Principles of Diathermy,

Radiotherapy and
Anesthesia

Dr. AMAR KUMAR

 DIATHERMY (ELECTROCAUTERY)

It is the method to control bleeding or to cut the tissues during surgery.

TYPES

Based on type of current.

1. Unipolar cautery.

2. Bipolar cautery. It is safer because its effect is seen only in between electrode
points. Adjacent tissues will never get damaged.

Based on type of action:

1. Coagulation cautery which causes hemostasis by tissue coagulation. Here

temperature is 100°C.

2. Cutting cautery: Here temperature is 1000°C which disintegrate the tissues. It is not
hemostatic.

3. Blended current is combination of both coagulation and cutting.

Uses

• For coagulation of bleeders during surgery to achieve hemostasis.

• To cut muscles, fascia, etc.
• It is essential for laparoscopic surgical procedures. Bipolar is commonly used.
• It is used to remove small cutaneous lesions, to control bleeding duodenal ulcer.

Disadvantages

• Infection.
• Cauterization of normal tissues.
• Explosive problems.
• Diathermy burn to the patient where diathermy plate is kept.
• Burn injury or electrical shock to surgeon and assisting personnel.

Precautions

• Proper earthing.
• Avoid loose contact of electrodes.
• It should be kept off when not in use during procedure.
A diathermy machine showing cutting, coagulation and bipolar energy sources.
Cutting and coagulation modes are plugged in.
Monopolar cautery (Blend) used for raising skin flaps during
thyroidectomy
 LASERS IN SURGERY
(Light Amplification Stimulated Emission of Radiation).

Molecules are placed in a compact area and power is passed through this so as to
activate the molecules . Molecules get activated at different periods and move in
different directions, which they hit to each other releasing energy. This energy is
allowed to act through optical system to the area wherever required.

Depending on the molecules used it is named.

Argon Laser.
Yttrium-Aluminium Garnet Laser (YAG Laser).
C02 Laser.
Neon Laser.
Holmium Laser.
Erbium Laser.
Uses of Laser
In cranial surgery in children.

In ENT to treat vocal cord lesions, laryngeal lesions.

• In ophthalmology it is very useful in
 Retinal surgery like for detachment.
 Iridotomy.
 Dacrocystitis.
 Capsulotomy.
 To liquefy human lens.
 In glaucomas, etc.

• In General surgery: In bleeding duodenal ulcer

 • For palliative decoring of tumors in carcinoma esophagus.

 • In carcinoma rectum,
 • In hemorrhoidal treatment (1st and 2nd degree),
 • In bladder tumor resection.
 • In cervical cancer.
 • To achieve bloodless field.
 • Often in making incisions in abdomen and other places.
Advantages of laser
• Blood less field.
• Faster.
• Small lesions can be removed easily and completely.
Precautions

All reflecting instruments should be avoided otherwise laser will reflect and can
Injure normal tissues or the working team in the OT itself.

All should wear protective spectacles to protect their eyes.

Disadvantage

Availability and cost factors.

Radiotherapy
• Radiotherapy is a clinical medical speciality in which ionizing radiations are used to
treat cancer and occasionally some benign diseases.

• Aims of radiotherapy:
a. In early cancer, eradication of tumor with preservation of structure and function of
normal tissue.
b. In advanced cancer, palliation of symptoms from either the primary tumor or
metastases to improve the quality of life.

• Biological effects of radiotherapy

Delivery Systems for Radiotherapy

i. Teletherapy
The beams of radiation are generated at a distance and aimed at the tumor within the
patient. It is also known as external beam radiotherapy and is most commonly used
form of radiotherapy.
Its advantages are:
• It can deliver high doses of radiotherapy to deep seated tumors.
• There is more homogenous distribution of radiation energy.
• It is skin sparing and avoids skin reactions.
• There is reduced absorption in the bones.
• There is reduced lateral scattering into adjoining Tissues
ii. Brachytherapy

The radioactive source is implanted directly into or adjacent to tumor tissue. It usually
requires an operative procedure and delivers concentrated radiation doses into the
tumor tissue. The doses are relatively high in comparison to doses received by the
surrounding normal tissue.
If radiation source is introduced into tissues it is called interstitial radiotherapy. If
radiation source is introduced into body cavities, it is called intracavitatory
radiotherapy. Various radioactive isotopes used are cobalt 60, iridium 192, caesium
137 and iodine 125.
Its advantages are:

• Sources are introduced and removed under remote control thus preventing exposure
to medical personnel.
• Position of applicator can be checked under X-rays.
• Precise dose of radiation can be delivered to the tumor tissue.

iii. Targeted Therapy

The radioactive isotope is administered systemically into the patient and it is targeted
to the site of tumor, e.g. systemic administration of iodine 131 in a patient with thyroid
cancer metastasis shows uptake of the isotope at site of metastasis.

These days targeted therapy is being used by attaching radioisotopes to monoclonal

antibodies that seek out and attach to specific tumor antigens.

Radiation Dosage (Dosimetry)

It is quantified on the basis of amount of radiation absorbed in the patient, not based
upon the amount of radiation generated by the machine.

Hence, its unit is called as Rad (Radiation absorbed dose). A Rad is 100 ergs of energy
deposited per gram of tissue.
A Gray (Gy) is equal to 100 rads.
 Clinical Applications of Radiotherapy

Pretreatment Evaluation of Patient

Before starting radiotherapy, the diagnosis should be firmly established by tissue
biopsy. The disease should be staged by detailed clinical examination and relevant
investigations.

Treatment Goals
Based on the type of tumor, stage of disease and condition of the patient,
radiotherapy can be used in four settings:
i. Curative
ii. Palliative
iii. Adjuvant
iv. Prophylactic

i. Curative radiotherapy:

Aim of the treatment is to eliminate all malignant cells. High doses of radiotherapy are
given. It involves high cost and patient inconvenience due to long courses of
treatment. There is considerable toxicity due to normal tissue damage.
 Curative radiotherapy has a special role in areas where preservation of anatomy
and functions is of critical importance, e.g. carcinoma tongue or larynx can be
destroyed by radiotherapy or removed by surgery and the chances of survival are the
same. But advantage of retaining speech is worth considering with curative
radiotherapy.

Radiotherapy is curative for a number of malignancies :-

• Hodgkin’s lymphoma
• Head and neck cancers
• Carcinoma breast
• Gynecologic cancers (cervix, ovary, uterus)
• Prostate cancer
• Carcinoma esophagus
• Carcinoma anal canal
• Testicular tumors
• Medulloblastoma
• Lung cancer (non-small cell)
ii. Palliative radiotherapy:
Aim of treatment is to control symptoms to improve the
quality of life. Minimum doses of radiotherapy are given to achieve maximum control
and minimum side effects. Short courses of treatment are given to avoid patient
inconvenience and to limit the cost.

Indications of palliative radiotherapy are

• Metastatic bone disease (for pain relief)

• Control of brain metastases
• Reversal of spinal cord compression
• Reversal of superior vena cava obstruction
• Opening of threatened airways
• Shrinkage of painful masses
iii. Adjuvant radiotherapy:
Radiotherapy can be combined with chemotherapy,
surgery or both. Aim is to get combined benefits of different treatment modalities so
as to control local as well as disseminated tumor, e.g. by giving preoperative
radiotherapy in locally advanced cancer, it becomes small and less vascular, thus
becoming resectable.

Similarly, if surgical removal of tumor is incomplete, then postoperative radiotherapy

to the surgical field helps in control of local disease.

In management of carcinoma breast:

• Surgery is for locoregional control of disease.
• Radiotherapy is given to control any residual disease in chest wall or axilla.
• Chemotherapy is given for systemic disease control.

iv. Prophylactic radiotherapy:

Certain cancers like acute leukemia and lung cancer
have high incidence of developing brain metastasis even after control of primary
disease.

In such high-risk settings, prophylactic cranial radiotherapy is given to prevent the

occurrence of brain metastasis.
 Toxicity
The side effects of radiotherapy are usually localized to the body site irradiated but
systemic effects may also develop, e.g. fatigue, anorexia, nausea and vomiting.

Organs having rapid proliferation of cells are most sensitive to radiotherapy, e.g. bone
marrow, ovaries, testes, vascular endothelium and mucosal lining of intestinal tract.

Organs with less renewal of cells are more resistant to radiotherapy, e.g. heart, skeletal
muscles, bones and nerves.

Acute toxicity includes skin erythema and ulceration, mucositis and bone marrow
depression. Most of these can be alleviated by interruption of treatment. Chronic
toxicities are more serious.

The most serious late toxicity is development of second solid tumor in or near site of
radiations, e.g. development of carcinoma breast in females after chest irradiation.
 Toxicity of radiotherapy

• Head and neck irradiation • Abdomen and pelvis

• Alopecia • Enteritis (Intestines)
• Dermatitis • GI hemorrhage
• Blindness (cataract and retinal damage) • Gut perforation
• Mucositis, Xerostomia (dry mouth) • Hepatitis (Liver)
• Anosmia • Nephrosclerosis (kidneys)
• Dental caries • Cystitis (bladder)
• Thyroid failure • Infertility (Testes, ovaries)
• Bone marrow irradiation • Fetus
• Pancytopenia, aplastic anemia • Chromosomal and developmental
abnormalities.
• Chest and mediastinal irradiation
• Myocardial infarction
• Constrictive pericarditis
• Lung fibrosis
• Spinal cord transection
• Carcinoma breast