Electrosurgery

Electrosurgery is a term referred for utilizing high-power and high-frequency alter-

nating current (AC) signal to bring the tissues’ temperature up to a level so that due
to the process of vaporization drying up or coagulation is achieved.

From: Control Applications for Biomedical Engineering Systems, 2020

Related terms:

Semiconductor, Dielectrics, Capacitance, Transistors, Electrostatics, Magnetic

Fields, Electric Potential

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A closed loop robust control system for

electrosurgical generators
NasimUllah, ... Jorge Herrera, in Control Applications for Biomedical Engineering
Systems, 2020

1 Introduction
Electrosurgery is a term referred for utilizing high-power and high-frequency al-
ternating current (AC) signal to bring the tissues’ temperature up to a level so that
due to the process of vaporization drying up or coagulation is achieved. As a result
of the phenomena cutting of tissues, hemostasis, blocking of lumen-containing
structures, and removal of huge volumes of tissue is achieved. Radiofrequency
electrosurgery technology differs from the commonly used cautery devices. The
cautery devices utilize the direct current (DC), while the ESU utilizes the AC power
for heating of the tissues. The ESU units are utilized for cutting or to stop bleeding
by causing coagulation (hemostasis). The target area of the tissues receives thermal
energy from the tip of the electrode due to which drying up, vaporization, and
scorching of the tissues is achieved.

The concept of electrosurgery has emerged since the start of the 19th century.
The first electrosurgical generator was introduced by Bovieas in 1928. With this
invention, the utilization and proof of concept of the high-frequency and high-power
AC current in surgical procedures was proved (Bovie and Cushing, 1928). The basic
working idea was to heat the tissues in an area of focus using the radio-frequency
high-power alternating current signals applied through active electrodes, which is
driven by an inverter unit. As a result, several functionalities, including cutting,
removal of tissues, and altering of blood flow across the damaged tissues, are
achieved (Webste, 1992). In order to have safe electrosurgery, proper handling of
the ESU unit is vital and the operators must be well trained.

The neural cells show excitation and stimulated behavior when it is exposed to
electric fields or current passes through it. However, this excitation is observed at low
signal frequencies. The excitation phenomena triggered in muscles and neural cells
at low frequency currents can cause adverse effects in patients such as pain, heart
failure, etc. The cell membranes are associated with voltage-gated ion channels. Due
to the presence of the voltage-gated ion channels, the neural cells show sensitivity
to the electric field or current. Typically, least normal value for neural cells frequency
is in the range of 0.1–10 ms. Thus, the operating frequency of the electrosurgical
generators is chosen in the range of radiofrequency (RF) range of 100 kHz to 5 MHz
(Polk, 1992).

The interaction of the radiofrequency high-power currents with the human tissues
changes its impedance; thus, the impedance offered at the output terminal of ESU
unit is variable and uncertain. The specified range of tissue impedance is between
0 Ω to 4k Ω. Due to this variation, the ESU unit must be designed in such a way as
to incorporate the uncertainty of the tissue impedance and be able to deliver power
in specified limit. Besides the power signal, maximum limit for current and voltage
signals also needs to be specified (Dodde et al., 2008, 2012). The current and voltage
limits are applied so that the thermal damage of the tissues is prevented (Gerhard,
1984). As a result of electrosurgery, the after effects of warmth development inside
the tissue result in its thermal damage. Thus, the device must be operated in
controlled manner. There are some issues such as scorch at the return electrode side
and surgical flames and these have been reported in the literature (Gardner, 1994;
Schneider et al., 2010). All the operators must be given training on health safety in
order to avoid serious injuries as a result of these issues.

In order to operate the ESU unit in an efficient way, it is necessary to operate the
inverter and converters units in close loop manner. To achieve the desired output
impedance characteristics, the average power of ESU machines is measured in sev-
eral cycles and the converters duty cycle is controlled using low-bandwidth controller
(Thompson, 2005; Becker and Klicek, 1998; Pearce, 1986). A control method using
adaption of peak current mode is reported by (Erickson and Maksimovic, 2004;
Tan and Middlebrook, 1995). To regulate the fixed frequency power, the switching
waveforms are generated by comparing the inductor current to its reference value.
However, these controllers lead to instability when the duty cycle increases more
than 50% (Shambroom, 2006). In addition, Palanker et al. (2008) reported the
similarity of human tissue to the chicken or porcine; therefore, in the R&D stage and
for calibrations, the ESU machine can be tested on chicken tissues before testing it
on the actual patient.

ESU devices are commonly built using the resonant inverter configuration (Jensen
et al., 2011). The design proposed in Jensen et al. (2011) has a simple architecture
and the proposed design has the capability to naturally limit the output current and
the voltage of the ESU device. However, the major disadvantage of the resonant
inverter-based topology includes the lack of flexibility for shaping the frequency of
the output power over a wide range of operations (Erickson and Maksimovic, 2001).
In order to address the problem, a new design was proposed by Jensen et al. (2015)
using the GaN fast switches. The new proposed design has the flexibility to adjust
the output frequency of the power signal over a wide range of operations. Friedrichs
et al. (2012) proposed a buck-boost converter-based topology for the ESU device,
which is able to minimize the steady-state error between the instantaneous power
and average power with square wave output.

Apart from the proposed topologies, closed loop control plays crucial role to ac-
curately adjust the output power of the ESU unit. In the discussed literature, only
classical control system has been reported for ESU devices (Friedrichs et al., 2012;
Jensen et al., 2011, 2015). As the ESU device is used in surgical procedures, its
control performance must not degrade with variable tissue impendence and other
applied disturbances. In order to ensure minimal thermal damage to the tissues of
the patient, the control loop must be robust to regulate the output power, voltage,
and current signals to the respective desired values. Fractional order control offers
additional benefits over the conventional integer-order control system in terms of
high degree of freedom, robustness against noise, and enhanced stability margins
(Ullah et al., 2017a, b, c). Some fractional-order sliding mode controllers have been
proposed in the literature such as for the DFIG-based wind energy system (Ullah
et al., 2017a, b, c), static series synchronous compensator (Ullah et al., 2017a, b, c),
uncertain system (Ullah et al., 2015a, b), and aerospace actuation system (Ullah et
al., 2015a, b). Apart from the additional advantages of the fractional order control,
the implementation of the fractional systems over the hardware platform is still an
open research problem. The implementation of the fractional order control system
on FPGA platform is discussed in detail in Ullah et al. (2017a, b, c). Based on
the foregoing literature survey, this chapter is focused on the derivation of the
mathematical model for the ESU unit. Based on the derived model, nonlinear
fractional-order control system based on sliding mode concepts is derived for the
voltage and current loops of the ESU device, respectively. Finally, the ESU device
is simulated for constant power mode with both fractional-order and integer-order
controllers.
The rest of the chapter is organized as following. Section 2 explains basic working
principle and design specifications of the ESU unit, Section 3 discusses mathemat-
ical modeling, Section 4 shows controller formulation, and Section 5 discusses the
results. Finally, the chapter is concluded in Section 6.

> Read full chapter

Operative (Surgical) Laparoscopy

Armin Schneider, Hubertus Feussner, in Biomedical Engineering in Gastrointestinal
Surgery, 2017

7.2.10 Impedance-Guided Dissection

Conventional electrosurgery has the main drawback that it is self-limiting. Desiccat-
ed and charred tissue gains increasingly resistance and stops the influx of power.

As described in detail in Chapter 6.2: Electrosurgery, the problem of self-insulation

is overcome by impedance-controlled electrocoagulation.

The first designs of impedance-controlled vessel sealing systems were produced for
laparoscopic surgery (Fig. 7.60).

Figure 7.60. Vessel sealing generator.From MITI.

Impedance-controlled vessel sealing systems act in the bipolar mode. Per se, they
are unable to achieve more than—though very effective—welding of the tissue and
vessels. Dissection has to be done by a blade integrated into the device. As soon as
the coagulation process is finished successfully, an acoustic signal indicates that the
blade can be pushed forward by activation of a mechanical handle (Fig. 7.61).
Figure 7.61. (A) Handpiece of impedance-controlled vessel sealing system; (B) tips
of the hand instrument.All from MITI.

The first devices were only available with a diameter of 10 mm. Currently, 5-mm
systems are the standard.

> Read full chapter

Selected Applications
Sverre Grimnes, Ørjan G Martinsen, in Bioimpedance and Bioelectricity Basics
(Third Edition), 2015

10.10 Electrosurgery
In electrosurgery, high-frequency (also called radio frequency, RF) current is used
to cut or coagulate living tissue. The method should not be confused with electro-
cautery, where the current is passed through a wire and not through tissue, and the
wire is accordingly heated. In electrosurgery heat is developed in the tissue where
current flows, but the electrodes are cold. Bioimpedance is involved in different ways:

• Determining the RF current path and the influence from metal implants if
such are present.
• Controlling the RF output characteristic.

• Controlling special coagulation processes.

• Safety monitoring the important neutral return plate functions.

Thus the bioimpedance participation concerns both functions and safety. It illus-
trates a typical feature often found with bioimpedance: bioimpedance devices are
embedded in larger instrumentation as rather anonymous parts. This is especially
true because use of RF high power directly to patient tissue implies high risk factors
imposing strict safety requirements.

A unipolar (in the field of surgery called monopolar) circuit is used in general
surgery, Figure 10.19. The active electrode has a very high local current density in
the tissue near the electrode, and the return current is taken care of by a large area
neutral electrode. The neutral electrode is often covered with sticky hydrogel for
direct fixation to the skin. The active electrode may be handheld and free, or may be
endoscopic: long and thin insulated types either flexible or rigid and with an open
metal sphere at the end (see Section 6.2.1).
Figure 10.19. Monopolar electrosurgery.

Bipolar forceps are used for microsurgery, they represent a dipole current source in
the tissue and no neutral return electrode is used (see Section 6.2.3).

The waveform used is more or less pure sinusoidal in cut mode, but highly pulsed
with a crest factor of 10 or more for the spread coagulation mode. In spread co-
agulation, tissue contact is not critical; the current is passed to the tissue mostly
by fulguration (electric arcs). The electromagnetic noise generated may be severe
over a broad frequency spectrum, causing trouble for other medical instrumentation
connected to the same patient.

Electrosurgery is based upon the heat effect of the current, and this is proportional
to tissue conductivity and the square of the current density (and the electric field).
The power volume density Wv is falling extremely rapidly with distance from the
electrode, as shown by the equation for a voltage driven half sphere electrode at the
surface of a half infinite homogeneous medium: Eq. 10.12. With constant amplitude
current i the power volume density Wv is:

(10.12)

Tissue destruction therefore occurs only in the very vicinity of the electrode. Power
dissipation is linked with conductance, not admittance, because the reactive part
just stores the energy and sends it back later in the AC cycle. Heat is also linked with
the rms values of voltage and current, ordinary instruments reading average values
cannot always be used. The temperature rise ΔT is given by Eq. 6.8. Because heat is
so current density–dependent, the heat effect is larger the smaller the cross-sectional
area of the electrode, or in a tissue zone constriction. This is an important reason
for the many hazard reports with the use of electrosurgery in hospitals.
High frequencies have been chosen to avoid nerve and muscle stimulation; see the
sensitivity curve of Figure 10.20.

Figure 10.20. Frequency dependence of let-go currents.Statistic for 134 men and 28
women.According to Dalziel (1954, 1972).

Typical power levels in unipolar electrosurgery is about 80 W (500 Ω, 200 V, 400 mA
rms), in bipolar work 15 W (100 Ω, 40 V, 400 mA rms). The frequency content of
the sine wave is of course just the repetition frequency, usually around 500 kHz. In
pulsed mode, the frequency content is very broad, but most of the energy will be in
the frequency band 0.5–5 MHz. In pulsed mode, the peak voltage can reach 5000 V,
so insulation in very humid surroundings is a problem.

Argon gas is sometimes used as an arc guiding medium. The argon gas flows out
of the electrode mainly for two purposes: to facilitate and lead the formation of an
arc between the electrode and tissue surface, and to impede oxygen in reaching the
coagulation zone. In this mode of operation, no physical contact is made between
the metal electrode and the tissue, the surgeon points the pen toward the tissue
and coagulation is started just as if it was a laser beam (which it is often mixed up
with). The gas jet also blows away liquids on the tissue surface, thus facilitating easy
surface coagulation.

Ablation
Through catheters it is possible to destroy tissue with RF currents in a minimally
invasive procedure. In cardiology, this is called ablation. Both DC and RF current have
been tried for this purpose. Choice of bipolar or monopolar technique is important,
Anfinsen et al. (1998).

10.10.1 Risk Analysis

The number of reported incidents and accidents has been higher for electrosurgery
apparatus than other electromedical instrumentations. One reason for this is that it
is made for therapeutic interventions with use of high RF power, implying that wire
lengths of 2–3 m do exhibit strong antenna effect.

Burns

The whole patient is electroactive in monopolar mode. The RF potentials of many

body segments may easily attain some tenths of volt rms, and insulation of these
body segments is critical. The current path in the body is much shorter in bipolar
modus, this is therefore a preferred lower risk modus.

Unintended tissue destruction occurs at tissue constriction sites where the current
density is high. Burns can occur at current densities above about 100 mA/cm2 in 10 s.
Peak voltage above 3 kV due to high crest factors in coagulation makes the insulation
critical and high voltage insulation breakdowns may result in tissue burns.

Noise Source

An electrosurgery unit is a 2–300 W radio transmitter in the medium wave band

around 1 MHz and connected to antenna wires of about 3 m lengths. In coagulation
mode the power is strongly pulsed with peak powers of 1 kW or more. In fulguration
modus, the contact between active electrode and tissue is to a large extent by electric
arcs, which in themselves are powerful noise transmitters.

Nerve Excitation

High-frequency current used in electrosurgery does not result in living tissue

excitation. However, electric arcs imply a local rectifying effect generating nerve
and muscle excitation in the very vicinity of an arc. In the active electrode wire, a
blocking safety capacitor is inserted so the rectified voltage shall result in only small
AC low-frequency currents; see Figure 10.21.

Figure 10.21. Typical electrosurgery output circuit.Notice double plate neutral elec-
trodes for monitoring of skin contact. Safety blocking capacitor shall prevent recti-
fied low-frequency currents in tissue.
Even so, there may be local low-frequency current loops in multiple arc situations,
Slager et al. (1993). Rectification is strongly unwanted, and the resulting nerve
stimulation still is a problem in certain surgical procedures.

10.10.2 Embedded Bioimpedance Devices

Controlling the RF Output Power Characteristic

The optimal output characteristic is linked with the very variable load resistance.
Tissue resistivity increases when coagulated. Fat has higher resistivity than muscles
and blood, and the contact geometry is very dependent on the electrode chosen and
the way it is held by the operator. If constant amplitude current is chosen, power
would be proportional to load resistance, and tissue would quickly be carbonized
in high resistance situations. If constant amplitude voltage were chosen, power
would be inversely proportional to load resistance, and when tissue layers around
the electrode coagulate, current stops flowing. Modern instrumentation therefore
measures both output voltage and current, and the output impedance regulates for
an isowatt characteristic delivery.

Determining the RF Current Path in Monopolar Modus

The current path between the active electrode and the neutral plate will depend on
the tissue conductivity volume distribution. The site of the surgical intervention is
given, but the site of the neutral electrode can be more freely chosen for optimum
safe delivery.

Patients with Metallic Implants

The use of electrosurgery on patients with metallic implants or cardiac pacemakers

may pose problems. Metallic implants are usually considered not to be a problem if
the form is round and not pointed, Etter et al. (1947). The pacemaker electrode tip
is a small area electrode, where relative small currents may coagulate endocardial
tissue. The pacemaker catheter positioning should therefore not be parallel with the
electrosurgery current density lines. This is illustrated in Figure 10.22 for a heart
pacemaker implant.
Figure 10.22. Monopolar electrosurgery and an implant; for example, a pacemaker
with intracardial catheter electrode.Importance of catheter direction with respect to
current density direction.

Controlling Critical Coagulation Processes in Vessel Sealing (LigaSure)

Vessel sealing for stopping bleeding is a critical process; if it fails, it may result in
reopening the patient. Using the special bipolar electrode shown in Figure 10.23 it is
possible both to seal and to cut the vessel. When the vessel is positioned in the jaw,
the tissue is pressed together by the grip. The impedance is increasing during the
denaturation and impedance is monitored with the two electrodes shown. When the
tissue impedance has reached a correct level, the power is switched off automatically
(and not by the surgeon). When the pressure, the high frequency current level and
the time is correct the inner walls of the vessel has melted together with little
tissue damage and the knife can be used to cut the vessel so that both ends are
sealed. Figure 10.23 left shows the cutting blade that is used after the coagulation
is completed and the ends of the vessels have been sealed off. The outer surface of
the jaw is made of electrically insulated material so that other tissues in unintended
contact will not be injured, Figure 10.23 right.
Figure 10.23. Control of critical coagulation (Ligasure).Left: Open gap with cutting
device. Right: Closed gap and coagulation under controlled pressure.Courtesy:
Tormod Martinsen.

Safety Monitoring of the Neutral Return Plate Function

The neutral plate is often split in two, and a small current is passed between the
two plates via the skin and tissue. Impedance is measured, and if this impedance
is outside preset or memory set limits, the unit will warn to inform about poor and
dangerous plate contact (cf. Figure 10.21).

> Read full chapter

Classical (Open) Surgery

Armin Schneider, Hubertus Feussner, in Biomedical Engineering in Gastrointestinal
Surgery, 2017

6.2.15 Clinical Aspects of Electrosurgery

Modern surgery would be inconceivable without electrosurgery. However, it is also
potentially dangerous, mainly through causing thermal injuries, frequently leading
to significant morbidity and mortality and medicolegal actions.

According to surveys, 18% of general surgeons and gynecologists have seen at least
once visceral burns, and many of them admitted one or more ongoing causes of
litigations due to these burns [17]. Insulation failure [18] plays a major role as well
as burns due to the neutral electrode.

Great care has to be taken to avoid these specific risks of electrosurgery, e.g., through
continuous training and education. In order to improve the surgeons knowledge
[19], some specific programs like the “Fundamental use of surgical energy (FUSE)
certification” were developed [20].

> Read full chapter

Basal Cell Carcinoma☆

L.A. Hansen, in Reference Module in Biomedical Sciences, 2015

Standard Therapies
Removal of the lesion, through surgical excision, Mohs surgery, cryosurgery, or
electrosurgery is the usual treatment. Ionizing radiation may be used for some basal
cell carcinomas that are located in delicate regions of the face or for patients for
whom surgery in contraindicated (Fitzpatrick, 2000).

Agent name Discussion

5-Fluorouracil In patients with small tumors for whom surgery
is contraindicated, topical treatment with 5-f-
luorouracil, a pyrimidine antagonist, may be used
(Fitzpatrick, 2000). 5-fluorouracil can also be
combined with curettage and electrodessication
(Epstein, 1985)

Imiquimod Topical imiquimod combined with cryosurgery

or curettage can be effective for treating low
risk basal cell carcinoma (reviewed in Lazareth,
2013). Imiquimod is a Toll-like receptor-7 ago-
nist that stimulates innate and cell-mediated im-
mune responses
Vismodegib This orally available Smoothened inhibitor is ap-
proved for treatment of basal cell carcinomas.
Vismodegib resulted in a 30% response rate for
metastatic disease and a 43% response rate for lo-
cally advanced disease (reviewed in Mohan and
Chang, 2014)

> Read full chapter

Skin Cancer☆
L.A. Hansen, in Reference Module in Biomedical Sciences, 2015

Standard Therapies
Removal of the lesion, through surgical excision, Mohs surgery, cryosurgery, or
electrosurgery is the usual treatment, except for Kaposi's sarcoma and mycosis fun-
goides. Adjacent lymph nodes may also be removed for diagnostic and therapeutic
purposes, particularly in advanced cases of melanoma. Radiation therapies and
chemotherapy is sometimes used as well for advance cases of skin cancer.

Agent name Discussion

5-Fluorouracil In patients with small epithelial tumors for whom
surgery is contraindicated, topical treatment with
5-fluorouracil, a pyrimidine antagonist, may be
used (Fitzpatrick, 2000). 5-fluorouracil can also
be combined with curettage and electrodessica-
tion (Epstein, 1985).
Imiquimod Topical imiquimod combined with cryosurgery
or curettage can be effective for treating low
risk basal cell carcinoma (reviewed in Lazareth,
2013). Imiquimod is a Toll-like receptor-7 ago-
nist that stimulates innate and cell-mediated im-
mune responses.
Vismodegib This orally available Smoothened inhibitor is ap-
proved for treatment of basal cell carcinomas.
Vismodegib resulted in a 30% response rate for
metastatic disease and a 43% response rate for
locally advanced disease (reviewed in Mohan and
Chang, 2014).
Cisplatin, doxorubicin, 5-fluorouracil, topotecan, Chemotherapeutics such as cisplatin, doxoru-
etoposide bicin, 5-fluorouracil, topotecan or etoposide may
be used for locally advanced or metastatic SCC,
although the rarity of metastatic cutaneous SCC
has limited evaluation of these agents.
Dacarbazine Dacarbazine is an FDA-approved chemothera-
peutic for melanoma that is sometimes combined
with other agents. Dacarbazine has been used
with carmustin amd tamoxifen, cisplatin and vin-
blastine, or in combination with molecularly-tar-
geted drugs (reviewed in Karimkhani et al.,
2014).
Interferon alpha 2b Interferon alpha 2b is a type of immunotherapy
that increases disease-free survival for melanoma,
and is FDA-approved for the treatment of high
risk melanoma.
Interleukin-2 (IL-2) The FDA-approved immunotherapy IL-2 has
some effectiveness in treating metastatic stage IV
melanoma when given in high doses Guirguis
et al (2002). Although only a fraction (10-16%)
of patients respond to IL-2, most responders
demonstrate increased survival.
BRAF inhibitors The BRAF inhibitors vemurafenib and dabrafenib
target melanoma cells harboring activating mu-
tations in BRAF to increase survival in pa-
tients with metastatic melanoma (reviewed in
Karimkhani et al., 2014). As with many oth-
er molecularly-targeted agents, patients often
develop resistance to BRAF inhibitors through
up-regulation of alternative signaling pathways.
A genetic test for BRAF mutations in melanoma
patients has been approved to identify patients
likely to respond to BRAF inhibitors.
MEK inhibitors The MEK1/2 inhibitor Trametinib is approved for
treatment of melanoma with BRAF mutations.
Trametinib is also approved for use in combina-
tion with the BRAF inhibitor dabrafenib, which
increases progression-free survival (reviewed in
Karimkhani et al., 2014).
Ipilimumab Approved for unresectable or metastatic
melanoma, this antibody against cytotoxic T-lym-
phocyte antigen-4 (CTLA-4) results in a surpris-
ingly durable improvement in survival for as long
as 3 years (reviewed in Karimkhani et al.,
2014).
> Read full chapter

Lasers in dentistry
T. Dostálová, H. Jelínková, in Lasers for Medical Applications, 2013

20.4.3 Bone and soft tissue laser therapy

The radiations of some lasers reduce bleeding intraoperatively and cause less pain
to be felt postoperatively in comparison with conventional techniques such as
electro-surgery (Romanos et al., 2009). As mentioned in Section 20.2 and also in
Chapter 1, the degree of absorption in key tissue components is crucial to the effect
of the laser radiation on tissues; in this sense the content of water, hydroxyapatite,
and hemoglobin in oral tissues is important for efficient absorption of many
commonly used dental lasers.

Laser wavelengths with optical affinity for melanin, hemoglobin and water (the
main chromophores contained in gingiva and mucosa) can be used for soft tissue
applications. Visible wavelengths generated by argon (514 nm) or KTP (532 nm)
lasers are absorbed and scattered in the same proportion at the peak value of the
hemoglobin absorption curve, so these lasers have superficial penetration from
0.1 μm to 1 mm, and, therefore, a very good hemostatic effect in treating vascular
lesions (i.e. hemangioma). The absorption in water is minimal (see Fig. 1.1).

Such lasers as the semiconductor, Nd:YAG or Nd:YAP, generating radiation in

near-infrared wavelengths (800 to 1340 nm), are commonly used for cutting, vapor-
ization, and decontamination of soft tissue. Their interaction occurs at a different
point of the hemoglobin and melanin absorption curve.

The laser indications are: papilloma, fibroma, hemangioma, venous lake, cysts,
ulcers, herpes labialis, epulis, pyogenic granuloma, gingivectomy, and frenectomy.
Laser radiation can also be of assistance in treating dental trauma (Zanin et al., 2010).

Mid-infrared laser wavelengths generated by the Er:Cr:YSGG, Cr:Tm:Er:YAG, or

Er:YAG lasers and the far-infrared CO2 laser are mainly absorbed at different peaks
of the water absorption curve; the laser–tissue interaction is very superficial (from
0.1 to 0.3 μm) but effective for soft tissue applications because water is the prevalent
component in gingiva and mucosa, although there is less specificity and less he-
mostatic control. These wavelengths are highly absorbed in water and often provide
more efficient ablation whenever healthy or minimally pigmented and vascularized
tissue is treated. This laser radiation is therefore beneficial for soft and hard tissue
(i.e. bone) therapy.
Despite the advantage of the generated wavelength, power density also plays some
part in tissue removal. Figure 20.3 shows an example of cutting and drilling soft
dental tissue and bone by Er:YAG laser radiation. Porcine bone and gingiva tissues
were treated by Er:YAG laser radiation (free-running mode – 260 μs long and
Q-switched (see Chapter 4) – 60 ns long pulses), and the effect of cutting and
ablation was also investigated by Jelínková (Jelínková et al. 2004, 2007). From the
stereomicroscopic evaluation of the holes ablated by Er:YAG radiation it follows that
free-running pulses hundreds of microseconds long create less uniform structure
in comparison with the tens of nanoseconds long giant pulses. This is due to the
type of interaction processes, which cover either thermal ablation (generated by long
pulses) or photo-ablation following the interaction of the giant nanosecond pulses
with bone. In the case of thermal ablation the tissue inside the hole is melted, while
in the case of short pulses a more corrugated surface inside the hole is formed. This
can be an advantage in the case of ceramic filler. As regards drilling effectiveness,
the long free-running Er:YAG pulses remove more bone material compared with the
giant pulse.
20.3. Er:YAG laser radiation: (a) free-running regime, pulse length 210 μs (FWHM),
(b) interaction with bone, (c) interaction with mucosa, (d) Q-switched regime, pulse
length 83 ns (FWHM), (e) interaction with bone, (f ) interaction with mucosa.

> Read full chapter

Electrodes for Biopotential Recording

and Tissue Stimulation
Vera Lucia Da Silveira Nantes Button, in Principles of Measurement and Transduc-
tion of Biomedical Variables, 2015

2.6.1.1.1 Limb electrodes

This type of electrode usually has rectangular format and plane contact area. Its
surface can also be curved to a better adjustment to the format of arms and legs
(Figure 2.17A). They are used, for instance, as return plate in electrosurgery and right
leg electrode in ECG recording. The inner side of the electrode receives a layer of
electrolytic gel and it is fixed with the help of elastic bands. Smaller sizes of plates
are also mounted in clip supports (Figure 2.17B), eliminating the need of the bands.
In addition to gold, silver, and stainless steel, they can be made of a metallic alloy
of copper, zinc, and nickel, known as German silver or alpaca. German silver is
extensively used because of its hardness, toughness, resistance to oxidation, and
high electrical resistance; the percentage of the three elements varies, ranging for
copper from 50% to 61.6%; for zinc from 17.2% to 19%; and for nickel from 21.1%
to 30%.

Figure 2.17. Limb electrodes: (A) curved plate, (B) fixation elastic bands and (C) plate
electrode mounted in clip support.

> Read full chapter

Introduction
Sverre Grimnes, Ørjan G Martinsen, in Bioimpedance and Bioelectricity Basics
(Third Edition), 2015

1.5.1 Clinical Applications

Many clinical applications are well established. Recording bioelectric signals from
the heart (electrocardiography) was introduced by Waller in 1887 and brought into
clinical use by Einthoven around 1905, and is still an important examination in
hospitals worldwide. Electrodermal activity was also started in the 1880s, but it took
many decades before the generation mechanism was understood. Electrosurgery
was in a similar same position during 1930s. Recording bioelectric signals from the
brain (electroencephalography) was introduced during the 1940s, and pacemakers
and defibrillators were put into use during the 1960s. Lung plethysmography and
respiration rate determination have been used in electrocardiographic monitors for
several decades. Split electrodes with bioimpedance monitoring of electrode–tissue
contact have been used for many years in critical medical electrode applications.

In the past few years, new applications have emerged. Immittance-based plethys-
mography is used to measure cardiac output both with transcutaneous electrodes
and with pacemaker implants. Electrical impedance tomography is used for lung
imaging in intensive care units. Different kinds of skin diagnostic methods are
used to treat skin cancer, dermatitis, skin moisture, sweat activity and hyperhidrosis.
Pain relief is obtained with transcutaneous electrical nerve stimulators or implanted
devices. Organ ischemia and rejection processes can be monitored. Diabetes para-
meters can be measured. The water balance can be determined together with the
monitoring of dialysis treatment. In vivo applications of electroporation and drug
therapy are exploited. Tissue ablation is performed with catheters or endoscopes
with radiofrequency current. Tissue characterization is done and needle position can
be determined. Joint angles can be determined with skin electrodes. Skin moisture
is measured, and sweat activity is logged on several skin sites simultaneously. Skin
potential and impedance can be measured simultaneously at the same skin site.

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Filtering Electronic Circuits

Joseph J. Carr, in The Technician's EMI Handbook, 2000

R-C EMI/RFI PROTECTION

Some circuits, especially those that operate at low frequencies, may use R-C low-pass
filtering for the EMI/RFI protection function. Consider the differential amplifier
in Figure 6.4. This circuit is representative of a number of scientific and medical
instrument amplifier input networks. A medical electrocardiogram (ECG) amplifier,
for example, is basically a differential amplifier with a high gain (1,000 to 2,000) and
a low frequency response (0.05 to 100 Hz). It picks up the human heart's electrical
activity as seen from skin electrodes on the surface.
 Fig. 6.4. R-C and high-voltage protection of low-frequency circuits such as ECG
amplifiers.

There are a number of problems that will afflict the recording, other than the
obvious 60 Hz problem. The ECG must often be used in the presence of strong
radio-frequency (RF) fields from electrosurgery machines. These “electronic scalpels”
are used by surgeons to cut and cauterize and will produce very strong fields on
frequencies of 500 kHz to 3 MHz. They must also survive high-voltage DC jolts
from a charge stored in a capacitor when the patient must be resuscitated. The
defibrillator machine is used to “jump start” a patient's heart that is in ventricular
fibrillation (a fatal arrhythmia). It will produce short-duration voltage spikes ranging
from hundreds of volts to several kilovolts, depending on the particular waveform
design and energy setting. And those potentials might be applied directly across the
ECG amplifier, placing it at risk.

Figure 6.4 contains both RF filtering and a means for limiting the defibrillator jolt.
The resistors and capacitors form a three-stage cascade RC filter, one for each input
of the differential amplifier. These components will filter the RF component. Typical
values range from 100K to 1 megohm for the resistors, and 100 pF to 0.01 μF for
the capacitors. The values should not produce a cutoff frequency of 100 Hz or less.
The high-voltage protection is provided by a combination of the input resistors and
a pair of zener diodes (D1 and D2) shunting the signal and common lines. In some
older ECG amplifiers, NE-2 neon glow-lamps were used in place of the zener diodes.

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