ENERGY DEVICES IN

SURGERY
SURG LT CDR K S PATEL
Scope
• Types of Energy Devices
• Basics of electricity
• Basics of energy devices
• Application/uses
• Do’s and Don’ts while using them
Energy Devices
Energy devices in surgery
• Electrical / Radiofrequency
Monopolar
Bipolar
• Ultrasonic
Harmonic scalpel
Thunderbeat
•Vessel sealing technology
•Cryosurgery
• Laser
History
• Use of electrocautery (fire-drill) is described in ancient medicine
3000 BC

• In 1881, Morton: electric current in 100,000 Hz does not produce

shock

• 1926-Cushing and Bovie made first electrosurgical generator

Basics of electricity
• Current-Flow of electrons during a period of time
• Circuit- pathway for uninterrupted flow of current
• Voltage-Force pushing current to a particular direction
• Resistance/Impedance
Temperature Vs Tissue Effect
45 degree C: collagen uncoils & may reanneal
60 degree C: irreversible protein denaturation
coagulation necrosis begins
80 degree C: carbonization begin
drying and shrinkage of tissues
90-100 degree C: complete cellular destruction by vapourization
gas and smoke production
Electrosurgery Vs Electrocautery
The terms electrocautery and electrosurgery are frequently used
interchangeably; however, these terms define two distinctly different
modalities.
• Electrocautery: use of electricity to heat an object that is then used to
burn a specific site e.g. a hot wire
• Electrosurgery: the electrical current heats the tissue. The current
must pass through the tissue to produce the desired effect.
Electrosurgical devices
• Monopolar
• Bipolar
MONOPOLAR
Monopolar
• Most commonly used electrosurgical modality.
• The active electrode is in the wound.
• Patient return electrode is attached somewhere else on the patient.
• 4 components: generator, active electrode, patient, patient return
electrode
• Produce variety of tissue effects depending on waveform
Tissue Effect
• Cutting
• Blending
• Fulguration
• Coagulation
• Desiccation
Waveform And Effect
Types Electrosurgical Generators
two types of electrosurgical generators:
• Ground referenced generators
(typically older, outdated units)
• Isolated generators
(today’s state-of-art technology)
Grounded Electrosurgical
Grounded Electrosurgical
• Circuit is completed by grounded element/ earthing
• May use alternate pathway
• Causes thermal effect/burn
Isolated Electrosurgical
Isolated Electrosurgical
• In 1968,isolated generator technology revolutionized electrosurgery

• Circuit is completed by the generator, not by ground

• Current does not recognize grounded objects as pathways to complete the

circuit

• Patient return electrode is recognized as preferred pathway

• Hazards of current division and alternate site burn are eliminated.

Complications
• Return electrode site burn

• A return electrode burn occurs

when the heat produced, over
time, is not safely dissipated by
the size or conductivity of the
patient return electrode
Do’s and Don'ts
• Proper/ full contact between body and return pad
• Conductive gel may be used
• Placed on the same side of surgery and near to it
• If metallic prosthesis-opposite side of body and near
• If prosthesis on both sides-than in between
• With vascular and muscle mass
• Avoid over bony prominences
• Common position-thigh, abdomen ,back
Patient return electrode monitoring
technology
• -protects patient from pad site
burn
• -monitor impedance at the
patient/pad interface
• -system deactivate if
impedance is high
• -such electrode can be
identified by its split
appearance i.e. two separate
areas and a special plug with
center pin
 Direct Coupling
- When the active electrode touches
another metal instrument.

-The electrical current flows from one to

the other and then proceeds to tissue
resulting in unintended burn.

- Do not activate the generator while

the active electrode is touching a metal
object or not in vision.
Capacitative coupling
• During MIS procedure, an inadvertent
capacitor may be created by the surgical
instruments

• An electrostatic field created b/w two

conductors, resulting induced current in
second conductor

• Hybrid cannula are worst , metal part will

create a capacitor but plastic anchor will
prevent the current from dissipating
through abd wall.This current may exit to
some adjacent tissue, result in significant
injury

• Use the lowest power setting

Insulation Failure
• Insulation covering of an endoscopic
instrument has been damaged

• Cracks or breaks in the shaft’s insulation allow

the electrical energy to escape and burn
unintended tissue.

• The insulation of endoscopic instruments must

be inspected before, during and after each use

• Most damage to insulation occurs during

instrument processing, specifically during
sterilization. Heat with subsequent cooling
causes insulation to shrink and then expand.
During this process cracks and breaks can
occur
Applied aspects
• Inspect insulation carefully
• Use lowest possible power settings
• Use a low voltage waveform(cut)
• Use brief intermittent activation vs prolonged activation
• Do not activate in open circuit
• Do not activate in close proximity or direct contact with other
instrument
• Use bipolar electrosurgery when appropriate
• Do not use hybrid canula. Select an all metal canula system as the
safest choice.
• Active electrode monitoring system: to avoid problems of insulation
failure and capacitive coupling
ULTRASONIC DEVICES
• Ultrasonic vibrations instead of
electrical current
• Instrument blade vibrate at 55500 hz
along the long axis
• Ultrasonic probe employ both
compression and friction to deliver
mechanical energy to target tissue
• Ultrasonic probe contain piezoelectric
component, that converts electric
energy into mechanical energy/heat
• Amino acids unwind and reshape and
hydrogen bonds break resulting in
protein denaturation and coagulum
formation
Advantages
• Dual action-coagulation and cut
• Low heat generation
• No lateral tissue damage
• Better visual field-no smoke
• No current through patient
• Less tissue damage-less post op pain
• Precise dissection
Disadvantage- Longer time for effect
THUNDERBEAT
• THUNDERBEAT is integration of
both bipolar and ultrasonic
energies delivered simultaneously
from a single versatile instrument.

• benefits of each individual energy;

the ability to rapidly cut tissue with
ultrasonic energy; and the ability to
create reliable vessel seals with
bipolar energy.
•
CUSA( Cavitron ultrasonic surgical aspiration)
• Cavitation- Formation of Vapour by
pressure reduction intead of heat.
• Utilizing a hollow titanium tip that
vibrates along its longitudinal axis,
fragmentation of susceptible tissue
occurs while concurrently lavaging
and aspirating material from the
surgical site.
• The CUSA selectively ablates
tissues with high water content
such as liver parenchyma,
glandular, and neoplastic tissue.
VESSEL SEALING TECHNOLOGY
• Combination of pressure and
energy to create a seal.
• Feedback controlled output so
reliable seal in minimal time
• Seal strength comparable to
sutures/clips, can withstand >3
times normal SBP
• -ligasure: 0 - 4.5 mm
• -enseal : 1 mm
LigaSure
• Applies optimal pressure to
vessel
• Measure initial resistance of
tissue and chooses appropriate
energy settings
• Delivers pulsed energy with
continuous feedback control
• Senses that tissue response is
complete and stops the cycle.
Cryosurgery
• Uses extreme cold is used to
destroy diseased tissue
• Formation of ice crystels having
lower density
• Impair blood circulation
• Cryopobe is placed via USG/MRI
guided
• Liquid nitrogen/Argon gas
• Damaged tissue-naturally
absorbed/scab formation