68 Harmonic Scalpel Technology

J ULIA SEIDEL AND A MULYA K. SAXENA

68.1 Introduction 68.2 Indications

The Ultracision® harmonic scalpel (Johnson & The Ultracision® harmonic scalpel is indicated for
John- son Medical Products, Ethicon soft-tissue incisions when bleeding control and
Endosurgery, Cin- cinnati, OH, USA) is the minimal thermal injury are desired. The instrument
first ultrasonic surgi- cal device for cutting and can be used as an adjunct to or substitute for elec-
coagulation. It provides atraumatic surgical trocautery, lasers, and steel scalpels.
dissection and hemostasis us- ing direct
application of ultrasound. With the Ul- tracision®
harmonic scalpel, no electric current is sent
through the patient. Hence, all the risks associ- ated
with the direct use of electric current are thus
avoided.

68.3 Contraindications 68.4 Components

1. Bone incisions. The Ultracision® harmonic scalpel system consists
2. Contraceptive tubal ligation. of the following components:
1. Generator.
2. Handpiece with connecting cable.
3. Foot switch.
4. Coagulating shears.
5. Blade system (5 and 10 mm).
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68.4.1 Generator

The Generator is a microprocessor-controlled

power supply that drives the acoustic transducer
system. (Courtesy of Johnson & Johnson Medical
Products, Ethicon Endo-Surgery, Vienna, Austria)

68.4.2 Handpiece

The ergonomic handpiece converts the electrical en-

ergy from the generator into mechanical ultrasound
vibrations. These vibrations are transmitted to the
at- tached Ultracision® harmonic scalpel device.
(Cour- tesy of Johnson & Johnson Medical
Products, Ethi- con Endo-Surgery, Vienna, Austria)
 Julia Seidel and Amulya K. 4

68.4.3 Foot switch

The Foot switch is used to activate the output of the

generator. It has two pedals: With the left pedal, one
of five ultrasound energy levels previously selected
on the generator will be activated. The right pedal
fixes the level at 5. (Courtesy of Johnson & Johnson
Medical Products, Ethicon Endo-Surgery, Vienna,
Austria)

68.4.4 Laparosonic Coagulating Shears

The laparosonic coagulating shears (LCS) is a

multi- functional device that has been developed
to use the full potential of ultrasound technology. It
cuts, coagulates, grasps, and dissects to improve
overall procedural efficiency. (Courtesy of Johnson
& John- son Medical Products, Ethicon Endo-
Surgery, Vi- enna, Austria)

68.4.4.1 Shear Tip Variations

Shear tips may be straight or curved (inset). The

straight shear tips are also available in (1) knife-
down or (2) blunt variations. (Courtesy of John-
son & Johnson Medical Products, Ethicon Endo-
Surgery, Vienna, Austria)
470 Chapter 68 Harmonic Scalpel Technology

68.4.5 Harmonic Scalpel Blades: 10 mm

There a two types of 10-mm blade: ball coagula-

tor (top) and dissecting hook (bottom). (Courtesy
of Johnson & Johnson Medical Products, Ethicon
Endo-Surgery, Vienna, Austria)

68.4.6 Harmonic Scalpel Blades: 5 mm

There are four types of 5-mm blades: (a) curved

blade, (b) sharp hook, (c) dissecting hook, and (d)
ball coagulator. (Courtesy of Johnson & Johnson
Medical Products, Ethicon Endo-Surgery, Vienna,
Austria)
 Julia Seidel and Amulya K. 4

68.5 Comparison of Tissue-Sealing

Technologies
Harmonic scalpel technology controls bleeding
by captive coagulation at low temperatures
ranging from 50 to 100ºC. By contrast,
electrosurgery and lasers coagulate by burning
(obliterative coagula- tion) at higher temperatures
(150–400ºC). Blood and tissue are desiccated and
oxidized (charred), forming eschar that covers
and seals the bleed- ing area. Rebleeding can
occur when blades are re- moved during
electrosurgery, as they stick to tissue and disrupt
the eschar.
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68.6 Transducer Technology

1. The transducer, found in the handpiece, consists
of piezoelectric ceramics that expand and con-
tract to convert the electrical energy from the
generator into mechanical vibration.
2. The ultrasonic vibration is transmitted from
the transducer through an extending rod to the
at- tached blade.
3. The blade extender is supported by silicone
rings positioned at nodes to direct the flow of
energy in a longitudinal direction and to
prevent en- ergy from being dissipated on the
sheath.
(Courtesy of Johnson & Johnson Medical Products,
Ethicon Endo-Surgery, Vienna, Austria)
 Julia Seidel and Amulya K. 4

68.7 Power Level and Function

1. The blade or tip of the harmonic scalpel vibrates
axially with a constant frequency of 55,500 Hz.
2. The longitudinal extension of the vibration
can be varied between 25 and 100 µm in 5
levels by adjusting the power setting of the
generator.
3. The maximum longitudinal displacement is
50–100 µm, depending on the type of blade and
the set power level.
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68.8 Tissue Effects

of Harmonic Scalpel

68.8.1 Cavitation

Cavitation is achieved by the formation of vapor

bubbles at body temperature due to the rapid vol-
ume changes of the tissue and cell fluids, and is
in- duced by the transmitted vibration to the
tissues. Cavitation is usually divided into two
classes of be- havior: inertial and noninertial
cavitation. Nonin- ertial cavitation is applied in
the harmonic scalpel to achieve the desired tissue
effects.

The Ultracision® harmonic scalpel system

yields three possible effects: cavitation, coaptation
or coa- gulation, and cutting.

68.8.2 Coaptation and Coagulation 68.8.3 Cutting

The joint application of pressure and ultrasound By using tension, pressure, or both, the tissue is rap-
to the tissue fragments the protein compounds, idly stretched beyond its elastic limit by the high-
lead- ing to the adherence of collagen molecules frequency vibration and is cut smoothly by a
at low temperatures. Thus, coaptation is achieved at sharp blade or instrument tip. The cutting speed
a tem- perature range of 37–63°C. When the and ex- tent of coagulation are easily controlled
locally ap- plied energy acts for longer periods, the and can be balanced by varying four factors:
rise in tem- perature leads to denaturing of protein
1. Power.
– coagula- tion, at a maximum temperature of
2. Blade sharpness.
150°C.
3. Tissue tension.
4. Grip force/pressure.

68.8.4 Power Setting and Blade Sharpness
Increasing the power level increases the cutting
speed and decreases the coagulation. In contrast,
less power decreases the cutting speed and in-
creases coagulation. Cutting speed is also a function
of blade sharpness. The shear mode of the LCS cuts
faster than the blunt mode; the blunt mode pro-
vides more coagulation, assuring coagulation when
vascular tissue or vessels are encountered.
68.9 Injuries with Harmonic
Devices
68.9.1 Precautions
A thorough understanding of the principles and
techniques involved in ultrasonic procedures is
es- sential to avoid shock and burn hazards to
both the patient and medical personnel and
damage to the device or other medical
instruments.
Electrical connections should be properly
checked before any procedure is performed. It
should also be ensured that electrical insula-
tion or grounding is not compromised and do
not immerse the instruments in liquids.
68.9.3 Blade Injuries
1. Do not attempt to bend, sharpen, or otherwise
alter the shape of the blade. Doing so may cause
blade failure and surgeon or patient injury.
2. During prolonged activation in tissue, the in-
strument blades may become hot.
3. Blood and tissue build up between the blade
and sheath may result in abnormally high
tem- peratures at the distal end of the sheath.
Julia Seidel and Amulya K. 4
68.8.5 Tissue Tension and Grip Pressure
More coagulation can be achieved with slower cut-
ting when tissue tension is reduced. Increased tissue
tension leads to faster cutting with less coagulation.
Grip force, or pressure, is another factor con-
trolling the balance between cutting and coagula-
tion. Application of light pressure achieves more
coagulation with slower cutting. A firmer grip force
achieves less coagulation with faster cutting.
68.9.2 Handpiece Injuries
1. Handle the handpiece carefully, as damage may
shift its resonant frequency.
2. To prevent burn injury, discontinue use if the
handpiece temperature makes it
uncomfortable to hold.
3. Audible high-pitched tones may indicate
blade disconnection and may result in
abnormally high sheath temperatures and user
or patient injury.
68.9.4 Generator-Related Injuries
1. To prevent overheating during use, ensure
that the air vents on the base and back panels
of the generator are not blocked.
2. Avoid placing the generator on a soft surface.
3. Place the generator in the “standby” mode be-
fore removing or replacing an instrument,
hand switching adapter, or handpiece, or
when the system is not in use.
476 Chapter 68 Harmonic Scalpel Technology

Acknowledgment Recommended Literature

Johnson & Johnson Medical Products, Ethicon
En- dosurgery, Vienna, Austria.
1. Geis WP, Kim HC, McAfee PC, Kang JG, Brennan EJ Jr
(1996) Synergistic benefits of combined technologies
in complex, minimally invasive surgical procedures.
Clinical experience and educational processes. Surg
Endosc10:1025–1028
2. Koch C, Borys M, Fedtke T, Richter U, Pohl B (2002)
Determination of the acoustic output of a harmonic
scalpel. IEEE Trans Ultrason Ferroelectr Freq Control
49:1522–1529
3. Langer C, Markus P, Liersch T, Fuezesi L, Becker H
(2001) UltraCision or high-frequency knife in trans-
anal endoscopic microsurgery (TEM)? Advantages of
a new procedure. Surg Endosc15:513–517