Biophysics

Summary
Prospectors
• The student should be able to develop a comprehensive knowledge
on:
• Principles of
• Electrocardiography
• Cardiotocography
• Ultrasound
• Doppler
• X-rays and MRI;
• Principles of laser, electro surgery and cryotherapy;
• Principles of radiotherapy
• Principles of assessment of bladder function.
Electrosurgery
• cutting and coagulation of tissue using high-frequency electrical
current
• Electrosurgical units (ESU) use much higher frequencies, 500,000 to
3,000,000 Hz to minimize nerve and muscle stimulation
• The possible effects of applying current to tissue are
• coagulation
• cutting
• Fulguration
In coagulation
• a heating effect leads to cell death by dehydration and protein denaturation.
• Current is interrupted (or modulated), high-voltage, dispersed over a large
surface area (low current density).
• Bleeding is stopped by stimulating the clotting mechanism through a combination
mechanism
• distortion of the walls of the blood vessel
• coagulation of the plasma proteins
• dried and shrunken dead tissue.
• In an ideal situation, intracellular temperatures should not reach boiling
during coagulation, because if it does an unwanted cutting effect
may be experienced.
In Cutting
• occurs when sufficient heat is applied to the tissue to cause cell water
to explode into steam (vaporization).
• The cut current is a continuous wave form (or unmodulated), low-
voltage current, concentrating the energy on a small area (high
current density)
• Monopolar diathermy is most effective when the active electrode is
held a very short distance from the tissues.
• This allows an electrical discharge to arc across the gap creating a
series of sparks which produce the high temperatures needed for
cutting
In fulguration
• the diathermy matching is set to coagulation and a higher effective voltage
is used to make larger sparks jump an air gap thus fulgurating the tissues.
• This can continue until carbonization or charring occurs. The voltage and
power output can be varied by adjusting the duration of bursts of current,
as well as its intensity to give a combination of both cutting and
coagulation.
• This is known as blended current and provides both forms of diathermy
activity
• is a particularly useful technique to control diffuse bleeding from raw
surfaces of solid vascular organs, such as the liver bed, following
cholecystectomy.
COMPLICATIONS
1. Electrocution - Very low risk with modern equipment.
2. Explosion - Rare can occur with pooling of alcohol based skin
preparations or with colonic gases/manitol.
3. Burns -most common problem. far more common in monopolar than
bipolar diathermy
• These may occur as a result of:
• Faulty application of the indifferent electrode with inadequate contact area.
• The patient being earthed by touching any metal object, e.g. the Mayo table, the bar of an
anesthetic screen, an exposed metal arm rest or a leg touching the metal stirrups used in
maintaining the lithotomy position.
• Faulty insulation of the diathermy leads, either due to cracked insulation or instruments such
as towel clips pinching the cable.
• Inadvertent activity such as the accidental activation of the foot pedal, or accidental contact
of the active electrode with other metal instruments, such as retractors, instruments or towel
clips
4. Channelling
• if current passes up a narrow channel or pedicle to the active
electrode, enough heat may be generated within this channel
or pedicle to coagulate the tissues. For example,
• coagulation of the penis in a child undergoing circumcision;
• coagulation of the spermatic cord when the electrode is applied to the testis.
5. Pacemakers and Implantable Cardioverter Device

• can interfere with the working of a pacemaker potential danger to the patient’s health.
• Modern pacemakers are designed to be inhibited by high frequency interference.
• Precausions:
• Use low power setting
• Avoid keeping return plate near to pacemaker.  to avvoin current passing through it.
• to have a magnet available so that these can be reset if necessary.
• to use bipolar diathermy wherever possible.
• For ICD
• Caardiology opinion beforehand
• Off ICD
• Monitoring of the heart rate throughout the operation
• Defibrillator should always be available in case a dysrhythmia develops at any time
Additional Comlications In Laparoscopic surgery
1. Direct coupling
• results from inadvertent contact of two non-insulated instruments (such as a metal trocar
and a metal grasper).
• Electrical current flows from the primary to the secondary instrument, which acts as a second
conductor.
• This can lead to severe injury if the second conductor is in contact with bowel or other
sensitive structures .
• In laparoscopic cholecystectomy, monopolar electrosurgical energy is associated with
delayed, remote common bile duct injuries due to direct coupling.
 In Laparoscopic surgery
2. Capacitive coupling
• A capacitor is defined as two nearby conductors
separated by a nonconducting medium.
• example of a capacitor would be monopolar
scissors with an insulation layer placed through a
metal cannula.
• The alternating current flowing through the
scissors induces unintended stray current in any
conductor in close proximity with the monopolar
instrument.
• Hybrid trocar sleeves are prone to induce
capacitive coupling, since the plastic locking
anchor prevents the capacitive current from
dissipating in the abdominal wall, resulting in
electrical current passing through nearby
structures, such as bowel
In Laparoscopic surgery
3. Insulation failure –
• results from breakdown of the
insulation covering the shaft of
the active electrode
• This can happen during the
sterilization process or during the
surgical procedure.
• The distal one-third of the
laparoscopic instrument is the
most common site of insulation
failure.
• Insulation failure can also occur
from inappropriate repeated use
of disposable equipment.
INTERVENTIONS TO ENHANCE SAFETY
1. Return electrode monitoring system —monitors the resistance between the patient's body and the
dispersion pad,
2. Active electrode monitoring — prevents electrosurgical burns due to stray currents by adding a second
layer of insulation and a conductive sheath to the surgical instrument. The system continuously monitors
stray currents and automatically shuts off the ESU if the amount or character of the stray currents
becomes abnormal. This is the only safety tool that effectively prevents electrical burns from capacitive
coupling and insulation failure that occur during the surgical procedure.
3. Computer-controlled tissue feedback systems —
4. Visual inspection — Monopolar instruments can be visually inspected for insulation failure prior to
surgery
5. Testing wands — Special testing wands that can detect even microscopic insulation defects.
6. Body piercing —the general recommendation is to remove umbilical and labial body piercing prior to
surgery, as well as other metal objects that are close to the surgical site. Theoretically, faulty instrument
insulation can allow current to go from the surgical instrument to the metal object causing a skin burn. It
is not necessary to remove piercing or other metal jewelry distant from the operative site, since these
objects are too far away from the active electrode to receive substantial electrical current.
1. Use lowest possible power setting
2. Use a low voltage waveform (cut)
3. Use brief, intermittent activation
4. Do not activate in open circuit
5. Do not activate in close proximity or direct contact with another instrument
6. Use bipolar electrosurgery where appropriate
7. Use an all-metal or all-plastic cannula system (not metal-plastic hybrids)
8. Use a return electrode monitoring system
9. Use active electrode monitoring to eliminate concerns regarding insulation
failure and capacitive coupling during hysteroscopic and laparoscopic
electrosurgical procedures
EMERGING TECHNOLOGY
• Bipolar vessel sealing devices — (LigaSure™)
• applies a precise amount of bipolar energy and pressure
• to fuse collagen and elastin within the vessel walls.
• This results in a permanent seal that can withstand three times the normal systolic
pressure, and seals vessels up to 7 mm
• PlasmaKinetic tissue management system —
• advanced bipolar technology
• pulsed bipolar energy allowing intermittent tissue cooling, which limits lateral
thermal spread and tissue sticking
• The system has two different modes, the vapor-pulse coagulation mode and the
PlasmaKinetic tissue-cutting mode.
• allows for simultaneous cutting and coagulation of tissue
EMERGING TECHNOLOGY
• EnSeal® —
• vessel sealing by combining a compression mechanism with thermal energy
control in a bipolar sealing device.
The instrument is capable of achieving seal strengths up to seven times the
normal systolic pressures on vessels
• The compression mechanism applies uniform pressure along the full length of
the instrument jaw, achieving compression forces similar to those of a linear
stapler. Compression is combined with controlled energy delivery utilizing
NanoPolar™ thermostats to reach collagen denaturation temperatures in
seconds, which are maintained at approximately 100ºC throughout the power
delivery cycle. The device also has a cutting mechanism to allow one-step
sealing and transection of vessels and soft tissues.
Harmonic Scalpel® (ALTERNATIVE ENERGY SOURCES)
Ultrasonic cutting and coagulating device
• converts ultrasonic energy into mechanical energy at the functional end of
the instrument.
• A piezoelectric crystal in the handpiece generates vibration at the tip of the
active blade
• At 55,500 times per second over a variable excursion of 50 to 100
micrometers.
• This results in rupture of hydrogen bonds and produces heat, which leads
to denaturation of proteins and, eventually, separation of tissue.
• These effects are reached at tissue temperatures of 60 to 80ºC, resulting in
coagulum formation without the desiccation and charring caused by
temperatures of 80ºC and higher associated with traditional electrosurgical
methods.
• used successfully in a number of open and laparoscopic procedures.
• The advantages :
• minimal thermal spread
• decreased tissue charring
• Less smoke formation
• no risk of electrical injury due to the absence of electrical current within the patient
• allowing dissect, cut & coagulate using one instrument.
• Reduced operative time (Though Longer time to cut & coagulate)
• Less swelling , bleeding & bruising
• Enhanced recovery
• Disadvantages
• Only coagulates when Cutting
• Longer time to cut & coagulate
• The instrument has five levels, with most generators being preset to use level 3 for cutting and level 5 for
coagulation. The difference between level settings is the blade excursion length, with longer excursion on
higher levels.
• When the blade travels longer distances with each vibration, more heat is generated and the mechanical
effect is more pronounced, resulting in faster separation of tissue and decreased coagulation ability.
 LASER
• Light is electromagnetic radiation within the range of wavelength that is
visible to the human eye.
• Medical lasers produce photons of electromagnetic energy that can be
within, above or below this range.
• The ranges of frequency for each region of the electromagnetic spectrum
are as follows:
• Gamma rays: <0.1 nm
• X-Rays: 0.1 to 10 nm
• Ultraviolet: 10 to 400 nm
• Visible: 440 to 760 nm
• Near-infrared: 760 to 1400 nm
• Mid-infrared: 1400 to 20,000 nm
• Far-infrared: 20,000 to 100,000 nm
• Microwaves: >100,000 nm
l ight a mplification by s timulated e mission of r adiation
• Energy source — The source of external energy, known as the pump
source, used to excite the electrons. Can be electrical, optical or chemical.
• Resonant chamber — The resonant chamber or cavity contains the active
laser medium and reflective mirrors.
• Active medium — The active medium contains the atoms that produce the
electromagnetic radiation.
• Gas- CO 2 , Argon, Excimer
• solid crystalline materials - Nd:YAG (Neodymium doped: yttrium aluminum garnet)
• semiconductor materials
• liquid dye solutions.
Mechanism of action
• Photothermal - denaturation of proteins, coagulative necrosis, and
vaporization.
• Photoablative - delivery of energy that is sufficient to produce
thermal explosions or shock waves within the tissue leading to its
disintegration.
• Photochemical – by free radicals formation
• Photomechanically
• unique properties
• Monochromaticity - all the photons in a laser beam are of the same
wavelength
• Coherence - the synchronization of the laser beam in time and space
• Collimation - the elements of the laser beam are nearly parallel, No
divergent, narrow beam
• Heavy energy density
BASIC PRINCIPLES AND SAFETY OF ULTRASOUND
• Ultrasound - sound waves of a frequency greater than that which the
human ear can appreciate, namely frequencies greater than 20,000
cycles per second.
• frequencies of 2 to 12 million cycles per second are used in uss
• Sound- Pulsating pressure that causes mechanical disturbance when
travel through a medium at a fixed speed.
TRANSDUCERS
• Ultrasound waves are generated from piezoelectric crystals
 Kept with in the transducer that kept in contact to tissue
 when electrically stimulated.
 causes the crystals to mechanically deform
 this deformation leads to formation of an acoustic wave.
 Covert electrical energy to mechanical energy and vice versa.
• This is known as the piezoelectric effect.
• Produce 2 types of waves-
• Continuous wave
• Pulse wave
• Each transducer crystal functions as both a transmitter and receiver of
mechanical energy.
• When an ultrasonic wave travels through a homogeneous medium, its path is a straight line.
• when the medium is not homogeneous or when the wave travels through a medium with two or more
interfaces, its path is altered.
• The relationship between ultrasound waves and tissues can be described in terms of
• Reflection
• Degree of reflection = Acoustic impedence (Z) = density of tissue x wave velocity
• scattering,
• Occurs in 360o
• increases, at smaller structures (RBC) & rapidly when frequency increases
• refraction,
• Attenuation/Absorption
• Convert into thermal/ mechanical energy.- gives unwanted effects
• increases with frequency increases
• The last three factors all act to decrease the magnitude of the ultrasound wave.
• Diagnostic informations derived from complex echo trains derived from
• REFLECTION –at tissue boundaries
• SCATTERING- within tissue
Modes
• A-mode — amplitude modulation
• or only displays data in one dimension, it has limited uses. As an
• Ex- ophthalmologists may use it for determining the thickness of the cornea
• B-mode — Brightness mode
• Detects the varying intensities of the returning echoes displays as varying
degrees of brightness.
• The brightness of the amplitudes in B-mode is represented as pixels.
• Echoes with greater intensity are displayed with greater degrees of
brightness.
• Ex- B-scans use B-mode data and display it in two dimensions, providing a
static gray-scale ultrasound image.
• M-mode — Motion modulation
• Uses B-mode with a continuous update of the returning echoes
• forms a sequence of B-mode that shows changes over time
• Useful in cardiology, as well as in obstetrics and gynecology.
The ultrasound wave affects the tissue through which it travels

• By mechanical vibration-
• can result in cavitation or the formation of gas bubbles.
• typically occurs at the interface of tissues and gas.
• As there is no gas within the uterus, this is not thought to be a significant factor in currently used levels of
obstetrics diagnostic sonography
• By heating of this tissue
• Thermal effects have the greatest potential for adversely affecting the fetus.
• Routine B mode, as is used for typical two-dimensional (2D) imaging,
• does not increase the temperature above the 1 to 1.5 degree Celsius range
• is thought to be safe for fetuses, especially those early embryos at the time of embryogenesis.
• Spectral Doppler ultrasound, however,
• uses higher energy
• is created on a much smaller volume of tissue than typical 2D imaging does
• can result in changes in tissue temperature, especially at bone-tissue interfaces.
• So, should be used with great care, especially early in pregnancy
• The intensities used in transvaginal examinations are generally lower than those in transabdominal examinations.
However, thermal risk can only be assessed by determining the thermal index (TI) in each case.
thermal effects, cavitation, and vibration
• TI — TI is an estimate of the degree of temperature elevation
• 1 indicates a power causing a temperature increase of 1ºC.
• As long as the Thermal Index (TI) is maintained below 1.0,
• The temperature increase with diagnostic ultrasound is less than one degree Celsius at typical
acoustic output.
• This level of increase is not felt to be clinically significant.

• MI —
• MI is an estimate of the compressive and decompressive mechanical effects of
ultrasound pulses, which can potentially result in cavitation
• As long as the Mechanical Index (MI) is kept below 1.0.
• Similarly, diagnostic ultrasound used for medical imaging does not appear to cause cavitation
at usual obstetrical acoustic output
 PHYSICS OF DOPPLER ULTRASOUND
• Doppler frequency shift (fd)
• change in frequency of energy wave transmission observed
when relative motion occurs between the source of wave
transmission and the observer.
• An ultrasound (U/S) beam encountering circulating blood
is scattered by millions of red cells, which cause the
incident beam to undergo a frequency shift proportional
to the speed of red cell movement (ie, blood flow
velocity).
If the Doppler shift and the angle of beam incidence are
known, C-Speed of sound
assuming that the transducer frequency and the velocity of V- velocity of blood
sound in tissue remain relatively constant, flow
then the velocity of blood flow can be determined from the
following modification of the above equation:
• v = fd.c / 2 ft.cos q.
• This equation forms the basis for clinical application of
the Doppler principle.
• Determine both direction and velocity of flow.
MODALITIES OF DOPPLER ULTRASOUND
• Continuous wave — used for determining and monitoring the fetal
heart rate.
• Pulsed wave —
• When Coupled with screen allows selection of the desired vascular location
for Doppler insonation.
• Simultaneous real-time two-dimensional dynamic imaging of the fetal
anatomy provides the necessary guidance for the targeted Doppler
interrogation
‘B-Modal Real-time Grey-scale imaging system with pulse wave doppler and
colour flow imaging’
• This is essential for confident interrogation of deep vessels is used extensively
in clinical practice.
• Pulsed wave Doppler is also referred to as duplex Doppler when it is
combined with two-dimensional imaging.
CRYOSURGERY
• Cryosurgery is used to rapidly, safely, and effectively treat many common
skin lesions.
• Cellular destruction occurs secondarily to ice crystal formation that leads to
cellular dehydration, and subsequent protein and enzymatic
denaturization.
• Liquid nitrogen is the common cryogen of choice
• Destruction is more pronounced with rapid freezing and slow thawing
cycles.

Cryosurgery is typically used for removal of:

• Benign lesions (eg, warts, seborrheic keratoses)
• Premalignant lesions (eg, actinic keratoses)
• Rarely malignant skin tumors
Complications
Short-term complications:
• Pain is variable among individuals; however, be prepared for
vasovagal reactions and do not use cryotherapy in small children.
Lesions may be painful after freezing as a result of pressure from
edema caused by the blister.
• Hemorrhage is common. Inform patients that formation of a "blood
blister'' is normal, especially when treating thick lesions such as
warts.
• Infection is possible.
• Pyogenic granuloma occurs rarely with healing.
Long-term complications:
• Nerve damage is the most serious complication, and is especially likely
where nerves are superficial, such as on the sides of fingers, postauricular,
or the peroneal nerve.
• Pigmentary changes are common and may be especially disfiguring in black
patients.
• Hypertrophic scar formation and tissue defects with delayed healing are
possible if lesions are frozen too deeply or when freezing thick lesions.
• Permanent nail dystrophy may occur if a periungual lesion is frozen too
deeply.
• Recurrence of a lesion, particularly warts, is possible