Description on energy devices used most commonly in surgery.

1. Energy devices in surgery
Dr. Bikash Ch. Sah
Surgery 1st year PG

2. Devices
Electrical / Radiofrequency
1.Monopolar
2.Bipolar
Ultrasoinic
1.Harmonic scalpel
2.Thunderbeat
Vessel sealing technology
Laser
Cryosurgery

3. Electrocauterization
• Is the process of destroying or cutting
through soft tissue using heatconduction from
a metal probe heated by electric current.
• Is the application of a high-frequency (radio
frequency) alternating polarity,(AC) electrical
current to biological tissue as a means to
• Cut, coagulate, desicscate, or fulgurate tissue.

4. Electrosurgery Vs Electrocautery
The terms electro cautery and electrosurgery are
frequently used interchangeably; however, these
terms define two distinctly different modalities.
• Electrocautery: use of electricity to heat an
object that is then used to burn a specific site e.g. a
hot wire
• Electrosurgery: the electrical current heats the
tissue. The current must pass through the tissue to
produce the desired effect.

5. History
• Use of electrocautery (fire-drill) is described in ancient
medicine 3000 BC
• William T. Bovie made first electrosurgical generator.
He discovered that high frequency of 250,000-
2,000,000 used to incise, coagulate tissue and for
haemostasis
• The first use of an electrosurgical device in a surgical
operation was on October 1, 1926 at Peter Bent
Brigham Hospital in Boston, Massachusetts.
• Harvey Cushing (1869–1939) popularized the device in
neurosurgery; He first used it in an operating theatre in
1926 and rest is history

6. Electro surgery Electro cautery
Application of a high-frequency (radio
frequency) alternating polarity,(AC)
using heat conduction from a metal probe
heated by electric current
The heat is created by the resistance of
the tissue to the electrical current
.
uses electrical current to heat a metal
wire that is then applied to the target
tissue .
The current is passed through tissue by
electrode in the form of
blades, round ball, needle and loop
configurations
the current does not pass through tissue,
but rather is applied directly onto the
targeted area of treatment.

8. ELECTROSURGICAL DEVICES
Monopolar
Bipolar

9. Unipolar/ Monopolar

10. Most commonly used electrosurgical modality.
The active electrode is in the wound.
 Patient return electrode is attached somewhere
else on the patient.
• 4 components: generator, active electrode,
patient, patient return electrode(circuit's exit
point - the dispersive electrode, is a large surface
area as it function to disperse the current therby
preventing to thermal injury underlying tissue )

11. • same electrical current is transmitted across both the
dispersive electrode and the active electrode, so it is
not "neutral". The term "return electrode" is also
technically incorrect since
The amount of heat generated depends on
• size of contact area,
• power setting or frequency of current, ....
• duration of application, and
• waveform.
• Constant waveform generates more heat than
intermittent waveform.
• Frequency used in cutting the tissue is higher than in
coagulation mode.

12. Bipolar

13. • In the Bipolar instrument the current passes
between two tips of a forceps-like tool.
• It has the advantage of not disturbing other
electrical body activity (such as the
conduction system of the heart) and also
coagulates tissue by pressure.
• Lateral thermal injury is lesser than in in
unipolar devices

14. principle
• The radio frequency (RF) alternating current
heats the tissue by inducing intracellular
oscillation of ionized molecules that result in
an elevation of intracellular temperature

15. Temperature Vs Tissue Effect
• 45 degree C: collagen uncoils & may reanneal
• 60 degree C: Irreversible protein denaturation
coagulation necrosis begins ( instantaneous cell
death)
• 60-99 degrees C, the simultaneous processes of
tissue desiccation and protein coagulation occur
• 90-100 degree C: result into conversion of
intracellular liquid to gas. There will be massive
volumetric expansion and complete cellular
destruction by vaporization gas and smoke

16. Tissue effect

19. • Cut waveform: high continuous waveform
with high frequency vaporize or cut tissue.
Produce heat very rapidly
• Coagulation waveform: intermittent
waveform. Frequency ( per cycle) reduced.
Produce less heat so coagulation
• Blended current: not a mixture of cutting and
coagulation but a modification of frequency.

20. • High heat, more rapidly: vaporizaton
• Low heat, more slowly: coagulation

21. Electrosurgical Generators
Types
two types of electrosurgical generators:
• Ground referenced generators (typically older,
outdated units)
• Isolated generators (today’s state-of-art
technology)

23. Grounded Electrosurgical
• Circuit is completed by grounded element/
earthing
• May use alternate pathway
• problem is that it Causes thermal effect/burn
because the current can go to any grounded
object other than the patient return electrode
(ECG electrodes, OR bed, metal objects) and
cause alternate site burns.
• outdated technology

24. Isolated Electrosurgical
• In 1968,isolated generator technology
revolutionized electrosurgery
• Circuit is completed by the generator, not by
ground
• Current does not recognize grounded objects as
pathways to complete the circuit
• Patient return electrode is recognized as preferred
pathway
• Hazards of current division and alternate site burn
are eliminated

25. • Generators with isolated
circuits do not protect from
return electrode site burn
• A return electrode burn
occurs when the heat
produced, over time,
is not safely dissipated
by the size or conductivity of the patient return
electrode.

27. Patient return electrode
• The only difference b/w active electrode and
patient return electrode is their relative size and
conductivity
• At patient return electrode site: reduced contact
area- current concentration increased-
temperature increased- burn
• surface area impedance can be increased by
excessive hair, adipose tissue, bony prominences,
fluid invasion, adhesive failure, scar tissue

28. Do’s and Don'ts
• Proper/ full contact between body and return pad
• Conductive gel may be used
• Placed on the same side of surgery and near to it
• If metallic prosthesis-opposite side of body and
near
• If prosthesis on both sides-than in between
• With vascular and muscle mass
• Avoid over bony prominences
• Common position-thigh, abdomen ,back

29. Patient return electrode monitoring
technology
 protects patient from pad site burn
 Monitor impedance at the patient/pad interface
 System deactivate if impedance is high
 Such electrode can be identified by its split appearance i.e.
two separate areas and a special plug with center pin

30. Direct Coupling
 When the active electrode touches another metal instrument.
 The electrical current flows from one to the other and then
proceeds to tissue resulting in unintended burn.
 Do not activate the generator while the active electrode is
touching a metal object or not in vision.

31. Capacittive coupling
 During MIS procedure, an inadvertent
capacitor may be created by the surgical
instruments
 An electrostatic field created b/w two
conductors, resulting induced current in
second conductor
 Hybrid cannula are worst , metal part will
create a capacitor but plastic anchor will
prevent the current from dissipating through
abd wall.This current may exit to some
adjacent tissue,result in significant injury
 Use the lowest power setting

32. Insulation Failure
 Insulation covering of an endoscopic instrument has
been damaged
 Cracks or breaks in the shaft’s insulation allow the
electrical energy to escape and burn unintended tissue.
 The insulation of endoscopic instruments must be
inspected before, during and after each use
 Most damage to insulation occurs during instrument
processing, specifically during sterilization. Heat with
subsequent cooling causes insulation to shrink and
then expand. During this process cracks and breaks can
occur

33. RECOMMENDATIONS TO AVOID
ELECTROSURGICAL COMPLICATIONS IN
MIS
Inspect insulation carefully
Use lowest possible power settings
 Use a low voltage waveform(cut)
 Use brief intermittent activation vs prolonged
activation
Do not activate in open circuit
Do not activate in close proximity or direct
contact with other instrument

34. Use bipolar electrosurgery when appropriate
 Do not use hybrid canula. Select an all metal
canula system as the safest choice.
Active electrode monitoring system: to avoid
problems of insulation failure and capacitive
coupling

36. Ultrasonic vibrations instead of electrical current
Instrument blade vibrate at 55500 hz along the long
axis
Ultrasonic probe employ both compression and friction
to deliver mechanical energy to target tissue
Ultrasonic probe contain piezoelectric component,
that converts electric energy into mechanical
energy/heat
Amino acids unwind and reshape and hydrogen bonds
break resulting in protein denaturation and coagulum
formation

37. Harmonic scalpel

38. • The Harmonic scalpel is a surgical instrument used to simultaneously cut
and cauterize tissue.
• The harmonic uses ultrasonic vibrations instead of electric current to cut and
cauterize tissue.
•
• A Harmonic scalpel cuts via vibration.
The scalpel surface itself cuts through tissue by vibrating in the range of 55,500 Hz.
•
The high frequency vibration of tissue molecules generates friction in tissue,
which generates heat and causes protein denaturation.
This technique causes minimal energy transfer to surrounding tissue,
potentially limiting collateral damage.
• The HARMONIC SYNERGY Platform includes a
Curved Blade, a Hook Blade, and the Combination Hook Blade.

39. Advantages over electrocautery
• Dual action of coagulation and cutting
• Heat generated is low
• No lateral tissue damage
• No smoke is produced so visualization is better
• No current passes through the patient eliminating the
chance of electrical hazard
• Less tissue damage, so less post operative pain
• Precise dissection
• Reliable hemostasis
• cut through thicker tissue,
Disadvantage- Longer time for effect

40. THUNDERBEATTHUNDERBEAT is integration of both bipolar and ultrasonic
energies delivered simultaneously from a single versatile
instrument.
Benefits of each individual energy;
the ability to rapidly cut tissue with ultrasonic energy;
and the ability to create reliable vessel seals with bipolar energy.

41. • THUNDERBEAT provides unprecedented
versatility,including: ·
I. Reliable 7 mm vessel sealing
II. Minimal thermal spread
III. Quickest in-its-class cutting
IV. Reduced mist generation
for improved visibility
V. Fine dissection with fine jaw
design
VI. Fewer instrument exchanges
Revolutionary jaw design

42. CUSA( Cavitron ultrasonic surgical
aspiration)
 Cavitation- Formation of Vapour by pressure reduction intead
of heat.
 Utilizing a hollow titanium tip that vibrates along its
longitudinal axis, fragmentation of susceptible tissue occurs
while concurrently lavaging and aspirating material from the
surgical site.
 The CUSA selectively ablates tissues with high water content
such as liver parenchyma, glandular, and neoplastic tissue

43. VESSEL SEALING TECHNOLOGY
• Combination of pressure and energy to create a seal.
• Feedback controlled output so reliable seal in minimal time
• Seal strength comparable to sutures/clips, can withstand >3
times normal SBP
• ligasure: 0 - 4.5 mm
• enseal : 1 mm

44. LigaSure
 Applies optimal pressure to vessel
 • Measure initial resistance of tissue and chooses appropriate
energy settings
 • Delivers pulsed energy with continuous feedback control
 • Senses that tissue response is complete and stops the cycle

45. Laser

46. Effect
Photochemical effect: clinically referred to as photodynamic therapy. Photodynamic
therapy is used in palliation of oesophagial and bronchial carcinoma and ablation of
mucosal cancers of Gastrointestinal tract and urinary bladder.
Photosensitizer (photophrin II) is administered which is taken up by the tumor tissue
and later irradiated by laser light resulting in
highly toxic substances with resultant necrosis of the tumor.
Photoablative effect: Used in
Eye surgeries like band keratoplast, and
Endartectomy of peripheral blood vessels.
Photothermal effect: This property is used for
• Endoscopic control of bleeding e.g.
• Bleeding peptic ulcers,
• Oesophagial varices
Photomechanical effect: used in intraluminal lithotripsy

47. Lasers used in medicine
• Carbon dioxide (CO2) LASER technology,
• Pulsed dye LASER,
• Erbium (Er)-
• YAG (yttrium-aluminum-garnet) LASER,
• Diode LASER technology,
• Potassium titanyl phosphate crystal laser,
• Copper vapor and copper bromide lasers,
• Krypton laser

49. Soft Tissue surgery-
• The CO2 (carbon dioxide) laser remains the gold standard for thesoft tissue surgery
because of the ease of simultaneous photo-thermal ablation and coagulation (and small
bloodcapillaryhemostasis
Gastro-intestinal tract
 Peritoneum-Laser is used for adhesiolysis.
 Peptic ulcer disease and oesophageal varices - Laser photoablation is done.
 Coagulation of vascular malformations of stomach, duodenum and colon.
 Early gastric cancers provided they are less than 4 cm and without lymph node involvement.
 Palliative laser therapy is given in advanced oesophageal cancers with obstruction of lumen.
 Recanalisation of the lumen is done which allows the patient to resume soft diet and maintain
hydration.
 Ablative laser therapy is used in advanced colorectal cancers to relieve obstruction and to control
bleeding.
 Laser surgery is used in hemorrhoidectomy, and is a relatively popular and non-invasive method of
hemorrhoid removal.
 Laser-assisted liver resections have been done using carbon dioxide and Nd:YAG lasers.
 Ablation of liver tumors can be achieved by selective photovaporization of the tumor.
 Endoscopic laser lithotripsy is a safer modality compared to electrohydraulic lithotripsy.
Oral and dental surgery
• 1The CO2 laser is used in oral and dental surgery for virtually all soft-tissue procedures, such as gingivecomies,
vestibuloplasties, frenectomies and operculectomies.
• 2-In treating oral submucous fibrosis.
• 3-In Periodontology.The CO2 10,600 nm wavelength is safe around implants as it is reflected by titanium, and thus has
been gaining popularity
• 4-The laser may also be effective in treating peri-implantitis.

50. Microwave Energy
Microwaves are a form of electromagnetic radiation with
wavelengths ranging from one meter to one millimeter; with
frequencies between 300 MHz (100 cm) and 300 GHz (0.1
cm).
• Microwave — uses electromagnetic radiation to produce
the heat that creates the conduction block.
• Microwave ablation is claimed to provide the greater tissue
penetration that makes transmural ablation more likely
• and to produce no charring of surface tissue, thus reducing
blood clots.

52. Other energy sources apart from
Microwave energy for the Maze
procedure.
• Cryoablation (cryothermy) —
• High intensity focused ultrasound (HIFU) to heat the tissue and
create the conduction block.
• Laser — uses light energy –see above
• Non-irrigated (dry) bipolar radiofrequency — uses a clamp that
delivers radiofrequency (RF) energy and measures the transmurality
of the lesion to determine when conduction block at the pulmonary
veins is achieved.
• Irrigated (wet) bipolar radiofrequency — uses radiofrequency (RF)
energy and adds saline to cool the surface and let heat go deeper
into the tissue.
• Non-irrigated unipolar radiofrequency — unipolar devices are
smaller and more flexible, but are not as thorough in creating
transmural lesions

53. Cryosurgery
• Cryosurgery /cryotherapy is the use of extreme
cold used to destroy abnormal or diseased tissue.
• Cryosurgery depends on the destructive force of
freezing temperatures on cells.,when
their temperature sinks beyond a certain level
• ice crystals begin forming inside the cells and,
because of their lower density, eventually tear
apart those cells.
• In addition the blood vessels supplying the
affected tissue begin to freeze.

55. • External Uses
Plantar Warts, moles, skin tags, Morton's
neuroma and small skin cancers
Internal uses
• Malignancies
Liver cancer, Prostate cancer, Lung cancer, Oral
cancers,cancer cervix, Bone tumors

56. • Benign conditions,
• Haemorroids, Esophageal varices, Bleeding
Peptic ulcer. Soft tissue conditions such
as plantar fasciitis (jogger's heel) and
fibromas (benign excrescence of connective
tissue) can be treated with cryosurgery

58. Cryosurgery devices
Cotton-tip applicator.
Liquid nitrogen spray.
Cryoprobe

59. Technique of Cryosurgery In Cancer
Treatment
• A hollow instrument called a cryoprobe is used, which is placed in contact with the
tumor.
• Liquid nitrogen or Argon gas is passed through that cryoprobe. Ultrasound or MRI is used to guide the
cryoprobe and monitor the freezing of the cells. this helps in limiting damage to adjacent healthy tissues.
• A ball of ice crystals forms around the probe which results in freezing of nearby cells.
when it is required to deliver gas to various parts of the tumor, more than one probe is used.
• After cryosurgery, the frozen tissue is either naturally absorbed by the body in case of internal tumors, or
it dissolves and forms a scab for external tumors.
• Generally, all tumors that can be reached by the cryoprobes used during an operation are treatable. This
method of treatment is only appropriate for use against localized disease, and solid tumors larger than
1 cm.

60. Freezing agents
Liquid nitrogen
• This −196 °C (−321 °F) cold liquid may be
• sprayed on the diseased tissue,
• circulated through a tube called a Cryoprobe, or
• simply dabbed on with a cotton or foam swab.
Carbon dioxide
• available as a spray and is used to treat a variety of benign spots.
• It is also used as carbon dioxide"snow" formed into a cylinder or
• mixed with acetone to form a slush that is applied directly to the
treated tissue

61. Argon
• Used to promote ice formation using a principle known as
the Joule-Thomson effect.
• This gives physicians excellent control of the ice, and
• minimizing complications using ultra-thin
17 gauge cryoneedles.
Dimethyl ether
• A mixture of dimethyl ether and propane is used in some
preparations
• The mixture is stored in anaerosol spray type container at
room temperature and drops to −41 °C (−42 °F) when
dispensed.
• The mixture is often dispensed into a straw with a cotton-
tipped swab.

62. PROS
• Cryosurgery is a
minimally invasive procedure,
And is often preferred to more traditional
kinds of surgery because of its
minimal pain, scarring, and cost

63. CONS
• primarily that of damage to nearby healthy tissue.
• Damage to nerve tissue is of particular concern.
• Undergoing cryosurgery usually experience
• redness and minor-to-moderate localized pain, which
• most of the time can be alleviated sufficiently by oral
administration of mild analgesics
• Blisters may form as a result of cryosurgery, but these
usually scab over and peel away within a few days.