Newer Energy Sources in

Endoscopic Surgery
 Electrosurgery
High frequency alternating current (5,00,000 – 2 million Hz)

Ion position across cell membrane cannot

Rapid reversal change

Neuromuscular membrane No cardiac

does not depolarize fibrillation

• Neuromuscular stimulation < 1,00,000 Hz

• Household current – 60 Hz  May cause ventricular fibrillation
 Effect Of Heat
• 45-C Tissue Necrosis Starts

• 50 TO 80 -C Irreversible Protein Denaturation

Coagulative Necrosis

Water Vaporisation, Shrinkage

• 80 TO 100 - C

Tissue Dessication, Carbonisation,

• 100 TO 125 - C
Cellular Destruction

• 125 - C + Complete Oxidation Of Protein

Eschar Formation
 Effect of Heat at Different Temperature
Temperature (oC)
34-44 44-50 50-80 80-100 100-200 >200

Visible None None Blanching Shrinkage Steam Carbonisation

effect ‘popcorn’ cratering

Delayed Edema Necrosis Sloughing Sloughing Ulceration Larger

effect crater

Mechanism Vasodilation Disruption Collagen Dessication Vaporization Combustion

Inflammation of cell denaturation of tissue
metabolism hydrocarbons
Electro Coagulation

 Microwave energy – 500-750 Khz – heat production

 3 forms
- Cut
- Coagulation
- Blend
 Physics of Electrosurgery
 Current flow (Ohm’s law)
◦ Voltage = Current X Resistance (V=IR)
(Driving Force) (Amt of flow of
electrons)

Water takes the alternate channel if resistance in the

hose is increased
 Physics of Electrosurgery

CURRENT DENSITY= Amp./Area (sq. cms.)

TEMPERATURE = (Current density)2

HEAT PRODUCTION  Tissue resistance
 -1 Size of active electrode

No burn at passive electrode More effect at pin-point tip than

spatula
Physics Of Electro-surgery
Electrical Circuit

Pulse Generator

Active Electrode Passive Electrode / Earth

Tissue
 Electrosurgery

Monopolar Bipolar
Electrodes placed wide apart Electrodes placed close

 Passive electrode
◦ Closer to the operating site
◦ Large and uniform area of contact
◦ Avoid current passage through the heart
 Actions of Electrosurgery

Cutting Fulguration Dessication

Non-contact activity Non-contact activity Contact activity

 Cutting Mode

Pure Sine Wave (Continuous Activity) Non-Contact Activity

Low voltage activity

Sudden rise in
Sudden rise in intracellular intracellular pressure &
Sudden Heat temperature volume of gas

Electron cut a furrow in the

tissue Cell explodes

Contact activity  Dessicate  Mechanical cutting

Coagulation (Fulguration)
High voltage activity

Short Burst of Sine Wave (Duty Cycle 10% of Non-Contact Activity

time) • Require higher voltage to produce
spark
• Lower power, better coagulation
Heat but cools
during non-
activity period Non explosion of cells Coagulation
Dessication
(Most common effect used by surgeons)

Can happen in both cutting & coagulation waves Contact Activity

No spark generated

Heat Water in cell boils Drying of cells

Generators
Grounded (Older)
• Generator works even if
current is not returning back
to itself
• May have alternate area
burn
Isolated (Newer)
• Generator switches off if
entire current load is not
returned to it
• Eliminates alternate area
burn
 Circuit

Closed Open

Resistance less than Resistance greater than the

the voltage voltage

Current cannot pass  generator increases

Current easily passes  circuit
the voltage  erratic wave (Dangerous)
completed

Open circuit occurs

• When charged electrode is not in contact with tissue
• When dessicated tissue does not allow current flow
•Cutting wave does not change even during open circuit, hence safer
Electrosurgical effect Depends upon
 Temperature generated (normally 200-300oC)
 Shape & dimension of the probe
 Duration of activation (short burst depth & charring)
 Distance from electrode
 Tissue resistance
 Power generated (voltage)
 Amplitude & current wave form
Complication Of Diathermy
 Heat production
 Ground pad failure
 Injury – distant from the tip
 Alternate site injuries
 Demodulated current
 Electrical charges
◦ Direct coupling
◦ Capacitance coupling
 Skin burn
 Surgical glove injury
 Toxic aerosol
 Complication Of Diathermy
 Heat production
 Ground pad failure
 Injury – distant from the tip
 Alternate site injuries
 Demodulated current
 Electrical charges
◦ Direct coupling
◦ Capacitance coupling
 Skin burn
 Surgical glove injury
 Toxic aerosol
 Complication Of Diathermy
 Injury – distant from the tip

Higher current density at smaller

cross sections of tissues
Complication Of Diathermy
 Demodulated current
• Low frequency alternating current causing
neuromuscular depolarization
• Occurs when instrument is activated off the tissue
contact
E.g.-Buzzing of a haemostat
• Insignificant unless directly coupled to heart through
cardiac catheters
Electrical charges
Direct coupling
Capacitance coupling

Instrument
Instrument

Metal canula
Metal canula
Plastic sleeve

Abd.
Abd. wal wall
l

Spar
k

Charge - No Dessipation
Charge - Discharge
Accessible Spark
Capacitive Coupling
Capacitance coupling
Insulation Failure
How To Avoid
 Normal power setting – low
 Short bursts
 Tip under vision
 Other tissue – retract
 Check the insulation
Challenges
 Understanding of basic science of energy sources

 To minimize complications we require standardise

high quality teaching in this subject

 Individual must know to calculate & administer the

energy in a safe manner
Safe Use of Bipolar

 Remember lateral transmission of heat

 Power settings – low

 Hold small bits of tissues & try to have a wider area of

coagulation

 Stop buzzing as soon as popcorn effect is over

 Clean the crusts on the business tip

 Ligasure
 Unique combination of pressure & energy to create vessel
fusion

 Vessel fusion by melting the collagen & elastin in the vessel

wall & forming it a permanent plastic like seal

 Feedback control response automatically discontinue energy

delivery when seal cycle is complete
Ligasure
 Low voltage & high current (4 times of bipolar
generation but 1/5th to 1/20th voltage

 Bipolar mode of electrosurgery

◦ sealing by electrical energy + mechanical
◦ Collagen content of the tissue sensed by
the generator (feed back from tissue – 200
times /sec & adjusts the voltage & current
accordingly)

 Collagen & elastin within the tissue melt &

reform to form a seal zone

 Nature of the vessel wall actually changed

 When sealing completed  cooling cycle

begins  generator shuts off (sealing +
cooling  5 secs)
 No foreign material left

 The seal does not rely on thrombus formation

 Seal vessel upto 7mm

 Low thermal spread

 Lateral spread < 1.5mm

Thrombus formation
 No sticking, no charring

Sealing by ligasure
 Ultrasonic Energy
 Mechanical in nature & works at much lower
temperature
 Controls bleeding by coaptive coagulation (at
50-1000C)
 Coagulation occurs by means of protein
denaturation by the blade vibrating at 55500 Hz
 Secondary heat may produced
Ultrasonic Motion Through Blade Extender
 Ultrasonic wave is transferred to laparoscopic blade
extender
 Blade extender is supported by silicon rings
positioned at six nodes

Blade
extender

Nodes at silicone rings

Using Ultrasonic Technology
How it works?

Blade vibrates 55,500 Hz

Blade motion couples with tissue protein

Protein hydrogen bonds break & protein disorganizes

Protein coagulum seals small coapted vessels

Vibrating protein produces secondary heat

Deep coagulation seals larger coapted vessels

 Cavitational Effect
 Low pressure at blade tip causes fluids to vaporize
at low temperatures, separating tissue planes

Vapor
Energy at 37º C

Tissue layer

Cavitation Water

Cavitational tissue plane

dissection
Cutting & Coagulation
 Coagulation
Coaptaion of the vessel in
between blade & tissue pad

Protein denaturation and

sticky coagulation

Sealing of vessel

Can stand a pressure up to

300mm of Hg
Principles of Harmonic Scalpel Technology in
Surgery
Harmonic Scalpel Electrosurgery/Laser Surgery

Protein Tissue Eschar

Coagulation Dessication (oxidation)
50º C 100º C 150º C 400º C+

Proteins Vaporization Eschar forms

disorganize of water when tissues
to form a dessicates burn
coagulum tissues
Ultrasonic Energy
 Several factors influence the efficacy of
the coagulation
◦ Generator setting
◦ Tension on the tissue
◦ Grip force
◦ Safe of the instrument
 Vapour Pulse Coagulation (VPC)
Gyrus PK Tissue Management System

 Produces faster more uniform coagulation with pulsed energy

 VPC is pulse-off periods allow tissue to cool & moisture to
return to the targeted area
 Reduces hot spot & coagulum formation
 Evenly coagulated the target tissue
 Minimal thermal spread
 Less sticking & enhanced hemostasis
 Vessels upto 7mm can be sealed
 EnSeal System
(Smart Electrode Technology)
 Instruments adjust & dose energy simultaneously to various types of
tissue with its own impedance

 The electrode consists of millions of nanometer sized conductive

particles embedded in a temperature sensitive material

 Each particle acts like a thermostatic switch to regulate the amount

of current

 Each conductive nanoparticle interrupts current flow to a specific

region
 EnSeal System
(Smart Electrode Technology)

 Entire tissue segment is uniformly fused with

out charring or sticking
 Vessel walls are fused through compression,
protein denaturation & then renaturation
 Limited lateral thermal spread <1mm
(>600C)
 Argon Beam Coagulation

Blowing of electrically charged argon gas

Tissue penetration 0.5 mm
 Conclusion
 Energy sources used in endoscopic surgery are varied &
numerous & will continue to improve

 The choice of energy source is determined by the type of

equipment that the operator feels most comfortable using

 Surgeon must have a detailed knowledge of the physical

concepts require to generate the energy source
 Conclusion
 Surgeon must able to understand the complications that
may be created by the energy, how to avoid & how to deal
with them

 Clinical outcome appears to be the much the same &

depends more on the skill on the individual surgeon than
on the power source employed