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ELECTROSURGERY The use of heated metal to treat wounds and control bleeding was the origin of the thermal “cautery”. Electrically generated heat , “electrocautery” was first introduced by Claude Paquelin in 1875. Walter de Keating –Hart coined the term “fulgarisation” Doyen introduced the term “electrocoagulation” W Clarke defined the term electrodessication William Bovie is considered the father of modern electrosurgical unit. He developed it in 1926.
The term “electrosurgery” is a general term to describe all the different procedures employing electrically generated heat. The heat may be generated using either galvanic heat or A.C. THE BASIC PHYSICS OF ELECTROSURGERY IS TO BOOST THE VOLTAGE AND FREQUENCY WHILE DECREASING THE AMPERAGE OF ALTERNATING CURRENT FROM THE STANDARD WALL OUTLET. An occilating electromagnetic wave is generated, which is either a damped or undamped sine wave. This is passed onto the lesion producing molecular movements, leading to friction and heat production. Heat is also generated through the electric field of the tissue itself and the sum total provides the desired tissue destruction . THE TYPE OF SINE WAVE GENERATED DETERMINES THE TYPE OF TISSUE DESTRUCTION . METHODS OF TISSUE DESTRUCTION : Tissue destruction by electrosurgery is achieved by the effect of heat. The heat is the result of 3 factors ---1. OHMIC HEAT : This heat is produced by the tissue resistance to current flow. The relationship is directly proportional to the intensity of current.
CONVECTIVE HEAT : this results from the dissipation of electrical and thermal energy from the spark. The greater the voltage , the greater the spark and more its thermal energy . MECHANICAL ENERGY : Electromagnetic waves produced at the tip of the electrode result in oscillations and a force that disrupts cells and releases thermal energy.
These 3 modes of energy production result in tissue destruction by ------ Enzyme deactivation RNA & DNA destruction Cell wall damage Protein coagulation
Steaming of water content (cell explosion). These reactions occur together as the temperature ranges from 100 degree C ( steaming and dehydration) upto 600 degree C ( protein coagulation). The depth of tissue destruction depends on------ The temperature achieved The speed of temperature rise Type of electrosurgery ( fulgarisation/coagulation/ dessication). Histologically 3 zones are seen -------1. zone of eschar --- superficial zone of charred dehydrated tissue immediately around the electrode tip or spark contact. 2. zone of coagulation --- zone of precipitation is seen in electrocoagulation. This does not occur in fulgarisation or desiccation as charred tissue prevents further depth of damage. This zone determines extent of scarring 3. zone of erythema or inflammation ------ present immediately surrounding the destroyed tissue.
ELECTROSURGICAL APPARATUS ------It is a box with the following components 1. on and off switch with indicator light 2. “monopolar” sockets ---- 2 in number. One each for high and low current intensity. 3. “bipolar” sockets --- 2 in number. One socket for treatment electrode and the other attachment for ground plate. 4. foot/hand switch.
Dispersive or ground plate ---- used only in electrocoagulation/ electrosection procedures involving higher current intensity outputs. “Dispersive” is a better term since it defines the real purpose of the flat broad metal or silicon plate usually placed in contact with a large area of the skin eg. back, thigh. This plate provides a medium for completing the circuit and dispersing the current flowing through the body --- to prevent pooling of excess current inside the body and thereby avoid electrical effects such as pain, tetany and shock. This also increases the efficacy of the apparatus by “recycling” the power. A plate of 20 sq.cm usually suffices. treating needles.
INDICATIONS : BENIGN: Warts, acrochordons, molluscum contagiosum, milia, DPN, Small epidermal nevi, seborrheic keratoses, freckles, senile lentigens, mucosal and sebaceous cyst, vascular lesions ( telangiectasias, spider angioma, cherry angioma, small hemangioma, venous lakes, angiofibromas, pyogenic granloma), syringomas, trichoepithelioma, xanthelesma, xanthoma, rhinophyma, nevus sebaceous. PREMALIGNANT: Actinic keratoses, Bowen’s disease. MALIGNANT : small BCC, SCC. CONTRAINDICATIONS : ABSOLUTE : KELOIDAL TENDENCY, INFECTIONS OVER THE LESION, CARDIAC PATIENTS ESPECIALLY WITH PACE MAKERS. RELATIVE : Petit mal epilepsy, Hepatitis B, HIV infection. TYPES OF ELECTROSURGERY : 4 BASIC TYPES: 1. ELECTROFULGARISATION: Here superficial tissue is charred by sparks without actually touching the tissue. Long thick sparks are created by DAMPED SINE WAVES OF LOW AMPERAGE ( 1-2 on the dial) AND HIGH VOLTAGE. The electrode is kept at a small distance ( 2-3 mm) from the lesion and the current is given for a short burst of 2-3 sec at each site. The tissue destruction is rapid with cell dehydration and necrosis. Verruca plana, milia and DPN are treated in this way. Advantages ---- prevents deeper tissue
destruction. Disadvantage ---- there is risk of damage to the perilesional area. This is countered by the use of epilation needle electrodes. It is not effective for dermal lesions. ELECTRODESICCATION : here the lesion is touched with the electrode. The bursts of current are of longer duration( 2-4 sec) and the current intensity is slightly increased to create short fine sparks . THE END POINT IS WHERE THE LESION SHRIVELS UP AND LIGHTENS IN COLOR. The tissue destruction is deeper and involves superficial mummification and necrosis of cells after initial dehydration. Thrombosis of minute blood vessels also occur. Larger lesions tend to bubble when there is separation of the DEJ. The lesion is then removed with a gauze piece, curetted or cut at the base with a pair of scissors. The lesions usually treated by this method are ---- seborrheic keratoses, pyogenic granuloma, verruca vulgaris, condyloma acuminate, keratoacanthomas, acrochordons, molluscum contagiosum, xanthomas, xanthelesma, sebaceous hyperplasia, spider angioma. Advantages : minimal scarring an defective hemostasis. Disadvantage : the depth cannot be well controlled ---- recurrence is possible.
ELECTROCOAGULATION: Deeper tissue destruction occurs by this process. The lesion may or may not be touched depending on the depth of destruction required. Here short thick sparks are created due to DAMPED OR PARTIALLY RECTIFIED SINE WAVES OF HIGH AMPERAGE BUT LOW VOLTAGE. Due to high current, the dispersive plate is needed. The tissue destruction involves deep necrosis and coagulation with a hyalinized appearance. Thrombosis of midsized vessels ( 1-2 mm) also occurs. THE RESULTANT TISSUE APPEARS WHITE AND HOMAGENIZED WITHOUT CHARRING The primary use is to destroy recurrent verruca vulgaris, trichoepitheliomas, telangiectasias, small BCC and SCC, nail matrix coagulation in ingrown toe nails.
ELECTROSECTION : This technique cuts the tissue. It requires solid state current with dispersive plate. A high amperage, low voltage current is used to create RECTIFIED SINE WAVE. There is simultaneous hemostasis due to vessel coagulation. There is grater tissue destruction with delayed healing due to poor vascularity. PRECAUTIONS: INFLAMMABLE STERILIZATION PRODUCTS LIKE SPIRIT AND ALCOHOL MAY BURN ON PASSAGE OF THE SPARK ---SHOULD BE AVOIDED. ADEQUATE EXHAUST FACILITIES ARE NEEDED TO EVACUATE SMOKE FUMES FACE MASK GLOVES CHECK ALL CONNECTIONS AND WIRES TO ELIMINATE LOOSE CONNECTIONS THAT MAY CAUSE SHORT CIRCUITS, ELECTRIC SHOCKS AND FIRE HAZARDS. POSTOPERATIVE CARE: antibiotic creams. For bigger lesions --- dressing that is changed at 24 hours and then again after 5-7 days. COMPLICATIONS: Pain, bleeding, secondary infection, sacrring, post inflammatory hypo- or hyper- pigmentation, hypertrophic scar or keloid. CRYOSURGERY DEFINITION : It is a branch of therapeutics that makes use of local freezing for the controlled destruction or removal of living tissues. JAMES ARNOTT is the FATHER OF MODERN CRYOSURGERY. CRYOGEN: It is a substance used for cryosurgery. LIQIUD NITROGEN IS THE COLDEST REFRINGENT AND IS THE CRYOGEN OF CHOICE FOR DERMATOLOGICAL CRYOSURGERY IT IS THE ONLY CRYOGEN ADVOCATED FOR MALIGNANT SKIN LESIONS. . SALT ICE = -20 DEGREE C CARBON DIOXIDE SLUSH = -20 DEGREE C FLUOROCARBONS = -30 DEGREE C NITROUS OXIDE = -75 DEGREE C CARBON DIOXIDE SNOW = -79 DEGREE C LIQUID NITROGEN = -20 DEGREE C ( swab); -196 DEGREE C ( spray) MOA: The various mechanisms responsible for cellular injury are :
ICE FORMATION --- extracellular ice destroys damages the cell membrane while intracellular ice damages the mitochondria and endoplasmic reticulum. Faster cooling and Slow thawing is more destructive than slow cooling and rapid thawing. OSMOLARITY CHANGES ---- extracellular ice formation is associated with decrease in extracellular water and a resulting increase in solute concentrations. This brings about cell membrane disruption. VASCULAR CHANGES ---- there is ischaemic necrosis which starts around the vessels as a result of microthrombi within the capillaries and arterioles. THERMAL SHOCK DENATURATION OF LIPOPROTEIN COMPLEXES LOW TEMPERATURE CAN INDUCE EFFECTIVE IMMUNE RECOGNITION OF THE REMAINING VIRAL AND TUMOR CELLS.
DIFFERENTIAL SENSITIVITY OF CELLS : There is a minimum temperature below which cells die. In the skin, this is generally around -30 to -40 degree C. cells and tissue sensitivity to sub zero temperature are as follows : 1. melanocytes = -4 to -8 degree C 2. squamous cells = -20 degree C 3. dermal CT and fibroblasts = -30 to -40 degree C SHAPE OF CRYOLESION: The shape of the cryolesion is hemispherical as the ice front advances from the surface downwards.The depth of freeze approximates the radius of the flat surface of the frozen hemisphere. EQUIPMENT FOR CRYOSURGERY : These vary depending on the cryogen used. The equipment of the liquid nitrogen cryo is given ----
Cryocans --- where the LN is stored. Capacities vary from 1-60L. these are vacuum insulated containers.
(b) Withdrawal devices --- these are used to transfer the LN to the cryosurgical unit.
(c) (1) (2)
Cryosurgical unit --- these are of the following types hand held unit --- these units can only be used for the spray technique. The tank is of 500 ml. there is an instant on/off switch. They have screw on brass tips of 3 diameters --- 0.375mm, 0.5mm and 1 mm resp.
Table top unit --- this is a compact unit with a built in pyrometer that moniters the temp of the tissue being frozen which is a necessity while treating malignant tumours. The unit has both spray as well as probe facilities. A variety of TIPS ( cones, probes) can be attached. There are 2 storage cans of 1 litre capacity. The advantages of this unit over the hand held unit are --- the spray steam continuea unabated for a longer time. Therefore it can be used for prolonged continous or intermittent treatment. It allows for regulation of the volume of the nitrogen spray Excellent for the treatment of malignant lesions Can be used to treat intraoral/ vaginal/ anal/ rectal lesion as long as probes are available. The disadvantages include --- Costly Large quantity of LN is needed at each sitting.
(d) Accessories ---
Cryoprobes ( open end or closed end). Closed end devices are used when pressure is desired during freezing and when working near a vital area. Protective devices --- used to cover vital areas like eyes. Temperature monitering devices.
BENIGN LESIONS ------- warts, molluscum, cystic acne, acne scars, keloid, pyogenic granuloma, acrochordons, seborrheic keratoses, mucoid cyst PREMALIGNANT ------ Leukoplakia, Bowen’s disease, erythroplasia of queyrat, actinic keratoses. MALIGNANT LESIONS ---- BCC, SCC, basal cell nevus syndrome, lentigo maligna, lentigo maligna melanoma. Tumors less suitable for cryosurgery are those that are large ( over 2 cm in diameter), recurrent tumors of the feet or lower legs or those with a histopathological diagnosis of morphemic or mixed type of BCC. CONTRAINDICATION : Agammaglobulinemia Cold intolerance Cold urticaria Cryoglobulinemia Cryofibrinogenemia Raynaud’s disease
Pyoderma gangrenosum Collagen vascular and autoimmune diseases Concurrent treatment with immunosuppressives. Patients with renal dialysis Multiple myeloma
PRE-PROCEDURE STEPS : Photographs A biopsy to confirm the diagnosis in case of malignant and premalignant conditions Explanation of the procedure to the patient and obtaining a written informed consent. Analgesics may be given 1-2 hours before the procedure. PROCEDURE : There are 4 methods of application ---
Dipstick technique ---A cotton tipped applicator is dipped in liquid nitrogen and applied firmly to the lesions until a narrow halo of white ice forms around the bud. This is the simplest method and is suitable for treating benign lesions only. Spray technique--this is the most popular method. The spray technique using spray tip are of the following types --
spot freeze: this is a satisfactory method for fields upto 2 cm diameter. The maximum depth of adequate ice formation in the centre of the lesion is 0.5-0.6cm and the temp. attained is 40-60 degree C. paint spray method: the spraying is started at a lateral point of the lesion and carried back and forth over the entire extent of the lesion either horizontally or vertically. Useful for larger lesions. spiral spray method: the spray is started in the centre and carried in an ever widening spiral. Useful for larger lesions rotatory spray method: the spray is directed in multiple, concentric circles of increasing diameter till the whole lesion is frozen.
There is also a spray technique using cones or cylinders ---- it is known as restricted spray technique. The advantage is that the spray is concentrated and its lateral spread is restricted. The technique also gives a very rapid rate of fall of temperature and is therefore more destructive. This technique is useful in sites such as eyelids, inner canthi where lateral spread is to be restricted.
Liquid nitrogen is poured from the storage container to the spray unit slowly, using a funnel, until the unit is filled upto 2 inches from the brim. After the lid is screwed back, one should wait for 3-4 min for the pressure to build up. The appropriate spray tip is selected( the one that sparay swithin the borders of the lesion). For single short freeze, no LA is needed but if the lesion is large and requires more freeze time then local anaesthesia is needed. The periphery of the lesion is marked and a rim of normal tissue is included (benign, 1-2mm; premalignant, 3-5mm; malignant, 5-10mm) is included. K-Y jelly is applied to the lesion. The spray tip is held 1 cm away and a steady spray of liquid nitrogen is directed at the centre of the marked lesion. The ice field gradually extends upto the edge of the circle, the freeze time commences once solid ice is formed over the marked area. The spray is adjusted so as to maintain an ice ball of constant ice and for the required period ( 5-30 sec; normally not more than 30 sec). the lesion is allowed to thaw gradually. Thaw time is usually double of the freeze time. If a second freeze is required, the lesion should be allowed to thaw completely before re-freezing. The skin should be palpated to check for the disappearance of the firmness (ice) from the tissue.
cryoprobe technique---cryo probes vary in size from 1 cm to several cm in diameter. A probe suitable to the lesion to be treated is selected and is pre cooled before application to the surface of the lesion. Its probe tip is applied firmly to the lesion and cooling is commenced. The probe is allowed to thaw sufficiently before removing it from the treatment site. A repeat cycle, if required, should be commenced after allowing the lesion to thaw completely. MACROSCOPIC CHANGES AFTER CRYOSURGERY : During and immediately after a 30-40 seconds freeze, the skin shows a white ice field. Within a few minutes, a violet color appears in the periphery and moves centrally. Both in the skin and deeper, it is clearly demarcated from the surrounding healthy skin. Before long, the deeper tissue become pale while a hemorrhagic blister forms on the surface. This forms into a eschar which lasts for a few weeks. The frozen area contracts after 10-14 days. FOLLOW UP : The patient is asked to follow up after 10-15 days to assess the lesion or earlier if a large blister or secondary infection develop. THE PROCEDURE CAN BE REPEATED AFTER 3 WEEKS IF REQUIRED. FREEZE TIME FOR COMMON CONDITIONS ARE AS FOLLOWS---plane or filiform warts = 5 sec molluscum contagiosum = 5-10 sec acne cyst or scar = 5-10 sec skin tag = 5-10 sec seborrheoc keratoses = 10-15 sec common wart = 10-15 sec solar keratoses = 5-15 sec keloid = 20-30 sec prurigo nodularis = 20-30 sec bowen’s disease = 20-30 sec leukoplakia = 25-30 sec malignant lesions = for adequate depth of cryonecrosis of most tumors, one should perform at least two 30 sec freeze- thaw cycles with a 5 minute thaw period between each freeze.
SOME CONSIDERATIONS REGARDING CRYOTHEARPY : A Open Spray causes more rapid drop in temperature an freezes to a greater depth than a closed spray. The lateral spread of ice from the edge of the probe or the cone is approximately equal to the depth of the freeze. Individuals vary in their tolerability to cryosurgery, one should freeze cautiously at the first visit. Beign lesions should be undertreated while malignant lesions shoud be overtreated. Hyperkeratotic lesions should be debulked by paring or curettage prior to cryosurgery.
COMPLICATIONS : IMMEDIATE ---- pain, headache, edema ( at sites of lax skin), hemorrhage, blister formation and syncope. DELAYED ---- hemorrhage, post operative infection, granulation tissue formation, pseudoepitheliomatous hyperplasia, hyperpigmentation, milia, hypertrophic scar, atrophy, hair loss, nerve damage/ paresthesia ( usually temporary). ADVANTAGES : Patients of all ages can be treated even those at poor risk for surgery and GA. It is a OPD procedure Multiple tumors can be treated at the same time. Complications are rare and the cosmetic results are excellent. Cure rate is high in properly selected cases. Lesions on sites with poor skin mobility that are difficult to excise can be frozen with impunity Pre-irradiated lesions can also be treated by cryo. DISADVANTAGES : DISCOMFORT during the procedure Post operative edema can be significant post operative pigmentary changes can occur.
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