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Hand Instruments Handbook of Laparoscopy Instruments 69
https://t.me/medicina_free
necessary to drain fluids and irrigate wound surfaces until they are clean and can
be viewed adequately. Irrigation is used to clear debris or blood when bleeding is
encountered; if intense irrigation pressure is applied, it can be helpful to identify
the origin of the bleeding. Some surgical teams defend that irrigation can also be
used for hydrodissection and the creation of tissue planes. On the other hand,
many surgeons say that irrigation should be avoided because it may interfere with
the CO2 pneumodissection of the retroperitoneal spaces. These solutions must be
used at body temperature. Suction is performed either using a central vacuum
supply system or with an additional suction pump that usually works better.
Different laparoscopic suction instruments have been designed to remove
irrigation fluid or intraperitoneal air and smoke. Combination suction/irrigation
devices are also available. A larger 10 mm suction-irrigation instrument is ideal
for removing blood clots when brisk bleeding is encountered (pe.
hemoperitoneum after an ectopic pregnancy rupture). In the market, a suctionirrigation device with a bipolar current tip may be helpful in the case of ovarian
endometriomas and deep endometriosis. It is a more versatile device that allows
blunt dissection, coagulation, irrigation and fluid suction simultaneously [7].
Fig. (7.17). (a, b, and c) Suction and irrigation cannula.
70 Handbook of Laparoscopy Instruments Nagtode et al.
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CONCLUSION
Operative hand instruments, either disposable or reusable, are made up of three
parts mainly; a handle, an outer covering sheath and a working insert. Instruments
used for blunt dissection are graspers and dissectors mainly. Bipolar and
Maryland are the two critical dissectors used widely. Instruments used for sharp
dissection are scissors, knives, needle holders, coagulation devices, electrosurgery
hooks and a spatula. All reusable instruments have to be sterilised before each
use. Hence, the basic knowledge regarding these various instruments is
fundamental for a Laparoscopic surgeon to operate flawlessly.
REFERENCES
[1] Frisby J, Shah J, Buckley D, Darzi A. Depth cue reliance in surgeons and medical students. Surg
Endosc 2003; 17(9): 1472-4.
[http://dx.doi.org/10.1007/s00464-002-9178-y] [PMID: 12802650]
[2] Wentink B, Wentink M. Eye-hand coordination in laparoscopy - an overview of experiments and
supporting aids. Minim Invasive Ther Allied Technol 2001; 10(3): 155-62.
[http://dx.doi.org/10.1080/136457001753192277] [PMID: 16754008]
[3] Schurr M, Breitwieser H, Melzer A, et al. Experimental telemanipulation in endoscopic surgery. Surg
Laparosc Endosc 1996; 6(3): 167-75.
[http://dx.doi.org/10.1097/00019509-199606000-00001] [PMID: 8743357]
[4] Bholat OS, Haluck RS, Murray WB, Gorman PJ, Krummel TM. Tactile feedback is present during
minimally invasive surgery. J Am Coll Surg 1999; 189(4): 349-55.
[http://dx.doi.org/10.1016/S1072-7515(99)00184-2] [PMID: 10509459]
[5] Brydges R, Carnahan H, Dubrowski A. Surface exploration using laparoscopic surgical instruments:
The perception of surface roughness. Ergonomics 2005; 48(7): 874-94.
[http://dx.doi.org/10.1080/00140130500123704] [PMID: 16076743]
[6] Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS 2001; 5(1): 89-94.
[PMID: 11304004]
[7] Cicione A, Autorino R, Breda A, et al. Three-dimensional vs standard laparoscopy: comparative
assessment using a validated program for laparoscopic urologic skills. Urology 2013; 82(6): 1444-50.
[http://dx.doi.org/10.1016/j.urology.2013.07.047] [PMID: 24094658]
Handbook of Laparoscopy Instruments, 2023, 71-88 71
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CHAPTER 8
Energy Devices: Working Principles, Uses And
Complications
Raju Kamlakarrao Shinde
Yeshwant Ramrao
1
Department of Surgery, J.N.M.C., D.M.I.M.S., Sawangi- Meghe, Wardha, Maharashtra, India
Abstract: In ancient times, a hot iron rod was used for charring at the bleeding site to
stop bleeding. The earliest significant contribution to a sophisticated method of
generating heat to cauterize tissue from electrical current is by Bovie. Energy sources
are classified as radiofrequency electrosurgery, laser, ultrasonic, and argon beam
coagulation. The majority (85%) of surgeons use monopolar electrosurgery. The
electrosurgical effect on the tissue causes cutting, coagulation, fulguration, and
desiccation. It uses ultrasonic technology, the unique energy form that allows both
cutting and clotting at the precise point of impact, resulting in minimal lateral thermal
tissue damage. Cutting and coagulation are done at lower temperatures than those used
by electrosurgery or lasers. The Harmonic Scalpel has five power levels. Increasing the
power level increases cutting speed and decreases coagulation.
In contrast, less power reduces cutting speed and increases clotting. Argon-enhanced
electrosurgery incorporates a stream of argon gas to improve the surgical effectiveness
of the electrosurgical current. Argon gas is inert and non-combustible, making it a safe
medium to pass electrosurgical current.
1
1,*
, Sangita Devrao Jogdand1 and Lamture
Keywords: Argon gas coagulation electrosurgery, Bipolar cautery, Coagulation,
Cutting, Desiccation, Evaporation, Fulguration, Harmonic cautery, Laser energy,
Monopolar cautery, Ultrasonic cautery.
INTRODUCTION
In ancient times, hot iron rod was used for charring at the bleeding site to stop
bleeding while performing surgeries on breast, and neck tumors, which was very
painful and horrible; cautery is a term used when direct current (D.C.) is used for
controlling the bleeding. In modern science, alternating electric current (A.C.) is
used in higher frequency waveforms to produce different degrees of heat to
achieve the desired effect over tissue in the form of cutting, coagulation, desicca-
*
Corresponding author Raju Kamlakarrao Shinde: Department of Surgery J.N.M.C., D.M.I.M.S., Sawangi-
Meghe, Wardha, Maharashtra; India; E-mail: raju.shinde95@gmail.com
All rights reserved-© 2023 Bentham Science Publishers
Lamture Yeshwant Ramrao (Ed.)
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tion or fulguration in a safe way without any pain or electric shock. The earliest
significant contribution to a sophisticated method of generating heat to cauterize
tissue from electrical current is by Bovie.
There are different types of energies like electric current energy (alternate or
direct) or laser, ultrasonic waves, gases like Argon, or radiofrequency unit, which
are used to produce a varying degree of heat to achieve the desired temperature at
the operative site to have the expected type of tissue effect to control bleeding,
depending on the degree and duration of contact with tissue.
Up to 40 degrees centigrade, there is no irreversible damage to the cell, but as
temperature increases, there are different effects on living cells (Fig. 1). A limited
duration of heat between 40-500C will lead to local hyperemia and oedema;
longer contact time may cause cell death and devitalization. Temperature between
60-800C causes desiccation (drying), denaturation of cellular protein and
membrane destruction, whereas temperature above 1000C leads to vaporization of
the intracellular fluid. Vapour pressure causes the busting of tissue, and if it is
slow vaporization, then there is desiccation (drying), and a further rise in heat
causes tissue burn, i.e., carbonization [1].
Fig. (1). Effects of the active electrode in the tissue.
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Depending on the degree of temperature, the contact time required for cell death is
as follows [2].
Temperature Time required for cell death
450C 15 Minutes
500C 20 Seconds
550C 2 Seconds
1000C Less than 1 Second
Waveform over 100 kHz does not produce pain or electric shock. Hence higher
frequencies are used in different cautery devices to achieve desired tissue effects.
Different waveforms have different tissue effects (Figs. 2a - c); low voltage,
continuous waves are used for cutting the tissue, whereas low voltage intermittent
waveforms lead to reduced heat production that causes coagulation in the tissue
and percentage in intermittency in waves is called blending. There are three
blending modes. (Blend-1=50%, Blend-2= 60% and Blend-3=75% off cycles).
High voltage intermittent waveform is used to produce coagulation only where
there is 94% intermittency. An increase in off time will produce less heat and a
higher coagulation effect, whereas reducing off time will have a more cutting
effect than coagulation in the tissue.
Fig. (2a). Percentage of frequency, its relation to voltage and effects.
74 Handbook of Laparoscopy Instruments Shinde et al.
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Fig. (2b). Fulguration.
Fig. (2c). Desiccation.
Cutting effect is due to sparks of high intensity due to vaporization in thea.
tissue. It is readily achieved by an active tip electrode near the tissue without
touching it.
Fulguration is due to sparks with coagulation waveform that produce less heatb.
and more coagulum than vaporization in superficial tissue.
Desiccation, i.e., drying of the tissue when the electrode is in direct contactc.
with the tissue.
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Hence to achieve the desired effect at the operative site; power setting, the type of
tip (pointed versus blunt), the type of waveform, contact of tip to tissue (in contact
or off contact), type of the tissue, time of contact and dried tissue or coagulum at
the tip of the electrode are essential factors.
ELECTROSURGERY PARTS
●
Generator: Converting electrical energy into different ranges of frequencies
waves producing local heat, sparks, ultrasonic vibrations.
●
Handpiece (active electrode) generates heat or, in a specialized unit, transducer
converting ultrasonic frequencies to mechanical vibrations to achieve the desired
degree of heat and tissue effect like cutting, coagulation, desiccation or
carbonization.
●
Returning electrode- foot plate for dispersal of energy from the body.
●
Connecting cables to connect to electricity, hand pencil or foot switch, and foot
plate.
MONOPOLAR ELECTROSURGERY
The monopolar unit is composed of a generator, an active electrode and a
returning electrode. The unit circuit is completed by keeping the patient between
active and returning electrodes. The active electrode is positioned at the operative
site, whereas returning electrode is placed at a distant site from the operative site,
and both are connected to a generator.
The difference between active and dispersive (returning) electrodes is that an
active electrode has a tip which concentrates the current in high intensity to
produce the desired effect, whereas returning electrode is wide so that there is no
concentration of current at a smaller tissue area; hence it is very much crucial that
larger surface of returning electrode should be in contact with the patient's body.
There can be alternate pathways that can act as returning electrodes, like an
operation table, an operating surgeon or other equipment that plays a vital role
when returning electrode is not working properly, leading to multiple site burns
(Fig. 3).
76 Handbook of Laparoscopy Instruments Shinde et al.
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Fig. (3). Alternate path of grounding in monopolar cautery.
Returning electrode placement must be preferred in well-vascularized sites
avoiding bony prominences/ ischemic parts, or metal implants in the body or
equipment like a cardiac pacemaker.
Adaptive Technology in the Active Electrode
A computer-controlled advanced generator promptly measures tissue resistance
and modifies maximum output voltage instantly in active electrodes to minimize
excess lateral tissue injuries.
Returning Electrode Monitoring System
It is being developed in newer generators that measure the impedance due to
limited contact surface and deactivates the generator, which avoids hazardous
effects due to returning electrode failure.
Bipolar electrosurgery (cautery) (Fig. 4).
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Fig. (4). Bipolar unit and its electrode where tissue is between two electrodes.
In a bipolar unit, the active electrode and returning electrode are at the operative
site, and the path of the circuit is completed by tissue intervening between the two
tips of the electrodes; hence returning electrode is not necessary to apply.
Complications
Direct Coupling
Active electrode gets accidentally in contact with nearby instruments when the
generator is activated by the operating surgeon, which activates an alternate
pathway to complete the unit circuit and produce sufficient heat to cause potential
injury to organs in contact.
Insulation Failure
There are safety concerns while using these instruments in minimally invasive
surgery as instruments are long and coated with insulation which may get
damaged due to multiple times usage, washing and sterilization, and high voltage
leading to small or large holes in insulation. These sites of insulation failure when
getting in contact with adjacent organ cause heat leading to injury to the organ.
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Capacitive Coupling
When two current conductor metals are separated by a non-conductor, it
accidentally creates a capacitor effect i.e., the electrostatic field between two
conductor metals and thus, through laparoscopic or endoscopic procedures, the
electrostatic field may be created between the insulated active electrode and metal
ports; which passes current to metal port through the electrostatic field leading to
injuries. The plastic cannula cannot wholly eliminate capacitive coupling. More
significant damage can occur in the hybrid cannula, which is a combination of
metal and plastic, as current is prevented from dispersal to the abdominal wall,
which concentrates current in the metal part leading to higher-grade injury.
Active electrode monitoring systems can be used to avoid complications due to
insulation failure or capacitive coupling apart from the correct setting of the
generator system. To reduce the magnitude of injuries, a metal cannula should be
the first choice or a bipolar unit is preferable.
Uses: All types of major or minor surgeries to limit bleeding.
Advantages
●
Inexpensive and readily available.
●
Faster dissection and reduced bleeding with earlier recovery when any
electrosurgery unit is used.
●
Bipolar units provide compression over tissue and lower heat, increasing
patient’s safety and can be used in patients with functional implants.
Disadvantages
●
Greater magnitude tissue injuries are more common with unipolar units than a
bipolar unit.
●
Skin burns are reported due to the malfunction of the returning electrode.
●
No control over heat generation at the operative site due to devitalized tissue at
the tip of the active electrode.
●
Medical inflammable gases or liquid in the operating room may be exploded due
to generated sparks.
●
Functionality issues of metal equipment like cardiac pacemakers with
Monopolar units [3, 4].
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