ENERGY SOURCES &

ELECTROSURGICAL
DISSECTION
DR MUHAMMAD ZARIN
ASSOCIATE PROFESSOR
SURGICAL D WARD KTH
“Heat cures when everything
fails”

HIPPOCRATES….
INTRODUCTION

 An essential part of Surgery is dissection and securing hemostasis.

 Done by the use of energy.
 Remarkable improvements in energy sources
a) to increase the speed of surgery
b) while reducing the side effects of energy on surrounding tissues due to lateral thermal
spread.
Types of energy devices

 Monopolar
 Bipolar
 Ultrasonic
Monopolar Vs Bipolar

 Electrosurgery can be performed using either

 a monopolar or
 a bipolar instrument.
 The main difference between these modalities is the pathway of the current.
Monopolar Devices

 C A U T E R I Z A T I O N U S I N G H I G H F RE Q U E N C Y
E L E C T R I C A L C U RRE N T

 P A S S E D F RO M A S I N G L E E L E C T RO D E W H E RE
C A U T E R I Z A T I O N O C C U RS ;

 T H E P A T I E N T ' S B O D Y S E RVE S A S A G RO U N D .
Mechanism Of Monopolar Devices
Monopolar Instruments

  Common monopolar instruments used in laparoscopy include

i. shears,
ii. scissors,
iii. hook and
iv. spatula. 
Monopolar Cautery Devices
Harmonic Scalpel

 Ultrasonic device
 Piezoelectric crystal located at tip of instrument produces 55000
vibrations/second.
 Converts ultrasonic energy mechanical energy

producing cutting and coagulation effects.

 Lysis of H-bond heat denaturation of proteins
separation of tissue
 Tissue separation occur at 50-60 degree Celsius.
Harmonic scalpel

 Three compatible probes

a) Shear coagulate vessels up to 5mm
b) Hook
coagulate vessels up to 2mm
c) Blade
Advantages

 Minimal thermal spread

 No desiccation or charring of tissues
 No risk of electrical energy
 No smoke
Disadvantages of Harmonic scalpel

 Inability to coagulate vessels greater than 5mm

 Main disadvantage is production of mist affecting visibility.
 Can only coagulate tissues when it cuts.
Ligasure

 Seals tissue by high current and low voltage (180v)

 Electrosurgical collagen welding (basic mechanism)
 Combination of pressure and energy

Denatures collagen and elastin

Permanent plastic like seal

MECHANISM OF LIGASURE

 Hydrothermal rupture of collagen cross links

 60-90 degree Celsius

 Collagen allows renaturation of entangled unwound collagen strands

 High uniform mechanical compression increases entanglement upon thermal relaxation

 Permanently fuses tissue and vessels without desiccation

ADVANTAGES OF LIGASURE

 Average seal cycle is 2-4 sec

 Seal can withstand systolic pressure up to 3 times normal systolic pressure

 Can ligate vessels up to 7mm

 Impedance feedback --- adjust energy levels according to tissue impedance

 Feedback controlled response system to detect endof seal cycle

Ligasure
Thunderbeat

 Integrated Bipolar and ultrasonic technology

 Simultaneously delivers
I. Ultrasonically generated frictional heat energy &
II. Electrically generated bipolar energy.
Advantages of Thunderbeat

 Fastest in class cutting speed--- reducing operation time

 Reliable 7mm vessel sealing
 Precise dissection with fine jaw design
 Always available bipolar energy for hemostasis without cutting
 Minimal thermal spread
 Reduced mist generation help to maintain visibility
 Higher bursting pressure.
Thunderbeat
 Differences in visibility, operation time, burst
pressure and lateral thermal spread

Energy Visibility Operation time Burst pressure Thermal spread

system
Thunderbeat Unimpaired visibility Fastest in class Highest mean burst Least lateral thermal
cutting pressure spread
Ligasure Smoke production Slow surgery Moderate mean burst 2mm lateral thermal
affecting visibility pressure spread
Harmonic Mist production Slower surgery Lowest mean burst Less than 1mm
affecting visibility pressure lateral thermal spread

World Journal of Laparoscopic Surgery, January-April 2014;7(1):41-44

 Differences in bursting pressure

7mm Vessel Sealing

2000
1800
1600
1400
1200
1000
800
600
400
200
0
ThunderBeat LigaSure

Average Burst Pressure (mm Hg)

World Journal of Laparoscopic Surgery, January-April 2014;7(1):41-44

ENSEAL

 Adjusts energy according to tissue impedance.

 Smart electrode technology- millions of Nano conductive particles each with discrete
thermostatic switch.
 Each particle interrupts current flow to a specific tissue if temperature rises.
 If temperature below fusion level, particle turns back on.
Advantages

 Less heat required. Tissue volume reduced by compression.

 Vessels wall fused by compression, protein denaturation and then renaturation.
 Seals up to 7mm vessels.
 Thermal spread 1mm.
 Withstands up to 7 times systolic pressures.
ENSEAL
Electrical Burns

 Each year, there are 550 to 650 reported cases of electrode burns on patients because of
surgical electro cautery.
 These burns are due to inappropriate placement of dispersive pads during surgery.
 Electrosurgical safety requires;
a) knowledge of using the equipment properly, but also requires
b) routine preventative maintenance and
c) check-up of the device.
Thank you