT..
Unprecedented Versatility: Fewer instruments
exchanges
Reliable 7 mm Vessel sealing
Minimal thermal spread
Quickest in-its-class cutting
Improved Visibility
Fine dissection

40. LASER
Light Amplification by Stimulated Emission of Radiation
Electromagnetic waves
IR-UV
High intensity light beam
Optical resonator
Amplification
Heat to Tissue
Fibres
Cutting Coagulation

41. LASER..
When a laser beam projected to tissue:
There are generally three interaction mechanisms involved
1) Photocoagulation: 50-100⁰C
2) Photovaporization :> 100⁰C
3) Photoablation: High power ultraviolet wavelength, chemical
bonds are broken, without causing local heating
Thermal effects depend on Energy density

42. LASER
Irradiation (W/m²): Measure of power of a LASER device
Three main process
Photothermal
Heat Generation
Coagulum
Photochemical
Induction of
chemical reaction
Cell inactivity
Photoplasmal
Very high Irradiation
Plasma formation
Cell rupture

44. LASER..

45. LASER
Advantages
*Effective
*Less Scaring
*Excellent Haemostasis
*Allow precise Microsurgery
*Less postoperative pain &
oedema
*Outpatient procedure
Disadvantages
*Expensive
*Air Embolism
*OR Fire
*↑ operating Time

46. Irreversible Electroporation/ Nanoknife
•Non thermal Ablation device
•High Energy, Low Voltage DC current (3 kV)
•Spares blood vessels and bile ducts
(Hence,potential to treat tumors near blood
vessels)
A. Generator
B. Monopolar
Probe
C. Accusync Device

47. Irreversible Electroporation/ Nanoknife
 Indications:
i) Liver tumour
ii) Prostrate lesion
iii) Pancreatic Cancer
Contraindications:
i) H/o Cardiac arrhythmias
ii) Pacemakers
iii) Varices
Percutaneous > Open/Laparoscopic

48. Argon beam Coagulation
ARGON
RF current passes through
wire and Argon by the side
Argon gets ionised
Non contact, monopolar,
electrothermal hemostasis
Allows even, efficient and
broad application to tissues
Monopolar like device

49. 2 Modes
Pinpoint Spray

50. *Argon gas embolism
*Only Coagulation
*Good hemostasis
*Less smoke
*Constant thermal spread 2-3 mm
Disadvantages Advantages
Argon beam coagulation

51. Radiofrequency Ablation
Frictional Heat
Coagulative Necrosis
Creates Alternating electric field within tissues
Agitation of ions in target tissue
RF current 350-500 KHz passed through
electrode
Inbuilt Sensors: Prevents Overheating

52. Tumour ablation
Varicose vein
Debridement of cartilage

53. Radiofrequency Ablation..
Unipolar System
Pulsed current used→ Greater local current density
Simultaneous application of a cluster of three such
electrodes spaced 0.5 cm apart
produces larger mass (4-5 cm) of coagulation
Internally cooled RF electrodes with 6 different
exposure lengths , maintain the tip temperature
below 25ºC
Prevents tissue boiling (by ↑heat dissipation)

54. Radiofrequency Ablation...
Bipolar System
 3 bipolar channels can be attached at
same time(RF 470 kHz)
Bipolar electrode: The current flows
between two electrodes at the tip of
one applicator
Multipolar electrodes: Flow between
all possible combinations if two or three
applicators are used
 3D impedance feedback control.
No grounding pads
Habib Knife

55. Radiofrequency Ablation....
Multipronged Systems
Designed to increase the size of the lesion to
be ablated and decrease the number of needle
passes.
7-cm thermal lesion can be produced in single
session
The tip of the electrode
is placed in the anterior
border of the tumor

56. High Intensity Focused Ultrasound (HIFU)
•Non invasive
•High frequency ultrasound
waves are used to ablate deep
tissues
•Focused at a single point
MECHANISM OF ACTION:
Conversion of mechanical energy into heat (Tissue heats up)
 Mechanical cavitation of pressure waves in tissues (causes
the tissue to vibrate and mechanically stress the cells)

57. HIFU...
• PROSTATE CANCER: Earliest
widespread use
• Cosmesis: Body
contouring and Eyebrow
lifts
• Advanced pancreatic
cancer.
• Symptomatic fibroids
• Benign thyroid nodules
and hypertrophic
parathyroid glands
• Fibroadenoma

58. Photodynamic Therapy
1
• Photosensitizer (Porfimer)
given
• Absorbed by abnormal cells
2
• Diomed 630PDT laser(515-630
nm)
• Radicals formation
3 • Photocoagulatin
• Cellular damage/Necrosis
follows
1st Drug and Device combination
approved by FDA

59. •Light-mediated excitation of photosensitizer-loaded tumor cells
•Production of reactive oxygen species (ROS) within the cells
•Leading to cell death (predominantly apoptotic and necrotic).
•Also damage to the microvasculature , which further restricts
oxygen and nutrient supply.
Used in
• NSCL cancer
• Skin cancer
• Pancreatic cancer
• Recurrent bladder &
breast cancer

60. Cryotherapy
Nitrous oxide/Liquid Nitogen (-35⁰C applied)
Ice crystal formation in the cell
Osmotic cell
injury
Cell death
Vascular
damage
Ischemia
Cell death

61. Cryotherapy..
•Penetrates 3 mm in tissue
•Takes days to weeks for action
USED IN:
Skin conditions: Seborrhoeic keratosis,
Non traumatic SCC, Keloids
Airway lesions
Carcinoid tumours

62. MICROWAVE ABLATION
Generator Microwave energy
1
• Microwave energy
(2450MHz)
2 • Probe Placed in the tissue
under image guidance
3 • Small area ablated
• Needs multiple insertion
Used in area with high water Content

63. Microwave heating : An
alternating
electromagnetic
field causes polar
molecules(Water) to
continuous realign,
producing kinetic energy
and in turn,
heat.
Used in:
•Liver lesion
•RCC
•BPH
•Osteoid Osteoma
•Endometrial bleeding
•Lung Cancer

64. Radiosurgery
Used in:
•Brain tumors
•AVM
•Epilepsy
Gamma knife: Used in Neurosurgery
1
• Gamma radation sources
arranged in a circular fashion
2 • Focussed stereotactically
3
• Destroy finite areas of the
brain
• Arrest, NOT Disappearance:
inhibits proliferative
potential

65. Patient undergoing stereotactic radiosurgery

66. Hydrojet
Non thermal Cutting technology
Extremely thin, high pressure
stream of NS
Hydrodissection
Using specific range, saline
displaces fibrous and collageneous
tissue leaving vessels and nerves
intact(Later, coagulated under
direct vision)

67. The angled tip dissection probe of
the Helix Hydro-Jet™
Device: Simultaneous saline
application along with blunt
dissection.
HYDROJET
ADVANTAGES
*Precise
dissection
*Biological
DISADVANTAGES
*Saline obscures
Sx field
*No hemostasis

68. Floating Ball
Monopolar Coagulator with a 3
mm ball at its tip; angled at 15⁰
from the shaft
Saline solution is dropped from
the tip of the hand piece (240ml/hr)
and it transmits radiofrequency
energy(480KHz) to saline-tissue
surface interface
Dissipates heat more evenly
Peak temp 100⁰C
It shrinks collagen in the tissue
and obliterates its lumen.

69. In VATS
Liver lesion

70. Conclusion
• Making the correct choice of energy sources
makes a lot of differences
• Not only the correct choice but understanding
the limitations of these technologies is also
essential.

71. THANK YOU