Dr Hemant S Bhansali

MS; FCPS; FICS; FACG; PhD (Lap. Surg)

 1st PhD in INDIA in Laparoscopic Surgery
 Nanavati Superspeciality Hospital, Mumbai
 BSES (Brhama Kumari) Hospital,
 Karuna Hospital,
 Seven Hills Hospital,
 Kohinoor Hospital, Dr BA Railway Hospital
 Hon. Faculty Member, Ethicon Institute of Surgical
Education
 Tutor, BSS Course ,Royal College of Surgeons,
Edinburgh, UK
 Programme Director, MUHS
 Member, Board of Higher Studies, MUHS
Since the ages of ancient surgeons - Charaka
and Shushruta a constant problem
How to control hemorrhage ?.
 Historical Aspect
 1875, electric current was passed through
metallic wire loops until they were red hot
 1924 Dr Cushing, MD, a neurosurgeon and
William Bovie, Harvard first to use HF
current for cutting and coagulation.
 1970 the vacuum tube was replaced by solid
state circuit boards and Transistors.
Fathers of the Modern ESU
Physics of Electricity
Circuit = Pathway or flow of electrons
Current = Amount of electrons flowing (amps) (I)
Voltage = Driving force (volts) (V)
Resistance = Impedance or obstacle to flow of electrons (ohms) (R)
Ohms Law: (V = I x R)
Power = Energy/heat produced or used over a period of time (watts)
(P = V x I)
 Principles of Electro- surgery
 To convert a low voltage, low cycle AC
current into a high voltage ,high cycle RF
current suitable for electro-surgery, a
generator is used called ESU
 Current, Voltage Frequency
 voltage is plotted against time then the
shape of the graph is called as a waveform..
•The frequency is the number of such wave
cycles per second & is measured in hertz (Hz).,
The household electricity has 60 cycles per
second or 60 Hz frequency
ESUs produce currents with frequency of
400.000 to 1000,000 Hz
Any current below the frequency of 200.000 Hz
produce neuromuscular stimulation,
depolarization of cardiac muscles
Frequency spectrum
Electro Surgical Tissue
Effects
 the stimulation effect (Faradic
Effect) Freq. of 20Hz to 30KHz
 the polarization effect
( Electrolytic Effect)
 the heating effect (Thermal
Effect ) Freq. of 500 KHz to
2MHz
Cautery / Electrocautery / Electrosurgery

Electrocautery Electrosurgery
The process of The use of alternating
destroying tissue with an current passing through
Cautery object that
the patient to cut and
The surgical use is heated with electricity
coagulate tissue
of heat
There is no current
flowing through the
patient.
If the tissue is heated slowly,
following chain of events occur
Temperature Visual Change Biological Change
 100°C -------Smoke Plume Vaporization,
Carbonization
 90-100°C-------Puckering------------ Drying

 70-90°C----------White------------------- Denaturation
of Proteins
 60-70°C----------Blanching--------------- Coagulation
 45-600 C-------No/delayed-----------enzyme denature

 37-45°C---- No Effect---------------------- Warming

 Change of tissues effects with
waveform modification
 The operating mode of ESU varies in
voltage, current frequency and waveform
Two types of Waveform

 Continuous or undampened or non

modulated waveform of the ‘Cut’ mode
 Dampened or modulated waveform of ‘Coag’
mode
 Continuous or Undampened waveform

It has a continuous cycle

with a low voltage eg.50
W at 1000V
uninterrupted flow of ions
within the superficial layer
of cells will cause the
cellular contents to boil
and vaporize.
Deeper tissues in the
‘cut’ mode are not
heated and poor
hemostasis results.
 Modulated current or dampened
waveform

 In-between the two waves,

the ESU doesn’t produce
current
 The current flows only less
than 10% of time of the duty
cycle
 The tissue is not heated up to
the point of vaporization
 Peak voltage of 7000 V with
rated load of 50 ohms at a
power of 120 watts
 Waveform is at 250 KHz and is
repeated at 40 KHz
 Blended Current

 It is a function of cut type of waveform but

the current is interrupted and flows only part
of the time
 Types of Blend Forms
More Cut, Less ‘Coag.’
 Blend I 50% on and 50% off
 Blend II 40% on and 60% off
 Blend III 25% on and 75% off
More ‘Coag’,
Less Cut

Blended current can have peak to peak voltage of

4000 V.
 3 possible surgical effects

1Cutting,
2 Desiccation
3 Fulguration
The term ‘Coag’ found on any ESU is a
misnomer and does NOT refer to a setting
required ONLY for good hemostasis. It only
refers settings that accentuate high voltage with
lower amperage of current settings.

The ‘cutting ‘on an ESU is also a wrong

presentation and is NOT only for settings
desired for surgical cut. It only shows the
power settings with low voltage and high
amperage of current
 Monopolar Cutting
 Precise tissue effect but the hemostasis is not
achieved to desired level.
 Envelope of steam between tissue and
electrode
 Cut effect when the electrode is just
floating above the tissue and NOT
touching
 lateral heat damage responsible for
hemostasis
Typical Parameters of Monopolar
Cutting
 Voltage 1200-3500 V
 Wave Frequency 400 KHz in Pure Cut
(400 KHz with bursts at 30 KHz in Blend Cut)
 Rated load 300 Ohms
 Power 200-300 Watts
 Desiccation
 A slower, more controlled cellular dehydration
process.
 Can be done either by mono-polar or bipolar
circuit.
 Occurs only and only when the electrode is
in contact with tissue
 Results in deep, wide necrosis at the
point of contact of electrode and beyond
 A low frequency RF current at 250 KHz
repeated at 40 KHz interval
Desiccation
 Desiccation of Blood Vessel
 The blood vessel gets
coagulated by coaption

 The cells in the walls of

vessel first get
desiccated before the
heat coagulates the
blood proteins
 Desiccation of Blood Vessel
 For a large blood vessel the coaptive
process may produce a ‘hole’ in the wall
of the blood vessel allowing some
bleeding to occur before coagulation
 Coagulated blood in immediate vicinity of the
wall will raise the resistance high to prevent
ESU energy to reach the centre of the blood
vessel causing bleeding after cutting the
‘coagulated’ vessel
 A bipolar for desiccation is only having both
electrodes of device in direct contact with the
vessel wall
 Parameters
Monopolar Desiccation

 Voltage 3500 V
 Wave Frequency 250 KHz repeat at 40
KHz
 Rated Load 500 Ohms
 Power 120 Watt
 Bipolar Desiccation
 Voltage
 (a) Precise or low 300 V
 (b) Standard or medium 400 V
 (c) Macro bipolar or high 700 V
 Wave Frequency 500 KHz
 Rated load 100 Ohms
 Power 70 Watts.
 Fulguration /Spray
 A more rapid cellular dehydration process in
which electrical sparks are used to destroy tissue
 May be achieved by Bipolar /Monopolar device
by placing the active electrode above the target
tissue
 Energy is used to heat up the atmosphere
between the electrode and the tissue
 a superficial Eschar is produced. depth of
necrosis is minimal and not beyond 1 to 1.5 mm.
 Parameters for Fulguration
 Voltage 7000 V
 Waveform Frequency 400 KHz repeated
at 50 KHz
 Rated load 500 ohms
 Power 120 watts
 Spray
 Spray, similar to fulguration, the electrode is
not in contact with the tissue. But the
voltage is still higher
 large area than for fulguration is covered
 Voltage 9000 V
 Waveform Frequency 400 KHz
repeated at 30 KHz
 Rated load 500 ohms
 Power 120 watts
 Fulguration Dangers
 The arc does not always go to target tissue
 There is an inherent fire hazard
 There is no guarantee of where the current
flows or where other tissue is being affected
 The operator can easily become part of the
surgical site
 The effect can vary for a given setting
Instruments and Current Concentration

Tip Setting Watts Procedure

Needle Low 7 – 10 Plastic Surgery

Pencil Medium 30 – 40 General Surgery

Ball High 85 – 100 Ablation / GYN

2
Wave form
 The undampened waveform has low voltage

and more preferred

 Blended current used in open surgery as

hemostasis with cutting required

 Blended current is not ideal for laparoscopic

surgery as it produces tissue damage and

therefore more smoke.
Power Setting
Higher voltage means quicker tissue response
but more damage
3
Time
 (A) Time in which electrode is moved
through the tissue.
 (B) the time for which the electrode is
activated
Density of the tissue
 Real cause of pedicle type injury
Hydration of tissue.
 Edematous tissue offers less resistance to
the flow of electricity , presents a larger area
for the electrode and less power density
4
Presence of Eschar
 offers very high resistance to current
Presence of fluid in contact with the tissue
 The conductive solution dissipates the energy
so that it is ineffective at the tissue –electrode
interface
Presence of blood or blood clot
Distension media
 CO2 used is not a good conductor and may
alter the performance of electro-surgery for a
given settings.
Bi-polar ESU
Advantages of Bipolar current
 Restricted Power Levels
 Waveform Generation In Bipolar, the
waveform cuts by true Molecular resonance
and does not promote the propagation of
heating effects
 Low Output Impedance: output impedance of 0-
50ohms it is well suited to perform even in the wet
field
 Patient Electrical Exposure
 Thermal Injury:
 Ability to Operate Adjacent To Metallic Prosthesis
And Clips
 Reduced Liability
 Electro-surgery
Generators
A mono-polar ESU accepts
electrical power from a
standard electrical plug and
converts low frequency 60 Hz
current into a high frequency
600,000 to 1000,000 Hz RF
current.
Grounded Electro surgical
systems
II

 These were the first generation machines

 These units were spark-gap system with high
output and high performance
 The major hazard of a current division can
occur and finding any other lower resistance
pathway to return to the ground
 ECRI (Emergency Care Research Institute) has
clearly given the guidelines for the use
Isolated Electrosurgical Units
 This isolates the current from the ground by
referencing it within the generator circuit.
 The current produced by the generator returns
back to the generator and will ignore all grounded
objects that may touch the patient except the
return electrode.
 .With isolated generators, current division can not
occur and there is no possibility of alternate site
burns.
Two Types
A) Deactivated isolated system
B) Isolated system without Return Contact Quality
Monitoring System
Isolated system with Return Contact
Quality Monitoring System (RECQMS)
 This system uses split return pad & sends a
low voltage current of about 1 to 5 ma
through the pad cable system
 If the resistance at the pad , exceeds the safe
limit due to any reason; the machine will give
an alarm and shuts down
Tissue Response Technology
Generators
 This is a computer controlled feature of the
ESU which has a feedback circuit that
senses the target tissue density and
impedance /resistance ratio
 The voltage gets automatically adjusted in
cut mode with varying density of the tissue
to maintain same wattage
 Controlling the voltage output minimizes the
sparking and reduces the video-interference
and capacitative coupling
Tissue Dynamics: Hemostasis

Can Traditional Bipolar Technology Seal

Vessels?

Lumen apparent with naked eye Tissue shrinking and

thrombus formation
 Advanced ESUs
 The LigaSure/EnSeal uses bipolar energy to
totally occlude the lumen of a vessel, heating it
to the point where the vessel walls literally fuse
together
 works by fusing the collagen in vessel walls to
create a permanent seal, decreases the need
for traditional methods like sutures and clips
 The EnSeal/LigaSure is reported to seal and
divide vessels up to 7 mm in diameter
Tissue Dynamics: Hemostasis

Maximum vessel sealing requires optimization of:

 Compression

 Heat

 Time

No lumen apparent even Collagen Seal

with microscopic view

 Technology: Typical Laparoscopic Instrument Compression

tip

Maximum Compression at Heel

Tissue
Less at the Tip

heel
tip
Technology: I-Blade Compression

 Based on the same functional

principle as surgical staplers
 Incorporates parallel closure
 Compression is consistent through
the length of the jaw

I- BLADE TECHNOLOGY VIDEO

Technology: Electrode Design

Traditional

Electrode

Configuration

Offset Electrode Configuration

CLICK FOR ANIMATION

Technology: Controlling Temperature

POSITIVE TEMPERATURE COEFFICIENT (PTC)

Ligasure/EnSeal
 Plasma kinetic generator
 MIPTEC stands for "Microwave Induced
Plasma for Thermoelectric Conversion
 This MASER-beam is focused into a chamber
containing a prepared polarized (magnetically
charged) mass, until it achieves a plasma state
 Plasma is matter in a hyper energized form,
described as part liquid and part gas
 This mass achieves Plasma within a container
which is a large thermos and therefore retains
heat for an extended period of time.
 Argon ESU

Argon gas is a inert gas

which has the ability to get
easily ionized by electricity
and enhance the passage
of it but at the same time
being non combustible
Since the quality of arcing
during spray coagulation
depend upon the voltage
and the environment
through which it passes,
the replacement of the air
environment by Argon gas
enhances the coagulation.
 Power Efficiency Rating (PER)
 No two manufacturers make same type or
similar machines
 PER is the measure of ability of machine to
accurately perform
 Useful output /Energy Input = efficiency rating
x 100 =PER
 The perfect PER is 100 meaning that the
selected power is delivered 100 % of time
Patient return electrodes
 Patient return electrodes
 The rise in temperature of return electrode should
not be more than 317.3 millicelsius when a 360
joule current passes through it.

Mainly two types of dispersive electrodes

 Conductive dispersive :It has ohmic or
resistive contact with the subject
 Capacitive dispersive electrode :There is a
metal plate covered by dielectric insulating
film becoming the subject and it has no
ohmic contact with the subject
 Dispersive Electrode
Monitors
 1 Patient Sentry. Here the electrode is
connected to ESU by two conductors A and
B .When there is continuity of both the
conductors then only delivery of current is
possible through ESU
 2 Current Comparator Compares the
current between active & dispersive electrode
 3 Patient return Monitor uses a split
dispersive electrode to monitor impedance
between two electrodes
Return Electrodes
 Reuse of Dispersive Return
Electrodes

Two types :The reusable and the disposable

Serious hazards for Reusable (M of H France)
 Improper connection with return wire to ESU

: current to find an alternative path

 Bending of the metal plate may not allow

proper contact with the body :improper,

inadequate and uneven application with the
skin causing an increase in the impedance
with great risk of burns.
 Use of water soaked cloth on
return electrode
Metallic dispersive electrode is wrapped in a
wet cloth to increase the electrical conductivity
of the return plate.
BUT
Resistance
Of normal skin 25,000 ohms
Of wet skin 1500 0hms
Of calloused skin 2,000,000 ohms
YET
 YET
 Conductivity of Pure water Zero
 Conductivity of cotton cloth Zero(*)
 Saline 0.1 w/v % 2.0 m S/cm
 Saline 0.7 w/v % 12.6 m S/cm
 Saline 2.0 w/v % 33.0 m S/cm

 Conductivity of the return current from patient to

the dispersive plate is through water which again
can not take place unless it is highly ionized or
saturated with NaCl to make it conductive
Dispersive or passive pads
site location
 Active electrodes
 The response of the tissue to current depends upon
the current density. The current density is dependent
upon the area of contact between the tissue and the
electrode
 Insulation of Electrode
 Insulation to be tested by 1.5 times the
output voltage at specified frequency of ESU
-ANSI and AAMI

If the typical ESU has the voltage of 4000 V

peak to peak at the frequency of 500 KHz,
the insulation should be tested for integrity
at 6000 V (1.5 times) at 500 KHz.
 ESU, Hole in Surgical Glove
and shock
1 DC Conduction :due to bad quality of glove or
thickness of glove , a hydrated glove ,
‘Ballooned’
2 RF Capacitive Coupling: sweaty skin of the
surgeon , separated by an insulating material
like glove
3 High Voltage Dielectric Breakdown: high
voltages as in fulguration , the glove barrier
can not withstand the effect of high energy
force
 Electro surgery safety concerns
during laparoscopic surgery
The overall incidence of recognized injuries is
between two patients per 1,000 operations
Direct couplings
when the active electrode touches the other
electrode or when the active electrode is near
other instrument and the ESU accidentally
activated

when the ports are placed too close together or the two
instruments are almost parallel to each other than at an
angle..
 Insulation failure
Use of very high voltage current used in ‘Coag’
mode can get sparked through the
compromised insulation material
 Integrity of Insulation
 Insulation Failure is a Reality
 To be tested with higher voltage source
rated at 3kV rms+/- 10% at 50Hz or 4.2kV
DC.
 Division of Active Electrode
 Zone 1 is the area at the tip of the active
electrode in view on the monitor. The
insulation failure is due to damage during
insertion through the metal cannula .
 Zone 2 is area extending from the point of the
instruments just going out of the view to the
rim of the cannula
 Zone 3 is the area of active electrode covered
by the cannula or reducer
 Zone 4 its handle and cannula that is outside
the patient’s body.
 For a safe electro-surgery, the aim and
assurance should be to deliver the energy in
and through Zone 1 only

Zone 1 Zone 3

Zone 2 Zone 4
 Capacitive Coupling

Capacitance is
transferring electrical
energy through intact
insulation to nearby
conductive instruments
like trocar sleeves,
laparoscope, suction
irrigation probes or even
grasping forceps
Longer and shorter
cannula, more voltage
>capacitance
All Metal Cannula, All
Plastic Cannula, Hybrid
Cannula
2
Plastic cannula system
 also does not eliminate the
capacitance

Hybrid cannula system

 worst case
 the current produced in
the cannula now can not
be bled off through the
abdominal wall
 capacitively created
current continues to build
up in cannula especially at
the point of exit i.e. tip
Active electrode monitoring or
Electro shield monitoring system
Electromagnetic Propagation
1 Radiated electromagnetic waves
 Disturbances seen on monitor while using ESU. It

transmits RF waves at a lower power which are

perceived by Monitor receiver and reacts to it by
horizontal lines or disturbances
 At this frequency, twitches of the muscles can also

be seen
2 Conducted electromagnetic interference
 Occurs as a result of a physical connection (direct or

indirect) between the adjacent devices.

 E.g. disturbances of ECG tracing while using ESU.
Ultrasonic
Technology: Mechanical Wave Energy
Energy is transported through a
medium(solid, liquid or gas)
by the propagation of waves.
Infrasonic Audible Range of Ultrasonic
Human Hearing

< 20 Hz 20 - 20,000 Hz > 20,000 Hz

100

Diagnostic Imaging
10 Hz 261 Hz 55,500 Hz
(Earthquake) (Violin) (HARMONIC®)
Lithotripsy

Doppler (flow characterization)

Technology: Ultrasonic Hand Piece

The HARMONIC® System

Electrical energy from the generator is
converted
to mechanical motion in the hand piece.
Transducer Blade

Piezoelectric ceramics Mount Mechanical Wave

Tissue Dynamics: Coagulation Process

Coagulation H+ bonds are Denatured protein Internal tissue Simultaneous cutting and
with ultrasound requires broken; protein in the cells is forms a sticky heat generated coagulation
compression of denatured. coagulum. from friction; then seals or welds takes place at a
blood vessel. vessel walls. lower temperature

than Electrosurgery,

with minimal lateral

thermal spread.
Human Factors: Actions of Ultrasound on Tissue

All Surfaces of the Ultrasonic Blade are Active.

Cutting Coagulation Cavitation

BACK SCORING/DRILLING VIDEO CAVITATION VIDEO

Ultrasonic Instrument Temperature Profile

4-6 seconds
Tissue Dynamics:
Arterial Burst Pressure

Seal Strength, Side-by-Side Comparison

Tissue Dynamics:
Blade Temperature vs. Thermal Spread

Gregory W. Hruby, Franzo Marruffo, Evren Durak, et al., Evaluation of Surgical Devices for Vessel Sealing and Peripheral Energy in a Porcine Model: HARMONIC ACE®, HARMONIC® LCS-CS, LigaSure™ V, and Trisector. Presented at the Abstract at AUA

conference 2007
 Electrosurgical Burns
 Endogenous Burns: Results from the use of an
active electrode with a high current density in
order to cut or desiccate a tissue
 Exogenous Burns :heat of burning substances
like detergents and disinfectants ,alcohol or
the anesthetics gases side, light source, active
ESU with electrode outside
 Pseudo Burns : Friction burns or pressure
necrosis –corona burns of port-edges
 Checklist and
Troubleshooting
Pre-operative
1 Understanding the functioning of ESU.
2 Understanding different dials and the mystical
numbers in a digital display or analog one They
NOT necessarily represent total power delivered
3 Identify & understand the switches for ‘cut,’ ‘coag’
Blend Bipolar, Spray
4 Checking ESU by touching soap means particular
function is working and NOT the power setting
5 Check the dispersive electrode and place accordingly
2
6 A rubberized plate is better than a steel
plate. No wet cloths to cover the plate
7 Avoid contact to any part of the metal like
operation table, IV stand etc.
8 Do not put the drapes between the plate and
patient
9 No towel clips to fix active electrode cable
Intra-operative
1 Allow alcohol/spirit to dry before draping
2 Use the lowest possible power settings to
achieve the desired surgical effect.
3
3 Do not trip over cord
4 If patient is repositioned, check for patient
return electrode
5 When active electrode NOT in use, do not
place on patient but in insulated holster
6 Don’t coil active or return electrode cable to
prevent current leakage
7 If possible, avoid “buzzing” hemostats in a
way that creates metal to metal arcing
8 Keep active electrodes clean. Eschar buildup
will increase resistance, reduce performance
9 cover foot paddle with plastic bag
410 If ESU alarm is present, check the entire
system
11 Do not use the generator top as a storage
space for fluids, bottles
Post Operative
1 Turn off ESU with all dials to zero
2 Inspect patient return electrode for damage
3 Inspect site of return electrode for burns
4 Discard disposable electrodes
5 Clean the ESU, foot pedal, power cord, reusable
accessories
6 Store ESU, electrode cords in safe place
Electro-surgery
Thank You